Clinical Presentation & Management in Haiti

Most persons infected with the cholera bacterium have mild diarrhea or no symptoms at all. Only about 7% of persons infected with Vibrio cholerae O1 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 the patient gets intravenous (IV) rehydration, he/she should start drinking ORS as soon as he/she is 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, 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

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.

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.
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 1-2 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.

An 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 large volume of stools during rehydration treatment, and including all patients who are hospitalized. Do not give antibiotics to asymptomatic persons. 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)

These recommendations are based on the antibiotic resistance profile of V. cholerae isolates from the Haiti cholera outbreak, as reported on December 14, 2010, and local drug availability.

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

Current antibiotic testing results show*:

Antibiotic Susceptibility
Azithromycin Susceptible
Tetracycline Susceptible
Doxycycline Susceptible**
Ciprofloxacin Reduced susceptibility
Sulfisoxazole Resistant
Furazolidone Resistant
Nalidixic acid Resistant

*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.

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

Appropriate oral antibiotics
Patient classification First choice Second choice
Adults
(non-pregnant)
Doxycycline: 300 mg by mouth in one dose Azithromycin:1 gram in a single 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 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.

References
  1. WHO. First steps for managing an outbreak of acute diarrhea.Cdc-pdfExternal WHO/CDS/NCS/2003.7.Rev.1. 2010.
  2. 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)