Medical care

Recommendations for cholera clinical management
Washington, D.C., 28 October 2010 These guidelines will be reviewed and may be modified if new evidence comes to light or there are changes in the susceptibility profile of the pathogen. Description of suspected cases of diarrhea caused by Vibrio cholerae O:1
These cases are characterized by the abrupt onset of painless watery diarrhea, usually without fever, that can rapidly become voluminous and is often followed by vomiting. The majority of V. cholerae O: 1 infections are asymptomatic, and moderate diarrhea from V. cholerae O:1 infection may be indistinguishable from other causes of gastroenteritis. Approximately 5% of infected patients will develop a severe form of cholera characterized by profuse watery diarrhea, vomiting, and dehydration. The “dry” form of the disease is difficult to diagnose because there is little stool output, since the fluids have accumulated in the intestinal lumen. Cholera is not transmitted from person to person; its transmission is fecal-oral. In addition to the standard precautions, contact precautions must be observed when treating children in diapers or Table 1- Summary of main clinical manifestations
 Incubation period: 24-48 hours, but can vary from 5 hours to 5 days.  Diarrhea and vomiting may be accompanied by abdominal cramps.  Watery diarrhea has been classically described as “rice water.”  5% of cases present severe symptoms, with dehydration and manifestations of hypovolemia. These cases can prove fatal within hours if they do not receive timely treatment. Recommendations
1. Recommendations for triage
2. Clinical assessment: hydration status
3. Rehydration
4. Antibiotic treatment
1. Recommendations for triage
The main objective of triage is to prioritize care for seriously ill patients and prevent suspected cases from coming into contact with other patients as quickly as possible. It is therefore recommended that a different entrance to the health facility be set aside for patients with diarrhea. If this is unfeasible, the triage point should be as close as possible to the entrance and suspected patients should be directed separate wards with sanitary facilities and safe water in order to guarantee excreta disposal, hand hygiene, and the cleanliness of the environment where the clinical assessment and full triage are performed. 2. Clinical assessment: hydration status
Assessment of patients’ hydration status is based on the presence of the symptoms and signs outlined in Table 2. The presence of one of these signs or symptoms immediately classifies Patients at the extreme ages of life, especially children under 18 months, require close monitoring and immediate measures if their condition worsens. These patients must be prioritized Table 2. Classification of dehydration
Severe dehydration
Incapable of drinking or nursing (infants) Moderate dehydration
Dryness of the oral mucosa, tongue, and mucous membrane Mild or no dehydration
3. Rehydration
This is the essential component of treatment, whose object is to replenish the water and
electrolytes lost through diarrhea and vomiting.
Oral replenishment is preferred, with intravenous replenishment reserved for the rehydration of patients with severe dehydration or who eliminate more than 10-20 mL/kg/h. For electrolyte replenishment, the following treatment regimen is recommended: Table 2–Electrolytic replenishment
Dehydration
Treatment
Oral rehydration salts and close clinical monitoring, especially in children under 18 months of age. Consider that the patient be sitting up during treatment. If the taste of the solution causes nausea: oral rehydration via nasogastric tube. In home treatment, tell patients or caregivers how to prepare the oral solution and indicate hygiene measures and the warning signs or symptoms that would require a return to the health facility. See Annex for details about home care. Zinc Supplements
The use of zinc supplements reduces the duration and severity of diarrhea in children, whatever the infectious etiology. A 10-20 mg daily zinc supplement is recommended from the onset of the first symptoms and for 5 – 7 days afterwards. Table 3. Rehydration guidelines
In the case of infants that are breast-fed, this shall be always continued.
Dehydration
Guideline
Children under 2: 50-100 ml of oral rehydration solution (ORS), after each evacuation, providing a volume similar to the assessed fluid loss Children aged 1 to 14 years: 100-200 ml of oral rehydration solution (ORS), after each evacuation, providing a volume similar to the assessed fluid loss (gastrointestinal and urinary). Children over 14 and adults: drink the amount of ORS needed, ingesting a volume similar to the assessed fluid loss (gastrointestinal and urinary); up to two liters daily. Moderate1:
Administer in the first 4 hours:
Less than 4 months (less than 5 kg): 200-400 ml From 4 to 11 months (5 to 7.9 kg): 400-600 ml From 13 to 23 months (8 to 10.9 kg): 600-800 ml From 2 to 4 years (11 to 15,9kg): 800-1200 ml From 5 to 14 years (16 to 29.9 kg): 1200-2200 ml Over 15 years and adults (30 kg or more): 2200-4000 ml Rehydrate in two Intravenous Ringer Lactate is recommended, at the following perfusion rate: phases: Clinical assessment to determine whether to continue intravenous rehydration. It is recommended starting oral rehydration as soon as the patient is able to drink. The guideline for moderate dehydration is followed, always adapting to the volume of fluid loss. It is extremely important to keep a written record of fluid loss and intake in order to adjust the 1 WHO, First steps for managing an outbreak of acute diarrhoea, leaflet. WHO, Geneva, 2004. 2 Luis Suárez Ognio. Protocolo de Vigilancia Epidemiológica de Cólera. Oficina General de Epidemiología, Ministerio de Salud de Perú. 4. Antibiotic treatment
In addition to electrolytic replenishment, antibiotic treatment is recommended. Based on the susceptibility of the strains isolated to date in Haiti, where resistance has been confirmed to trimethroprim-sulfamethoxazole, furazolidone, nalidixic acid, and streptomycin; the following is Table 4–Antibiotic Treatment
dose or azithromycin, 20 mg/kg,
exceeding 1 g or erythromycin
12.5 mg/kg/ 6 hours for 3 days.
Children under 1 year, or Doxycycline, suspension, 2- mg/kg, in a single dose or
single dose or erythromycin

These recommendations are subject to revision as new evidence develops or the
susceptibility of the pathogen changes.
3 The FDA classifies azythromycin as a Category B drug, which means that there is no confirmed risk in studies with 4 Although doxycycline has been associated with a low risk of yellowing of the teeth in children, its benefits outweigh its risks. ANNEX - RECOMMENDATIONS FOR HOME CARE

How to properly prepare the oral solution
To prepare the oral rehydration solution (ORS), follow the steps below:
• Wash your hands with soap and clean water. • Pour one liter of clean water (water that has been boiled and cooled) into a clean • Pour all the ORS powder into the container with the water. • Mix well, until the powder is completely dissolved. • The ORS should be kept covered and administered at room temperature.

Warning signs:
Can the child drink or nurse?
Does the child vomit everything it ingests?
Has it had convulsions?
Is it lethargic or unconscious?
Source: Manejo del Paciente con Diarrea, Curso sobre Habilidades de Supervisión, Programa
Salud Materno Infantil, Control de las Enfermedades Diarreicas, OPS/OMS, December 1991
MOTHERS AND CAREGIVERS SHOULD
Prevent dehydration by administering more of the fluids available in the home, together with ORS solution, at the first sign of cholera Keep feeding the child (or increase the frequency of breast-feeding) during the episode and increase feeding afterwards Recognize the signs of dehydration and take the child to a health center so that ORS or intravenous electrolyte solution can be administered, and familiarize themselves with other symptoms that require medical treatment (for example, bloody diarrhea) Administer 30 mg zinc supplements to children daily for 10 to 14 days (administer 10 mg daily to infants under 6 months).

HEALTH CARE PROVIDERS SHOULD
Advise mothers to begin giving children appropriate fluids already in the home at the first sign of cholera Treat dehydration with ORS (or an intravenous electrolyte solution, in cases of severe dehydration) Stress the importance of continuing feeding or increasing breast-feeding during the episode and increasing it afterwards Administer antibiotics only when indicated (for example, when there is bloody diarrhea or shigellosis) and refrain from administering antidiarrheal drugs Administer 20 mg zinc supplements daily for 10 to 14 days (give infants under 6 months 10 mg daily) Warn mothers that when their children get cholera again they should give them more fluids than usual and continue to feed them
When treating cases of cholera, health care providers should give mothers or other caregivers
two 1-liter packets of ORS each to use at home, as well as zinc supplements for 10 to 14 days of
treatment. They should also hand out printed materials (with text and illustrations) containing
advice for preventing and treating cholera in the home.

Source: Clinical Treatment of Acute Diarrhea, WHO/UNICEF, 2004

Source: http://www.santelaurentides.qc.ca/fileadmin/documents/Acces_reseau_et_partenaires/CholeraPAHO.pdf