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

2. 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

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

4. 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

5. Triaging -Decision Making Chart

6. 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 days in children <5y
4. Use of antibiotics

7. Minimal to No Dehydration – Plan A Treatment

8. 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

9. 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

10. Putting IV Line

11. 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

12. 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