23 - Centers for Disease Control and Prevention



Recommendations for the use of antibiotics for the treatment of choleraSummary recommendationsOral or intravenous hydration is the mainstay of cholera treatment. In conjunction with hydration, treatment with antibiotics is recommended for moderately and severely ill patients, particularly for those patients who continue to pass a large volume of stool during rehydration treatment. Antibiotic treatment is recommended for all patients who are hospitalized.Doxycycline is recommended as first-line treatment for adults, while azithromycin is recommended as first-line treatment for children and pregnant women. During an epidemic or outbreak, antibiotic susceptibility should be monitored, for example through regular testing of sample isolates from various geographic areas. Antibiotic choices should be informed by local antibiotic susceptibility patterns.Education of health care workers, assurance of adequate supplies, and monitoring of practices are all important for appropriate dispensation of antibiotics.BackgroundMainstay of cholera treatment is hydrationIntravenous18 and oral19 hydration are both associated with greatly decreased mortality and remain the mainstay of treatment for cholera. Antibiotic effectiveness for the treatment of choleraAntibiotics have been used as an adjunct to hydration treatment for cholera since 1964. Antibiotic use for moderately and severely ill patients is also likely to reduce resource requirements. By decreasing duration of diarrhea and stool volume, antibiotics result in more rapid recovery and shorter lengths of inpatient stay, both of which contribute to optimizing resource utilization in an outbreak setting. The majority of published studies exploring effectiveness of antibiotics for cholera patients have been done in patients who were adequately rehydrated. In these studies, there was no mortality and therefore the impact of antibiotics on mortality can not be assessed.Antibiotic regimens for the treatment of choleraTetracycline has been shown to be effective treatment for cholera2,3 and is superior to furazolidone,7 cholamphenicol8 and sulfaguanidine8 treatment in reducing cholera morbidity. In Treatment with a single 300mg dose of doxycycline has shown to be equivalent to tetracycline treatment.9 Erythromycin is effective for cholera treatment, and appropriate for children and pregnant women.10 During the 1990s, norfloxacin,11 trimethoprim-sulfamethoxazole (TMP-SMX)12, and ciprofloxacin13 are effective but doxycycline offers advantages related to ease of administration and comparable or superior effectiveness. Recently, azithromycin has been shown to be more effective than erythromycin and ciprofloxacin14-15 and is an appropriate first line regimen for children and pregnant women. Antibiotic resistance Antimicrobial resistance to V. cholerae has been demonstrated in both endemic and epidemic cholera settings. Resistance can be acquired through the accumulation of selected mutations over time, or the acquisition of genetic elements such as plasmids, introns, or conjugative elements, which confer rapid spread of resistance. A likely risk factor for antimicrobial resistance is widespread use of antibiotics, including mass distribution for prophylaxis in asymptomatic individuals. Antibiotic resistance emerged in previous epidemics in the context of antibiotic prophylaxis for household contacts of cholera patients.16, 17 Unanswered questionsInadequate information still exists with respect to antibiotics in the following areas: Utility of antibiotics when aggressive rehydration is not possibleBecause studies on antibiotic treatment for cholera were conducted in patients who received adequate rehydration, the effect of antibiotics in settings where this is not possible remains unclear. Effect of antibiotics on secondary transmissionThere are insufficient data examining the effect of antibiotics on secondary transmission of cholera. However, in published studies to date antibiotics have not been shown to decrease secondary transmission of cholera within households.20, 21 7. Recommendations or Treatment RecommendationsVarious organizations that participate in cholera responses recommend the use of antibiotics in cholera-infected patients with moderate or severe illness and who have begun IV hydration. None of the guidelines recommend antibiotics as prophylaxis for cholera prevention, and all emphasize that antibiotics should be used in conjunction with aggressive hydration. In addition, the guidelines recommend that antimicrobial susceptibility testing should guide local drug choices. Available guidelines are summarized in Table 2 (insert link to Table 2 here—below table should become table 2)OrganizationRecommendationFirst-line drug choiceAlternate drug choicesDrug choices for special populationsPan American Health Organization22Antibiotic treatment for cholera patients with moderate or severe dehydrationDoxycyclineCiprofloxacin AzithromycinErythromycin or azithromycin recommended as first-line drugs for pregnant women and childrenCiprofloxacin and doxycycline recommended as second-line drugs for childrenInternational Centre for Diarrhoeal Disease Research, Bangladesh23Antibiotic treatment for cholera patients with some or severe dehydrationDoxycyclineCiprofloxacinAzithromycin CotrimoxazoleErythromycin recommended as first-line drug for children and pregnant womenWorld Health24 OrganizationAntibiotic treatment for cholera patients with severe dehydration onlyDoxycyclineTetracyclineErythromycin is recommended drug for childrenMedicins Sans Frontieres25Antibiotic treatment for severely dehydrated patients onlyDoxycyclineErythromycin Cotrimoxazole ChloramphenicolFurazolidone8. ConsiderationsOver-emphasizing antibiotics for treatment of cholera could divert resources from oral and intravenous rehydration. Doxycycline costs approximately $0.02 per 100mg tablet. Azithromycin costs approximately $0.16 per 250mg tablet.Antibiotics can cause nausea and vomiting. Gastrointestinal side effects should be carefully monitored, especially in dehydrated patients.Prospective surveillance for antibiotic resistance among bacterial isolates from any outbreak is important for understanding and minimizing the spread of resistance.References1. Centers for Disease Control and Prevention (CDC). Update: cholera outbreak—Haiti, 2010. MMWR Morb Mortal Wkly Rep, 2010; 59: 1473–79. 2. Greenough WB, Gordon RS, Rosenberg IS, Davies BI, Benenson AS. Tetracycline in the treatment of cholera. Lancet, 1964; 1(7329): 355-357. 3. Lindenbaum J, Greenhough WB, Islam MR. Antibiotic therapy of cholera. Bulletin of the World Health Organization, 1967; 36: 871-883.4. Rahaman MM, Majid MA, Alam AKMJ, Islam MR. Effects of doxycycline in actively purging cholera patients: a double-blind clinical trial. Antimicrobial Agents and Chemotherapy, 1976; 10(4): 610-612.5. Roy SK, Islam A, Ali R, Islam KE, Khan RA, Ara SH, Saifuddin NM, Fuchs GJ. A randomized clinical trial to compare the efficacy of erythromycin, ampicillin and tetracycline for the treatment of cholera in children. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1998; 92: 460-462.6. Kaushik JS, Gupta P, Faridi MMA, Das S. Single dose azithromycin versus ciprofloxacin for cholera in children: a randomized controlled trial. Indian Pediatrics, 2010; 47: 309-315.7. Pierce NF, Banwell JG, Mitra RC, Caranosos GJ, Keimowitz RI, Thomas J, Mondal A. Controlled comparison of tetracycline and furazolidone in cholera. British Medical Journal, 1968; 3: 277-280.8. Wallace CK, Anderson PN, Brown PC, Khanra SR, Lewis GW, Pierce NF, Sanyal SN, Segre GV, Waldman RH. Optimal antibiotic therapy in cholera. Bulletin of the World Health Organization, 1968; 39: 239-245. 9. De S, Chaudhuri A, Dutta P, Dutta D, De SP, Pal SC. Doxycycline in the treatment of cholera. Bulletin of the World Health Organization, 1976; 54: 177-179.10. Burans JP, Podgore J, Mansour MM, Farah AH, Abbas S, Abu-Elyazeed R, Woody JN. Comparative trial of erythromycin and sulphatrimethoprim in the treatment of tetracycline-resistant Vibrio cholerae O1. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1989; 83(6): 836-838.11. Bhattacharya SK, Bhattacharya MK, Dutta P, Dutta D, De SP, Sikdar SN, Maitra A, Dutta A, Pal SC. Double-blind, randomized, controlled trial of norfloxacin for cholera. Antimicrobial Agents and Chemotherapy, 1990; 34(5): 939-940. 12.Kabir I, Khan WA, Haider R, Mitra AK, Alam AN. Erythromycin and trimethoprim-sulphamethoxazole in the treatment of cholera in children. Journal of Diarrhoeal Diseases Research, 1996; 14(4): 243-247.13. Khan WA, Bennish ML, Seas C, Khan EH, Ronan A, Dhar U, Busch W, Salam MA. Randomised controlled comparison of single-dose ciprofloxacin and doxycycline for cholera caused by Vibrio cholerae O1 or O139. Lancet, 1996; 348(9023): 296-300.14. Khan WA, Saha D, Rahman A, Salam MA, Bogaerts J, Bennish ML. Comparison of single-dose azithromycin for childhood cholera: a randomized, double-blind trial. Lancet, 2002; 360: 1722-1727.15. Saha D, Karim MM, Khan WA, Ahmed S, Salam MA, Bennish ML. Single-dose azithromycin for the treatment of cholera in adults. The New England Journal of Medicine, 2006; 354(23): 2452-2462.16. Weber JT, Mintz ED, Ca?izares R, Semiglia A, Gomez I, Sempértegui R, Dávila A, Greene KD, Puhr ND, Cameron DN, et al. Epidemic cholera in Ecuador: multidrug-resistance and transmission by water and seafood. Epidemiology and Infection, 1994; 112(1): 1-11.17. Towner KJ, Pearson NJ, Mhalu FS, O'Grady F. Resistance to antimicrobial agents of Vibrio cholerae E1 Tor strains isolated during the fourth cholera epidemic in the United Republic of Tanzania. Bulletin of the World Health Organization, 1980; 58(5): 747-751.18. O'Shaughnessy WB. Proposal of a new method of treating the blue epidemic cholera by the injection of highly oxygenized salts into the venous system. Lancet, 1831-1832; 1:366-71.19. Salazar-Lindo E , Seminario-Ottasco L , Carrillo-Parodi C , Gayasos- Villaflor A. The cholera epidemic in Peru [abstract]. In: Proceedings of the 27th Joint Conference on Cholera and Related Diarrheal Diseases, U.S.-Japan Cooperative Medical Science Program, Charlottesville, VA, 1991:9-13.20. Weil AA, Khan AI, Chowdhury F, Larocque RC, Faruque AS, Ryan ET, Calderwood SB, Qadri F, Harris JB. Clinical outcomes in household contacts of patients with cholera in Bangladesh. Clinical Infectious Diseases, 2009; 49(10): 1473-1479.21. Echevarria J, Seas C, Carrillo C, Mostorino R, Ruiz R, Gotuzzo E. Efficacy and tolerability of ciprofloxacin prophylaxis in adult household contacts of patients with cholera. Clinical Infectious Diseases, 1995; 20(6): 1480-1484.22. Pan American Health Organization. Recommendations for clinical management of cholera. November 2010. . Cholera Outbreak Training and Shigellosis (COTS) Program . World Health Organization. Global Task Force on Cholera Control. WHO_CDS_CSR_NCS_2003.7. . World Health Organization. Global Task Force on Cholera Control. WHO_CDS_CSR_NCS_2003.7 ................
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