Difference between revisions of "Cholera"

(Management)
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==Management==
 
==Management==
* Aggressive volume repletion.  Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss. </ref>* Sack DA, et al. Cholera. Lancet 2004; 363:223.</ref>
+
* Aggressive volume repletion.  Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss. <ref>Sack DA, et al. Cholera. Lancet 2004; 363:223.</ref>
 
* Oral rehydration solution includes in 1L of water: 2.6g NaCl, 2.9g Trisodium citrate, 1.5 g KCl, and 13.5 g glucose.
 
* Oral rehydration solution includes in 1L of water: 2.6g NaCl, 2.9g Trisodium citrate, 1.5 g KCl, and 13.5 g glucose.
 
:*If severe dehydration, bolus with 100 ml/kg over 3 hrs.  LR is solution of choice.  May require more than 350 ml/kg in first 24 hours.
 
:*If severe dehydration, bolus with 100 ml/kg over 3 hrs.  LR is solution of choice.  May require more than 350 ml/kg in first 24 hours.
 
* Antibiotic treatment decreases severity and duration of disease.  Antibiotic resistance patterns are changing constantly.  Most recommended currently is azithromycin 20mg/kg single dose.   
 
* Antibiotic treatment decreases severity and duration of disease.  Antibiotic resistance patterns are changing constantly.  Most recommended currently is azithromycin 20mg/kg single dose.   
:*Alternatives: ciprofloxacin 1g single dose; doxycycline 300mg single dose; TMP-SMX double strength BID for 3 days; erythromycin 500 QID for 3 days.  <ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref>
+
:*Alternatives: [[ciprofloxacin]] 1g single dose; [[doxycycline]] 300mg single dose; [[TMP-SMX]] double strength BID for 3 days; [[erythromycin]] 500 QID for 3 days.  <ref>Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6</ref>
 
* Give children Zinc and Vitamin A.
 
* Give children Zinc and Vitamin A.
  

Revision as of 00:36, 2 October 2014

Background

  • Endemic to Asia, Africa, and Central and South America [1]
  • Occasionally seen on the Gulf Coast of US, due to inadequately cooked seafood.

Pathophysiology

  • Usually Vibrio cholera, which produces an enterotoxin which causes a secretory diarrhea[2]

Natural History

  • Transmission via ingestion of contaminated food or water, usually undercooked seafood
  • Incubation period between hours to 5 days, depending on size of inoculum (usually 1-2 days)[3]
  • Most people are asymptomatic, and simply have bacteria in their feces for 7-14 days
  • Diarrhea is most severe in days 1-2, usually resolves in 7 days

Clinical Features

  • Classic “rice water” diarrhea with fishy odor; usually painless
  • Fluid losses can be significant, up to 1L/hr, leading to severe fluid and electrolyte depletion. However, most cases are mild.
  • Occasionally seen: sudden watery vomiting, borborygmi, abdominal cramping.

Later manifestations:

  • Fluid loss may lead to: sunken eyes, dry mouth, cold clammy skin, decreased skin turgor, or wrinkled hands and feet (also known as “washer woman’s hands”)
  • Acidosis from loss of bicarbonate; muscle cramps from loss of K, Ca

Differential Diagnosis of Watery Diarrhea

  • Enterotoxigenic E. coli (most common cause of watery diarrhea)[4]
  • Norovirus (often has prominent vomiting)
  • Campylobacter
  • Non-typhoidal Salmonella
  • Enteroaggregative E. coli (EAEC)
  • Enterotoxigenic Bacteroides fragilis

Workup

  • Diagnosis largely clinical presentation + epidemiological risk factors
  • Fecal smears will NOT show leukocytes or erythrocytes.
  • Diagnosis can be confirmed by stool cultures on TCBS medium (tell the lab cholera is suspected, so appropriate medium is used)

Management

  • Aggressive volume repletion. Usually can be given orally if mild/moderate volume depletion; give rehydration solution to replete electrolyte loss. [5]
  • Oral rehydration solution includes in 1L of water: 2.6g NaCl, 2.9g Trisodium citrate, 1.5 g KCl, and 13.5 g glucose.
  • If severe dehydration, bolus with 100 ml/kg over 3 hrs. LR is solution of choice. May require more than 350 ml/kg in first 24 hours.
  • Antibiotic treatment decreases severity and duration of disease. Antibiotic resistance patterns are changing constantly. Most recommended currently is azithromycin 20mg/kg single dose.
  • Give children Zinc and Vitamin A.

Sources

  1. http://www.who.int/cholera/en/
  2. LaRocque R and Pietroni M. “Approach to the Adult with Acute Diarrhea in Developing Countries”. UpToDate.com
  3. Mobula LM. Community health facility preparedness for a cholera surge in Haiti. Am J Disaster Med. 2013 Autumn;8(4):235-41
  4. Marx et al. “Cholera and Gastroenteritis caused by Noncholera Vibrio Species”. Rosen’s Emergency Medicine 8th edition vol 1 pg 1245-1246.
  5. Sack DA, et al. Cholera. Lancet 2004; 363:223.
  6. Neilson AA, Mayer CA. Cholera - recommendations for prevention in travelers. Aust Fam Physician. 2010 Apr;39(4):220-6