Treatment

Prognosis

The prognosis of cholera can range from excellent to poor, depending on the severity of dehydration and how quickly the patient is given and responds to treatments. If people with cholera can be treated quickly and properly, the mortality rate is less than 1%. However, with untreated cholera, the mortality rate rises to 50%- 60%.

In general, the less severe the symptoms and the less time people have dehydration symptoms, the better the prognosis; in many people, if dehydration is quickly reversed, the prognosis is often excellent.

For certain genetic strains of cholera, such as the one present during the 2010 epidemic in Haiti and the 2004 outbreak in India, death can occur within two hours of the first sign of symptoms.

What is the treatment for cholera?

ORS (oral rehydration salts)

The CDC (and almost every medical agency) recommends rehydration with ORS (oral rehydration salts) fluids as the primary treatment for cholera. ORS fluids are available in prepackaged containers, commercially available worldwide, and contain glucose and electrolytes. The CDC follows the guidelines developed by the WHO (World Health Organization) and are as follows:

WHO Fluid Replacement or Treatment Recommendations (as per the CDC)

Patient condition	Treatment	Treatment volume guidelines; age and weight
No dehydration	Oral rehydration salts (ORS)	Children < 2 years: 50 mL-100 mL, up to 500 mL/day Children 2-9 years: 100 mL-200 mL, up to 1,000 mL/day Patients > 9 years: As much as wanted, to 2,000 mL/day
Some dehydration	Oral rehydration salts (amount in first four hours)	Infants < 4 mos (< 5 kg): 200-400 mL Infants 4 mos-11 mos (5 kg-7.9 kg): 400-600 mL Children 1 yr-2 yrs (8 kg-10.9 kg): 600-800 mL Children 2 yrs-4 yrs (11 kg-15.9 kg): 800-1,200 mL Children 5 yrs-14 yrs (16 kg-29.9 kg): 1,200-2,200 mL Patients > 14 yrs (30 kg or more): 2,200-4,000 mL
Severe dehydration	IV drips of Ringer Lactate or, if not available, normal saline and oral rehydration salts as outlined above	Age < 12 months: 30 mL/kg within one hour*, then 70 mL/kg over five hours Age > 1 year: 30 mL/kg within 30 min*, then 70 mL/kg over two and a half hours

·              Repeat once if radial pulse is still very weak or not detectable

·           Reassess the patient every one to two hours and continue hydrating. If hydration is not improving, give the IV drip more rapidly. 200mL/kg or more may be needed during the first 24 hours of treatment.

·        After six hours (infants) or three hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

Antibiotics

In general, antibiotics are reserved for more severe cholera infections; they function to reduce fluid rehydration volumes and may speed recovery. Although good microbiological principals dictate it is best to treat a patient with antibiotics that are known to be effective against the infecting bacteria, this may take too long a time to accomplish during an initial outbreak (but it still should be attempted); meanwhile, severe infections have been effectively treated with tetracycline (Sumycin), doxycycline (Vibramycin, Oracea, Adoxa, Atridox and others), furazolidone (Furoxone), erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone), or ciprofloxacin (Cipro, Cipro XR, Proquin XR) in conjunction with IV hydration.

In many areas of the world, antibiotic resistance is increasing. In Bangladesh, for example, most cases are resistant to tetracycline, trimethoprim-sulfamethoxazole, and erythromycin. Rapid diagnostic assay methods are available for the identification of multiple drug-resistant cases. New generation antimicrobials have been discovered which are effective against in in vitro studies.

Zinc supplements

Research has shown that zinc may decrease and shorten the duration of diarrhea in children with cholera.

Drugs

(1)   Tetracycline : an antibiotic (trade name Achromycin) derived from microorganisms of the genus Streptomyces and used broadly to treat infections.

(2)       Sulphonamides : more effective and less toxic antibiotics

Sari filtration

An effective and relatively cheap method to prevent transmission of V. cholera is the practice of folding a sari multiple times to create a simple filter for drinking water. Folding saris four to eight times may create a simple filter to reduce the amount of active V. cholera in the filtered water. The education of proper sari filter use is imperative, as there is a positive correlation between sari misuse and the incidence of childhood diarrhea; soiled saris worn by women are vectors of transmission of enteric pathogens to young children. Educating at-risk populations about the proper use of the sari filter method may decrease V. cholera-associated disease.

Electrolytes

As there frequently is initially acidosis, the potassium level may be normal, even though large losses have occurred. As the dehydration is corrected, potassium levels may decrease rapidly, and thus need to be replaced.

Vaccine

The first vaccines against cholera were developed in the late nineteenth century. These injected whole cell vaccine became increasingly popular until they were replaced by oral vaccines starting in the 1980s. Although no longer in use, the injected cholera vaccines are effective for people living where cholera is endemic. They offer significant degrees of protection for up to two years after a single shot, and for three to four years with annual booster. They reduce the risk of death from cholera by 50% in the first year after vaccination.

There are two variants of the oral vaccine currently in use: WC-rBS and BivWC. WC-rBS (marketed as "Dukoral") is a monovalent inactivated vaccine containing killed whole cells of V. cholerae O1 plus additional recombinant cholera toxin B subunit. BivWC (marketed as "Shanchol" and "mORCVAX") is a bivalent inactivated vaccine containing killed whole cells of V. cholerae O1 and V. cholerae O139. mORCVAX is only available in Vietnam. These oral vaccines provide protection in 52% of cases the first year following vaccination and in 62% of cases the second year.

Bacterial strains of both Inaba and Ogawa serotypes and of El Tor and Classical biotypes are included in the vaccine. Dukoral is taken orally with bicarbonate buffer, which protects the antigens from the gastric acid. The vaccine acts by inducing antibodies against both the bacterial components and CTB. The antibacterial intestinal antibodies prevent the bacteria from attaching to the intestinal wall thereby impeding colonisation of V. cholerae O1. The anti-toxin intestinal antibodies prevent the cholera toxin from binding to the intestinal mucosal surface thereby preventing the toxin-mediated diarrhoeal symptoms. Dukoral also protects against traveler's diarrhea.

The cholera vaccine is largely used by backpackers and persons visiting locations where there is a high risk of cholera infection. However, since it does not provide 100% immunity from the disease food hygiene precautions should also be taken into consideration when visiting an area where there is a high risk of becoming infected with cholera. Although the protection observed has been described as "moderate", herd immunity can multiply the effectiveness of vaccination. Although the vaccine can be dangerous for children, administration of the vaccine to adults can confer protection to children