Treatment of cholera

Seek expert advice. In untreated severe cholera the death rates may exceed 70% (1).

The mainstay of treatment is rehydration therapy:

• mortality in this condition can be reduced to less than 0.2% through the use of effective and appropriate rehydration therapy
• therapeutic regimes are usually oral although, in severely dehydrated individuals with features of collapse, intravenous rehydration may be necessary.

Adjunctive antibiotic treatment helps to eradicate the infection and also decreases the stool output and duration of the illness. While doxycycline is the preferred first-line treatment, the choice of antibiotic should be informed by local antibiotic susceptibility patterns. If resistance to doxycycline is documented, a single dose of azithromycin or ciprofloxacin is recommended as an alternative option (5)

• it also helps in decreasing the duration of shedding of viable organisms in stool from several days to 1–2 days
• the first dose should be administered after the initial fluid deficit is corrected and vomiting has resolved
• tetracyclines
  • tetracyclines -
  • used empirically for outbreaks caused by documented susceptible isolates
  • not recommended for pregnant women or children younger than 8 years due to risk of irreversible discolouration of permanent teeth (1)
  • doxycycline (1)
• fluoroquinolones
  • ciprofloxacin
  • there is evidence that single-dose ciprofloxacin achieved clinical outcomes similar to, or better than, those achieved with 12-dose erythromycin treatment in childhood cholera - however ciprofloxacin treatment was less effective in eradicating Vibrio cholerae from stool (2)
  • decreased susceptibility to fluoroquinolones has been reported commonly in endemic areas and is associated with treatment failure (1)
• macrolides
  • erythromycin
  • azithromycin
    • single dose azithromycin is the preferred drug in children (1)
    • comparison of single-dose ciprofloxacin (1000mg) versus single-dose azithromycin (1000mg) (3)
      • single-dose azithromycin was more effective than single-dose ciprofloxacin in the treatment of severe cholera in adults
      • the study authors stated that the lack of efficacy of ciprofloxacin may result from its diminished activity against V. cholerae O1 strains circulating in Bangladesh at the time of the study
      • NNT of 3 (CI 2 to 3) with azithromycin for clinical success
      • NNT of 2 (CI 2 to 2) with azithromycin for bacteriological success

Notes:

• antibiotic resistance is a problem in the treatment of cholera with previously used antibiotics. Relatively recently there has been the emergence of ciprofloxacin resistance (3). An in vitro study has described an azithromycin resistant strain of cholera (4).

References:

1. Harris JB et al. Cholera. Lancet. 2012;379(9835):2466-76
2. Saha D et al. Single-dose ciprofloxacin versus 12-dose erythromycin for childhood cholera: a randomised controlled trial. Lancet 2005; 366:1085-93.
3. Saha D et al. Single-dose azithromycin for the treatment of cholera in adults. N Engl J Med. 2006 Jun 8;354(23):2452-62
4. Centre for Population and Health Research. Health and Science Bulletin 2005;3(2)
5. Centers for Disease Control and Prevention. Recommendations for the use of antibiotics for the treatment of cholera. Jun 2022 [internet publication]