Clinical Cholera Case Management CME PRESENTATION 4/2/16 By Pastory Mondea

Cholera – case definitions Diarrhea – 3 or more loose stools/24 hours Suspected Person > 5 years with severe dehydration or death from acute watery diarrhea with or without vomiting. Person aged over 2 years with acute watery diarrhea in an area where there is a cholera outbreak. Confirmed Clinical illness PLUS laboratory confirmation of infection: Isolation of V. cholera O1 or O139 from vomitus or stool

Important Clinical Features and Laboratory Findings Hypovalemic Dehydration Hypokalemia Hyponatremia or Hypernatremia Hypocalcemia Acidosis Renal failure Hypoglycemia These need to be intervened

Important to Note Cholera kills Cholera can be treated and death can be prevented in most cases! 3 key interventions to reduce Case Fatality Rate (CFR) Early case detection Improve access to care Appropriate case management Cholera treatment starts at home

Triaging -Decision Making Chart

Cholera Treatment Depends on severity of dehydration and cholera case confirmation 1. Oral Rehydration Solution (ORS) – home made or manufactured 80% of patients recover with ORS 10-20% need administration of IV fluids 2. IV fluids – RL, NS (dextrose unaccepted, no electrolyte replacement) 3. Zinc supplementation - Use daily x 10-14 days in children <5y 4. Use of antibiotics http://rehydrate.org/ors/low-osmolarity-ors.htm

Minimal to No Dehydration – Plan A Treatment http://www.bing.com/images/search?q=oral+rehydration+solution&view=detailv2&&id=30D455D47FD3B3D47C4581EA0BF9BAC77C58E189&selectedIndex=4&ccid=4t3j1PQK&simid=608010002184736627&thid=JN.D14JX5iNQaUYWN4MjbhutQ&ajaxhist=0

Moderate dehydration – Plan B Treatment ORS administration in the first 4 hours (generally 75 x weight (kg)) If unable to take oral, use NG tube Vomiting often ceases within 2-3 hours after dehydration has improved. If pt. is thirsty, administer more ORS Observe pt. to ensure required amount of ORS is administered If after 4 hours, pt. has signs of dehydration, use Plan C Monitor urine output

Severe dehydration –Plan C Treatment - Intravenous fluids -Large bore 18 gauge IV needles -Can use nasogastric tube if IV cannot be placed (20ml/kg 1st hour) Source: CDC trainers of trainers presentation

Putting IV Line

Antibiotic Therapy Recommended antibiotics – taken orally Doxycyclin – Not for children - Adult: 300 mg by mouth in one dose 2. Cirprofloxacin – not for children - Adult: 500 mg bid 3/7 3. Erythromycin – For Pregnant patients and children: 500 mg 4 times a day for 3 days, 48mg/kg/24 hrs tds x3/7(for children). 4. Cotrimoxazole - 48mg/kg/24 hrs bid x 3/7(for children). Source: National Guidelines for Prevention and Control of Cholera, Tanzania

Cholera Therapy - What Not To Use Anti-diarrheal agents Anti-spasmodic agents Anti-emetics Steroids Tea, sweetened or carbonated drinks in place of ORS Plain dextrose Prophylactic antibiotics