Highly Dangerous Infections: Cholera

Cholera is an acute infectious intestinal disease characterized by diarrhea,

demineralization, dehydration, metabolic acidosis, hypovolemic shock, and signs
of intoxication, as well as impaired function of vital organs. It is classified as a
quarantine infectious disease and can spread in epidemic and pandemic situations.
Etiology:
The causative agent of cholera is Vibrio cholerae, which has two types: the classic
type and the El Tor type. The cholera vibrio is slightly curved, rod-shaped, and
motile due to a single flagellum. It is Gram-negative and stains well with aniline
dyes, but does not form spores or capsules. Cholera vibrios are facultative
anaerobes that grow well in simple alkaline environments. They can grow in
synthetic media at favorable temperatures of 35-40°C. Some atypical strains
possess hemolytic properties. Cholera vibrio has a complex antigenic structure,
including a thermolabile N-antigen on the flagella and a thermostable somatic O-
antigen. Additionally, it has several non-specific thermolabile antigens. Based on
the characteristics of the O-antigen, three serovars of cholera vibrio are identified:
1. Ogawa vibrio
2. Inaba vibrio
3. Hikojima vibrio
The cholera vibrio produces three types of toxins: a) Endotoxin b) Exotoxin c)
Toxin that increases the permeability of blood vessels and intestinal cell
membranes.
Cholera vibrios die at high temperatures (56°C in 30 minutes or instantly at
100°C), are sensitive to drying, sunlight, and disinfectants, but can survive for 4-6
weeks or more at low temperatures (-1°C to -4°C), and sometimes persist through
winter. Cholera vibrio is susceptible to many antibiotics, including tetracycline,
chloramphenicol, aminoglycosides, rifampicin, erythromycin, and synthetic
penicillins. The El Tor biotype differs from the classical biotype in its resistance to
polymyxin.
Epidemiology:
1. Source of infection: Infected individuals and carriers of the vibrio.
2. Transmission routes: Mainly through water, occasionally through food and
household contact.
3. Susceptibility: Primarily affects children.
4. Seasonality: Seasonal.
 5. Immunity: Strong (long-lasting).
Pathogenesis:
The cholera vibrio enters the body through the mouth, passes into the stomach, and
reaches the small intestine, where it multiplies rapidly due to the alkaline
environment. It can also proliferate in the bile ducts. As the vibrios break down in
the intestines, endotoxins are released. Cholera toxins have enterotoxic effects,
damaging the intestines. These toxins activate adenylate cyclase in the intestinal
enterocytes, leading to an accumulation of cyclic adenosine monophosphate
(cAMP). This, in turn, causes hypersecretion of electrolytes and water by the
enterocytes into the intestinal lumen, resulting in painless secretory diarrhea
without abdominal distension.
The loss of fluids and electrolytes leads to hypovolemia, hypokalemia, acidosis,
and dehydration at the cellular level. In response, fluids from the tissues move into
the blood vessels. The water and salts secreted into the intestines are reabsorbed
mainly from extracellular fluids (90%). Extracellular dehydration causes a
significant reduction in circulating blood volume, plasma, and hematocrit, leading
to impaired circulation. The disruption of microcirculation in the organs
exacerbates tissue hypoxia, disrupts blood coagulation, and leads to metabolic
acidosis. Thus, dehydration is the primary mechanism in the pathogenesis of
cholera, while other processes (intoxication, acute kidney failure, shock) are
secondary consequences of uncompensated dehydration.
In cholera, fluid loss through diarrhea and vomiting, along with electrolyte
imbalance, disrupts myocardial function, damages the renal tubules, and causes
intestinal paralysis. In the past, cholera fatalities were due to hypokalemia, low
blood pressure, and acute renal failure caused by metabolic acidosis.
Pathomorphology
Patients who die from cholera exhibit severe dehydration, with facial features
becoming sharp, and skin appearing wrinkled and loose, especially on the fingers.
The body stiffens rapidly after death, lasting up to 3-4 days. The limbs are bent,
resembling the "gladiator" position. Sometimes, during the first hour after death,
skeletal muscles contract and relax intermittently, making it appear as though the
body is moving. Histological examination of the small intestine reveals serous or
serous-hemorrhagic enteritis without inflammatory signs. A large amount of cloudy
liquid is found in the intestine. The capillaries are congested and swollen, with the
membrane markedly edematous. Blood becomes thick and dark, primarily
accumulating in large veins, while smaller vessels and capillaries remain empty.
Dystrophic changes and microcirculatory disturbances are observed in
parenchymal and other organs.
Classification
I. Typical:
1. Mild
2. Moderate
3. Severe
II. Atypical:
1. "Dry cholera"
2. "Fulminant"
3. Subclinical
4. Gastritic
Clinical Features
The incubation period lasts from several hours to up to 5 days, typically 2-3 days.
In vaccinated individuals, it can be prolonged up to 9-10 days. Symptoms may
include fluctuating body temperature (fever or chills), with body temperature rising
to 37-38°C, accompanied by headaches and aching in the limbs. In such cases,
patients often remain bedridden. This onset often goes unnoticed but poses a
significant epidemiological threat, especially if it occurs among individuals
working in food service and trade facilities, exacerbating the situation.
The disease begins acutely, with watery diarrhea, marked weakness, sometimes
dizziness, slight tremors, and a mild fever. Defecation is painless, and there is little
or no abdominal pain. Early on, stools are solid, but they quickly become watery,
resembling "rice water," with floating particles, and without pathological
admixtures like mucus, blood, or green discoloration. Mild cases involve 2-4
bowel movements, moderate cases 5-7, and in severe cases, the number of bowel
movements becomes too frequent to count. Vomiting follows diarrhea and starts
suddenly without nausea. Initially, vomit may contain food remnants and bile, but
it soon turns watery, resembling "rice water" or, less commonly, "meat washings."
Abdominal pain is not characteristic of cholera; if present, it may be due to muscle
spasms or concurrent gastrointestinal pathology. The abdomen appears sunken,
with no distension, and intestinal paralysis may occur. Excessive and
uncontrollable diarrhea leads to rapid dehydration, which may eventually subside,
but the patient's condition continues to deteriorate.
Signs of dehydration include dry skin and mucous membranes, altered facial
appearance, loss of tissue turgor, hoarse voice progressing to aphonia, seizures,
cyanosis, hypothermia, shortness of breath, and anuria. The patient may develop an
"algid state" (severe dehydration with cold extremities, cyanosis, and weak pulse).
Visually, patients show sharp facial features, sunken eyes with dark circles
("spectacle symptom"), cyanosis around the mouth and nose, acrocyanosis, or
generalized cyanosis. Extremities are cold, and the skin folds do not smooth out
when pinched.
Progressive dehydration leads to increased heart rate, decreased blood pressure,
thickened blood, hypokalemia, and shock, resulting in irreversible damage to vital
organs. Hypokalemia, blood thickening, hypoxia, metabolic acidosis, and
microcirculatory disorders also contribute to kidney failure, manifesting as
prolonged oliguria or anuria. Timely rehydration can prevent uremia.
Severity Criteria of Cholera:
1. Degree of dehydration (exicosis)
2. Degree of central nervous system (CNS) involvement
3. Degree of damage to the urinary system
4. Number of bowel movements
Mild severity
Characterized by 1st-degree dehydration (body weight loss of 3-5%). The disease
develops gradually, with semi-solid, infrequent bowel movements (3-5 times a
day). Vomiting occurs only 2-3 times, if at all. Dehydration and hemodynamic
disturbances are not pronounced. The skin remains moist, but there is some dry
mouth and mild thirst. Body temperature is usually normal or slightly elevated,
with no hypothermia. Early rehydration typically leads to recovery by the 3rd or
4th day.
Moderate severity
Involves 2nd-degree dehydration (body weight loss of 6-8%). The disease begins
acutely with typical cholera stools. The number of bowel movements correlates
with the degree of dehydration. Symptoms include severe weakness, dizziness, dry
mouth, intense thirst, and occasional fainting. The skin is pale, with cyanosis of the
lips and the mouth-nose triangle, and acrocyanosis. There may be short-term
muscle spasms. Dryness of the oral mucosa and hoarseness due to difficulty
swallowing are also noted. In children, facial features become sharp, and facial
expressions diminish. Pulse is rapid, but blood pressure is not significantly
affected.
Severe form
3rd-degree dehydration (body weight loss of 8-10%) develops rapidly. The disease
presents with a large volume of watery "rice water" stools and uncontrollable
vomiting, accompanied by intense thirst, muscle cramps, and rapid deterioration.
Within 4-8 hours, signs of severe dehydration and adynamia (weakness) set in. The
face becomes sharply defined, eyes sunken, mouth dry, with cyanosis of the skin,
and body temperature drops. This indicates the progression to the algid state.
In this state, body weight loss reaches 10-12%. All signs of 3rd-degree dehydration
become pronounced, including critical damage to vital organs, hypothermia,
repeated seizures, widespread cyanosis, severe dehydration, toxic respiration,
anuria, low blood pressure, and stupor or coma. Once dehydration reaches this
stage, the disease transitions into an irreversible state, often leading to death.
Atypical forms of cholera include:
 Hypertoxic and "dry cholera": This form begins suddenly with severe
intoxication, shock, early intestinal paralysis, and impaired fluid and
electrolyte absorption, leading to death without the onset of diarrhea or
vomiting.
 Subclinical cholera: This form is asymptomatic but can be diagnosed
through the detection of vibrio antibodies in the blood or the pathogen in
stool samples.
Cholera is rare in infants under 1 year of age but tends to be severe when it occurs,
with symptoms including:
 A rise in body temperature
 Rapid development of dehydration
 Severe neurological and cardiovascular damage
 Hypokalemia and hypoglycemia
 Frequent complications due to rapid dehydration
Vomiting and diarrhea lead to dehydration, and the severity of the disease depends
on the degree of dehydration. Therefore, dehydration status must be considered
during treatment.
In young children, the disease begins with a sudden rise in body temperature (up to
38-39°C), profuse diarrhea, unstoppable vomiting, and severe dehydration, leading
to nervous system and cardiovascular damage. Clinically, this manifests as
generalized tetany, seizures, and involuntary movements.

Dehydration is divided into 4 degrees:

I Degree of Dehydration: Vomiting and diarrhea do not exceed 4-5 times a day.
The patient's general condition worsens for 1-2 days. The amount of fluid loss by
the body does not exceed 3% of body weight. Patients in this condition may
sometimes not even seek medical help. This category of patients is extremely
dangerous from an epidemiological standpoint.
II Degree of Dehydration: Vomiting and diarrhea occur frequently, up to 15-20
times a day. The body experiences significant dehydration, and the patient
complains of dry mouth, thirst, weakness, and dizziness. The skin begins to dry
out, blood pressure drops, and urine production decreases, becoming concentrated.
Sometimes, muscle cramps occur in the calves. The body loses fluid amounting to
4-6% of body weight.
III Degree of Dehydration: This occurs when vomiting and diarrhea are very
frequent, even within the first few hours. The body loses large amounts of
electrolytes and fluids, amounting to 4-7% of body weight. The patient experiences
intense thirst, which is almost unrelenting. The skin becomes dry, and skin folds
remain for a long time without flattening. The patient’s voice becomes barely
audible. Blood pressure drops significantly. Severe muscle cramps and pain occur
in the face, hands, and legs. Urine output is minimal, and the blood thickens.
Levels of potassium and chloride in the blood decrease, while sodium levels rise.
IV Degree of Dehydration: This is the most severe form of dehydration, where
fluid loss exceeds 10% of body weight. Sometimes, the illness begins very rapidly
within the first few hours. Continuous vomiting and diarrhea cause extreme
dehydration within 8-10 hours. Body temperature can drop to 35°C, and the skin
becomes bluish with a grayish hue and wrinkles. Pulse and blood pressure become
undetectable. The face, eyes, and lips turn bluish. Almost all the muscles of the
body experience prolonged cramps and severe pain. Breathing slows and deepens
(Cheyne-Stokes breathing), and urine production stops. The number of red and
white blood cells in the blood increases.
Complications
Complications are divided into two types: those related to the progression of
cholera and those resulting from treatment.
The first group includes hypovolemic shock, acute renal failure (due to tubular
necrosis), paralytic ileus, heart arrhythmias, brain swelling, abscesses, pneumonia,
and sepsis.
The second group includes pulmonary edema (as a result of excessive fluid
administration during treatment), phlebitis, and thrombophlebitis. During
treatment, there is also a risk of coma, vascular spasms, prolonged depression, and
pronounced hypoglycemia.
Diagnosis
Epidemiological history is of great importance. It is essential to determine if the
patient has been in contact with other patients suffering from gastrointestinal
diseases, has come from a cholera-affected area, or has visited such epidemic
hotspots in the past 5 days. Cholera diagnosis can be confirmed in cases of
dehydration-related diarrhea.
Bacteriological methods play a decisive role in laboratory diagnosis of cholera. For
diagnostic purposes, vomit and stool samples from the patient are cultured in 1%
peptone water. If diarrhea and vomiting occur frequently, three consecutive
samples are taken. After obtaining the samples, antibiotics can be administered.
The samples must be delivered to the laboratory within 6 hours. If cholera vibrio is
found, preliminary results are available within 24 hours after processing the
laboratory material, with final results confirmed after 48 hours.
For rapid laboratory diagnosis of cholera, a fluorescent serological method is used.
This method helps confirm cholera diagnosis with 90% accuracy within 1.5-2
hours. The essence of this method is to detect cholera vibrio in stool smears using
fluorescent cholera antibodies, especially in patients with a cholera vibrio
concentration of 1 million or more.
In practice, agglutination reactions, detection of vibriocidal antibodies (tested
twice, on the 5th-6th day of illness and again after 10 days), as well as the
fluorescent serological method and phage adsorption reactions are commonly used.
If possible, it is important to determine blood electrolyte levels and hematocrit and
adjust treatment accordingly. Particularly in the summer, cholera patients may
develop concurrent diseases like dysentery, salmonellosis, and other
gastrointestinal infections. In such cases, cholera symptoms may include a rise in
body temperature to 38-39°C, abdominal pain that comes and goes, and the
presence of mucus or blood in the stool. It is necessary to examine the intestinal
contents for both cholera vibrio and enteric bacteria.
Differential Diagnosis
Cholera must be differentiated from the following conditions:
 Bacterial diarrhea (caused by Shigella, Salmonella, Escherichia coli,
Staphylococci, or conditionally pathogenic bacteria such as Proteus,
Klebsiella, or Pseudomonas).
 Viral diarrhea (caused by rotavirus, enterovirus, ECHO virus, Coxsackie
virus, adenovirus with diarrhea syndrome, or influenza with abdominal
syndrome).
Rotavirus Infection: This infection primarily affects children under 2 years old. It
is transmitted via the fecal-oral route, with the source of infection being the patient
or a virus carrier. During colder seasons, it can also spread through food and water.
Rotavirus infection typically has a moderate course and is characterized by three
main symptoms: fever, vomiting, and diarrhea lasting 6-7 days. Symptoms are
generally mild and short-lived. Body temperature can remain elevated between
37.7-38.5°C for 3-4 days. In many cases, rotavirus gastroenteritis is accompanied
by upper respiratory tract inflammation or pneumonia. Respiratory symptoms
include redness and swelling of the soft palate, nasal congestion, and sore throat.
Adenovirus Infection: In the early days of the illness, some patients complain of
pain in the epigastric and periumbilical regions, which is associated with
mesenteric lymph node enlargement. In young children, digestive disturbances
(diarrhea) are often observed on the 3rd-4th day of illness. Alongside this, cervical
lymph nodes may become enlarged, membranous conjunctivitis may develop, and
eyelid swelling may be detected.
Influenza with Abdominal Syndrome: For differential diagnosis, it is important
to consider the seasonal nature of the flu, epidemiological history, and
characteristic flu symptoms (acute onset, severe headache, generalized body pain).
Flu patients have a distinctive appearance: glossy eyes, conjunctival redness,
teariness, pale face, swollen eye sockets, dry lips, and hyperemia in the mouth,
throat, and tonsils. Fever usually lasts 2-5 days, with complications developing
quickly. Gastrointestinal symptoms include loss of appetite, nausea, vomiting, a
coated tongue, and abdominal pain. Severe abdominal syndrome (diarrhea and
vomiting) is common in children under one year of age.
Primary Enzymopathies: Diarrhea syndrome can also occur in hereditary enzyme
deficiencies (lactase, sucrase, fructase, maltase, enterokinase, peptidase).
Membrane digestion takes place on the surface of the villi of the small intestine
with the participation of these enzymes. The absence or deficiency of these
enzymes disrupts carbohydrate absorption, leading to fermentation in the intestines
and causing diarrhea. In diagnosing this disease, it is important to identify family
members with carbohydrate malabsorption. Lactose deficiency presents in the first
days of a baby's life, manifesting as diarrhea after breastfeeding or consuming
cow's milk due to impaired lactose absorption. The infant becomes restless, refuses
to feed, and exhibits signs of intestinal peristalsis and bloating. Stools are liquid,
foamy, and watery, with a pH below 5.0. Vomiting and dehydration occur. Medical
treatment is ineffective, and the child loses weight, becoming susceptible to
infections. Diarrhea becomes chronic. However, when placed on a lactose-free diet
(vegetable or meat-based soups, porridges, almond or soy milk, potato puree with
minced meat, egg yolk, fruit jelly, and juices), the child's condition improves. If the
disease is diagnosed on time and the child follows a special diet, they can develop
normally.
E. coli Infection (Enterotoxigenic Escherichia coli): High fever is a hallmark of
this infection. The clinical forms of the disease vary and can involve enteritis or
gastroduodenitis. In severe cases, pronounced toxicosis develops, which can last
for an extended period. The disease has an acute onset: body temperature rises to
38-39.5°C, vomiting occurs frequently, and watery stools develop. In some cases,
digestive disturbances last for several days, after which toxicosis worsens and
diarrhea increases. The abdomen is often distended and tender on palpation.
Sometimes, intestinal paralysis or even paralytic ileus develops.
Foodborne Salmonella Infections: In cases of foodborne illness caused by
Salmonella, the incubation period is very short—between 6-24 hours after
consuming spoiled food. The patient's condition worsens rapidly, with nausea,
repeated vomiting, and sharp abdominal pain. The abdomen becomes noticeably
distended. Body temperature may rise to 38-39°C, accompanied by a headache and
watery diarrhea. Oliguria, anuria, seizures, and skin pallor may develop. The
patient’s face may change, limbs become cold, and the patient may fall into a
coma. Foodborne infections usually occur in older children.
Salmonellosis (Gastrointestinal Form): This disease primarily affects the
gastrointestinal tract (gastritis, gastroduodenitis, gastroenterocolitis, enteritis,
colitis). The disease typically begins acutely, with fever, vomiting, frequent and
copious diarrhea, often with pus (acute gastroenteritis). In some patients, stools
resemble mud, occurring up to 5-7 times a day. Appetite decreases, the tongue
becomes coated and dry, and the abdomen is distended. In severe cases, signs of
intestinal toxicosis dominate. The skin appears pale, and mucous membranes are
dry. Infants may have cyanotic skin with decreased tissue turgor.
ECHO Virus Infection: This starts with low-grade fever, which rises to 38-38.5°C
by the 3rd-4th day. The fever is wave-like and normalizes by days 2-12. Symptoms
of intoxication develop moderately, with 1-2 episodes of vomiting, anorexia,
irritability, and sometimes drowsiness. Dehydration is not observed. Respiratory
symptoms worsen by the 3rd-4th day and last for 5-10 days, occasionally up to 6
weeks. Stools are watery, frequent (3-8 times a day), and rarely contain mucus.
Diarrhea resolves by days 3-7. The tongue is dry and coated with a white layer.
The abdomen is distended but soft and non-tender. Many patients have an enlarged
liver, and in 50% of cases, an enlarged spleen is observed.
Treatment of Cholera
Patients infected with cholera are isolated and prescribed a diet according to Table
4 (a dietary regimen for gastrointestinal conditions). The treatment focuses
primarily on replenishing the body’s weight deficit and replacing fluids and
electrolytes lost through diarrhea, vomiting, and respiration.
There are two types of rehydration: primary and compensatory.
1. Primary rehydration involves restoring the body’s lost salt and water. In
compensatory rehydration, the continuing loss of salt and water is
replaced. Oral rehydration therapy uses glucose-saline solutions such as
Rehydron, Citro-Glucosolan, and Glucosolan. The patient is given a
tablespoon of the solution every 3-5 minutes. The total volume of fluid
administered is determined based on the amount of fluid the patient has lost.
In cases of parenteral rehydration, solutions like Quartasol and Trisol are
used.
o For mild to moderate dehydration (Grade 1-2), fluid replacement
can be achieved using oral solutions like Oralit, Rehydron, Citro-
Glucosolan, or Glucosolan.
o For severe dehydration (Grade 3-4), intravenous (IV) fluids are
started immediately. Factory-prepared solutions like Trisol, Acesol,
Quartasol, Chlosol, and Rheomacrodex should be pre-prepared and
infused intravenously at a rate of up to 120 ml per minute for 1-2
hours. The amount of fluid administered during the first few hours can
reach 5-7 liters. The infusion continues until the pulse improves,
breathing normalizes, blood pressure stabilizes, temperature returns to
normal, and signs of hypovolemia (low blood volume) disappear.
Once this is achieved, oral fluid administration is started in addition to
the IV fluids. The amount of fluid to be administered is calculated
based on the continued loss of fluids. Rehydration therapy continues
until the diarrhea and vomiting stop.
o In severe cases, rehydration therapy involves a resuscitation specialist
who may insert a venous line through the subclavian area for
additional fluid administration.
Approximate fluid volume (in ml) to be given orally over 4-6 hours based on
the patient's age and weight:
Patient's Up to 4 4-11 12-23 2-4 5-14 15 years
Age months months months years years and above
Weight Up to 5 kg 5-7.9 kg 8-10.9 kg 11-15.9 16-29.9 30 kg and
(kg) kg kg above
Fluid (ml) 200-400 400-600 600-800 800- 1200- 2200-4000
1200 2200
In other cases, the estimated weight of the patient (in kg) is multiplied by 75 to
calculate the required fluid volume in milliliters.
2. Antibiotic therapy: Antibiotics such as Tetracycline, Levomycetin,
Neviramon, Furazolidone, and Lidaprim are administered for 5 days
depending on the patient’s age.
Antibiotics are only prescribed after the rehydration process is complete. Over a
period of 3 days, 50 mg/kg of Tetracycline is administered every 6 hours, along
with 10 mg/kg of Furazolidone and 30 mg/kg of Erythromycin.
The drug Ersefuril (nifuroxazide) has proven highly effective (100% sensitivity of
vibrios). It is available in capsules of 100 mg and in suspension form (90 ml).
Young children are given 2-3 measuring spoons of the suspension, while older
children receive 1 spoonful 3 times a day (or 1 capsule 3-4 times a day). School-
aged children are given 2 capsules 3-4 times a day.
Adults are prescribed Tetracycline 0.3-0.5 g, 4 times a day, Levomycetin 0.5 g 4
times a day, or Doxycycline 0.1 g twice a day for 5 days.
In recent years, cholera vibrios have become resistant to Tetracycline and
Levomycetin. In cases caused by resistant strains, quinolones like Ciprofloxacin
(Sifloks), Ofloxacin (Tarivid), and Norfloxacin (Abaktal) are effective. Adults are
given 2 tablets (500 mg) twice a day for 5 days. If these drugs are unavailable,
Ampicillin is used (2 tablets of 0.5 g, 4 times a day for 5 days).
3. In the recovery phase, patients are given easily digestible, nutritious food.
To maintain potassium levels in the blood, Potassium Orotate or Panangin
tablets are administered for 4-5 days. If treatment is correctly organized, the
patient's condition usually improves within 2-3 days, and they are
discharged after full recovery. Before discharge, two stool cultures taken 24
hours apart must show no presence of vibrios.
Prevention of Cholera
Cholera prevention focuses on preventing the infection from being introduced from
endemic regions. If vibrios are found in a water source, its use is strictly
prohibited, and bacteriological testing of water sources is conducted every 10 days.
Patients recovering from cholera are discharged only after a complete clinical
recovery, confirmed by three consecutive negative stool cultures. The first stool
sample is collected after administering a saline laxative (magnesium sulfate).
Those who have been in contact with cholera patients are monitored for 5 days and
undergo bacteriological testing once.
Disinfection is performed at the home of the cholera patient. Children older than 7
years receive a single immunization with cholera antitoxin, which provides
immunity after 20 days and lasts for about 5-6 months. People with digestive
symptoms in the cholera zone are hospitalized, tested for bacteria, monitored for 5
days, and treated with antibiotics.
Public Awareness to Prevent Cholera Spread
To eliminate the outbreak, the following measures are implemented by the
outbreak control team:
1. Treatment and discharge of patients.
2. Those who have been in contact with patients are monitored for 5 days.
Depending on the sensitivity of the strain isolated from the patient, one of
the following antibiotics is administered according to WHO
recommendations:
o Doxycycline 300 mg once (adults only).
o Tetracycline 12.5 mg/kg, 4 times a day for 3 days (children); 500 mg,
4 times a day for 3 days (adults).
o Trimethoprim 5 mg/kg, twice a day for 3 days (children); 160 mg,
twice a day for 3 days (adults).
o For pregnant women: Furazolidone 100 mg (2 tablets), 4 times a day
for 3 days; for children, 1.25 mg/kg, 4 times a day for 3 days.
o Sifloks (Tarivid, Pefloxacin) 250 mg, twice a day for 3 days (adults).
3. The outbreak zone and hospital are disinfected.
4. Efforts are made to ensure access to clean drinking water and proper
disinfection of wastewater. The cleanliness of living areas is strictly
maintained.
5. Patients discharged from the hospital are placed under dispensary
observation for 3 months, with monthly medical examinations and stool tests
for cholera vibrios.
6. If no new cases of cholera are detected within 10 days after the last patient
or carrier is discharged from the hospital, the outbreak is declared over.