Clinical Presentation and Management in Haiti

Most people infected with the cholera bacterium (Vibrio cholerae O1) have mild diarrhea or no symptoms at all. Only about 10% of people infected with cholera bacterium have illness requiring treatment at a health center.

Cholera patients should be evaluated and treated quickly. With proper treatment, even severely ill patients can be saved. Prompt restoration of lost fluids and salts is the primary goal of treatment.

Symptoms of Moderate or Severe Cholera

Profuse, watery diarrhea
Vomiting
Leg cramps

Key Points About Rehydration

Rapid high-volume rehydration will save lives.
Many patients can be rehydrated entirely with oral rehydration solution (ORS).
Even if patients get intravenous (IV) rehydration, they should start drinking ORS as soon as they are able.

Watch the following video: Managing Dehydration.

Signs and Symptoms of Dehydration

Moderate Dehydration

Restlessness and irritability
Sunken eyes
Dry mouth and tongue
Increased thirst
Skin goes back slowly when pinched
Decreased urine
Decreased tears and depressed fontanels in infants

Severe Dehydration

Lethargy or unconsciousness
Very dry mouth and tongue
Skin goes back very slowly when pinched (“tenting”)
Weak or absent pulse
Low blood pressure
Minimal or no urine

Signs of Adequate Rehydration

Skin goes back normally when pinched
Thirst has subsided
Urine has been passed
Pulse is strong

Guidelines for Treatment

Guidelines for Treating Patients with Some Dehydration

Oral Rehydration

Patients who vomit should be given small, frequent sips of ORS solution, or ORS solution by nasogastric tube. ORS solution should be made with safe water.

Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration. Use the patient’s age only when you do not know the weight.

Approximate amount of ORS solution to give in the first 4 hours to patients with some dehydration
Age	<4 mo.	4-11 mo.	12-23 mo.	2-4 yr.	5-14 yr.	≥15 yr.
Weight (kg)	<5	5-7	8-10	11 -15	16-29	≥30
ml	200-400	400-600	600-800	800-1200	1200-2200	2200-4000

The approximate amount of ORS (in milliliters) can also be calculated by multiplying the patient’s weight in kg by 75.
A rough estimate of oral rehydration rate for older children and adults is 100 ml ORS every five minutes, until the patient stabilizes.
If the patient requests more than the prescribed ORS solution, give more.
For infants: Encourage the mother to continue breastfeeding.

Notes

The volumes and time shown are guidelines based on usual needs. If necessary, amount and frequency can be increased, or the ORS solution can be given at the same rate for a longer period to achieve adequate rehydration. Similarly, the amount of fluid can be decreased if hydration is achieved earlier than expected.
During the initial stages of therapy, while still dehydrated, adults can consume as much as 1000 ml of ORS solution per hour, if necessary, and children as much as 20 ml/kg body weight per hour.
Reassess the patient after 1 hour of therapy and then every 1 to 2 hours until rehydration is complete.
Resume feeding with a normal diet when vomiting has stopped.

Guidelines for Treating Patients with Severe Dehydration

Intravenous Rehydration

Patients with severe dehydration, stupor, coma, uncontrollable vomiting, or extreme fatigue that prevents drinking should be rehydrated intravenously.

Intravenous solutions

Best — Ringer’s Lactate Solution
Acceptable — Normal Saline
Unacceptable — Plain glucose (dextrose) solution

Start intravenous fluids (IV) immediately. If the patient can drink, give ORS solution by mouth while the IV drip is set up. Give 100 ml/kg Ringer’s Lactate Solution divided as follows:

Guidelines for severe dehydration
Age	First give 30 ml/kg IV in:	Then give 70 ml/kg IV in:
Infants (<12 mos.)	1 hour*	5 hours
Older (≥1 yr.)	30 minutes*	2 ½ hours

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

Reassess the patient every 1 to 2 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.
Also give ORS solution (about 5 ml/kg per hour) as soon as the patient can drink.
After 6 hours (infants) or 3 hours (older patients), perform a full reassessment. Switch to ORS solution if hydration is improved and the patient can drink.

Guidelines for Using Antibiotics

An appropriate antibiotic given orally will reduce the volume and duration of diarrhea. Treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass a large volume of stools during rehydration treatment, and for all patients who are hospitalized. Do not give antibiotics to asymptomatic or mildly ill people. Selection of antibiotics should be based on the antibiotic resistance profile of V. cholerae, local availability, and patient’s clinical classification. Zinc given orally can reduce the duration of most infectious diarrhea in children. No drugs should be given for treatment of diarrhea or vomiting besides antibiotics and zinc.

Appropriate oral antibiotics (to be given by mouth)

V. cholerae can be resistant to certain types of antibiotics. These recommendations are based on the antimicrobial resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability. The antimicrobial resistance profile of V. cholerae in Haiti has not changed significantly since 2010.

The V. cholerae isolates from people with cholera in Haiti have undergone antimicrobial susceptibility testing ¹.

The results of antimicrobial susceptibility testing show*:

Appropriate oral antibiotics
Antibiotic	Susceptibility
Azithromycin	Susceptible
Tetracycline	Susceptible
Doxycycline	Susceptible**
Ciprofloxacin	Decreased susceptibility***
Sulfisoxazole	Resistant
Furazolidone	Decreased susceptibility***
Nalidixic acid	Decreased susceptibility***

*Susceptibility testing of selected isolates from ill patients in Haiti will continue, and clinicians should be alert for changes in antibiotic treatment recommendations based on clinical experience in Haiti.

**Susceptibility inferred based on tetracycline testing.

***Although the reliability of disk diffusion results for ciprofloxacin, furazolidone, and nalidixic acid has not been validated by the Clinical and Laboratory Standards Institute (CLSI), additional antibiotics are tested using this and other methods for the epidemiological monitoring of strains. Proposed breakpoints for furazolidone and nalidixic acid are based on multi-laboratory studies. Ciprofloxacin zone sizes are based on interpretation of disk diffusion results for Shigella and Enterobacteriaceae ².

Multiple first choice and second choice options are presented. Selection of antibiotics should be based on individual case consideration and available medications.

Recommended Antibiotics for Treatment of Patients with Moderate or Severe Cholera

Recommended Antibiotics for Treatment of Patients with Moderate or Severe Cholera
	First choice	Second choice
Adults (non-pregnant)	Doxycycline: 300 mg by mouth in one dose	Azithromycin: 1 gram in one dose Tetracycline: 500 mg 4 times a day for 3 days Erythromycin: 500 mg 4 times a day for 3 days
Pregnant women	Azithromycin: 1 gram in one dose	Erythromycin: 500 mg 4 times a day for 3 days
Children ≥12 months old and capable of swallowing pills and/or tables	Azithromycin: 20 mg/kg in one dose Erythromycin: 12.5 mg/kg 4 times a day for 3 days Doxycycline: 2-4 mg/kg in one dose*	Tetracycline: 12.5 mg/kg 4 times a day for 3 days
Children <12 months old and others unable to swallow pills and/or tablets	Azithromycin oral suspension: 20 mg/kg in one dose Erythromycin oral suspension: 12.5 mg/kg 4 times a day for 3 days Doxycycline oral suspension: 2-4 mg/kg in one dose*	Tetracycline oral suspension: 12.5mg/kg 4 times a day for 3 days

*Doxycycline is safe for treatment of cholera in children at the recommended dose. The Pan American Health Organization recommends doxycycline as a second-line choice because of limited regional availability and to avoid future overuse in children.

Zinc Supplementation

Zinc supplementation significantly reduces the severity and duration of most childhood diarrhea caused by infection. When available, supplementation (10-20 mg zinc per day) should be started immediately.

Clinical Presentation and Management — Download Materials

Fact Sheets

Brochures

Posters

Sjölund-Karlsson M, Reimer A, Folster JP, Walker M, Dahourou GA, Batra DG, Martin I, Joyce K, Parsons MB, Boncy J, Whichard JM, Gilmour MW. Drug-resistance mechanisms in Vibrio cholerae O1 outbreak strain, Haiti, 2010. Emerg Infect Dis. 2011 Nov;17(11):2151-4. DOI: 10.3201/eid1711.110720.
Laboratory Methods for the Diagnosis of Epidemic Dysentery and Cholera [PDF – 115 pages]. 1999.
French translation.
First steps for managing an outbreak of acute diarrhea. WHO/CDS/NCS/2003.7.Rev.1. 2010.
WHO. Management of the Patient with Cholera. Geneva, Switzerland: World Health Organization, Programme for Control of Diarrhoeal Diseases, 1992. (WHO/CDO/SER/15 rev 1)

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