Cholera Treatment

The main principles of treatment for patients with cholera are:

  • restoration of the volume of circulating blood;
  • restoration of the electrolyte composition of tissues;
  • the effect on the pathogen.

Treatment should begin in the first hours from the onset of the disease. In severe hypovolemia, rehydration should be carried out immediately by intravascular administration of isotonic polyionic solutions. The treatment of cholera patients includes primary rehydration (replenishment of water and salts lost before treatment) and corrective compensatory rehydration (correction of ongoing loss of water and electrolytes). Rehydration is seen as a resuscitation measure. Patients with severe cholera who need emergency care are sent to the rehydration department or ward immediately, bypassing the emergency room. During the first 5 minutes, the patient must determine the pulse rate and respiration, blood pressure, body weight, take blood to determine the relative density of blood plasma, hematocrit, electrolyte content, degree of acidosis, and then start the injection of saline.

For treatment, various polyionic solutions are used. The most tested is the Trisol solution (solution 5, 4, 1 or solution No. 1). To prepare the solution, pyrogen-free bidistilled water is taken, 1 g of which is added 5 g of sodium chloride, 4 g of sodium bicarbonate and 1 g of potassium chloride. Quartasol solution is currently considered to be more effective, containing 4.75 g of sodium chloride, 1.5 g of potassium chloride, 2.6 g of sodium acetate and 1 g of sodium bicarbonate on I liter of water. You can use the solution “Acesol” -on 1 liter of pyrogen-free water 5 g of sodium chloride, 2 g of sodium acetate, 1 g of potassium chloride; Chlosol solution – on 1 l of pyrogen-free water 4.75 g of sodium chloride, 3.6 g of sodium acetate and 1.5 g of potassium chloride and Lactosol solution containing 6.1 g of sodium chloride in 1 l of pyrogen-free water, 3 , 4 g of sodium lactate, 0.3 g of sodium bicarbonate, 0.3 g of potassium chloride, 0.16 g of calcium chloride and 0.1 g of magnesium chloride. The World Health Organization recommended a “WHO solution” – 4 g of sodium chloride, 1 g of potassium chloride, 5.4 g of sodium lactate and 8 g of glucose per 1 liter of pyrogen-free water.

Polyionic solutions are administered intravenously, preheated to 38 ~ 40 ° C, with a speed of II degree of dehydration of 40-48 ml / min, in severe and very severe forms (dehydration of III-IV degree), the introduction of solutions at a rate of 80-120 ml / min The volume of rehydration is determined by the initial fluid loss calculated by the degree of dehydration and body weight, clinical symptoms and the dynamics of the main clinical indicators characterizing hemodynamics. Primary rehydration is carried out for 1 to 1.5 hours. After the introduction of 2 l of the solution, further administration is carried out more slowly, gradually reducing the speed to 10 ml / min.

To inject fluid at the required speed, sometimes you have to use simultaneously two or more systems for a single transfusion of fluid and inject solutions into the veins of the arms and legs. In the presence of appropriate conditions and skills, the patient is put on a cavitation catheter or catheterized in other veins. If venipuncture is not possible, venesection is performed. The introduction of solutions is crucial in the treatment of seriously ill patients. Cardiac drugs in this period are not shown, and the administration of pressor amines (adrenaline, mesatone, etc.) is contraindicated. As a rule, after 15-25 minutes after the start of the introduction of solutions, the patient begins to detect pulse and blood pressure, and after 30-45 minutes shortness of breath disappears, cyanosis decreases, lips warm, voice appears. After 4-6 hours, the patient’s condition improves significantly. He begins to drink on his own. By this time, the volume of liquid introduced is usually 6-10 liters. With prolonged administration of the Trisol solution, metabolic alkalosis and hyperkalemia may develop. If necessary, continue infusion therapy, it should be carried out with solutions of “Quartasol”, “Chlosol” or “Acesol”. Patients are prescribed potassium oro-tat or panangin 1-2 tablets 3 times a day, 10% sodium acetate or citrate solutions, 1 tablespoon 3 times a day.

To maintain the achieved state, carry out the correction of ongoing losses of water and electrolytes. You need to enter as many solutions as the patient loses with feces, vomit, urine, in addition, take into account that an adult loses 1-1.5 liters of fluid through breathing and through the skin. To do this, organize the collection and measurement of all secretions. Within 1 day, you have to enter up to 10-15 liters of solution or more, and for 3-5 days of treatment – up to 20-60 liters. To monitor the course of treatment, the relative density of the plasma is systematically determined and put on the map of intensive care; hematocrit indicator, severity of acidosis, etc.
When pyrogenic reactions appear (chills, fever), the solution does not stop. A 1% solution of diphenhydramine (1-2 ml) or pipolfen is added to the solution. With pronounced reactions, prednisone is prescribed (30-60 mg / day).
It is impossible to carry out therapy with an isotonic solution of sodium chloride, since it does not compensate for the deficiency of potassium and sodium bicarbonate, can lead to plasma hyperosmosis with secondary dehydration of cells. The erroneous introduction of large quantities of 5% glucose solution, which not only does not eliminate the deficiency of electrolytes, but, on the contrary, reduces their concentration in plasma. Blood transfusions and blood substitutes are also not shown. The use of colloidal solutions for rehydration therapy is unacceptable.

Patients with cholera who do not have vomiting should receive the following composition in the form of drink “Glucosol” (“Regidron”): sodium chloride -3.5 g, sodium bicarbonate-2.5 g, potassium chloride-1.5 g, glucose- 20 g per 1 liter of drinking water. Glucose improves the absorption of electrolytes in the small intestine. It is advisable to pre-harvest samples of salts and glucose; they must be dissolved in water at a temperature of 40-42 ° C immediately before giving the patient.

In the field, oral rehydration with sugar-salt solution can be used, for which 2 teaspoons of table salt and 8 teaspoons of sugar are added to 1 liter of boiled water. The total volume of glucose-salt solutions for oral rehydration should be 1.5 times the amount of water lost with vomiting, bowel movements and perspiration (up to 5-10% of body weight).

In children under 2 years of age, rehydration is carried out by drip infusion and is continued for 6-8 hours, and in the first hour only 40% of the volume of fluid necessary for rehydration is administered. In young children, loss compensation can be provided by infusion of a solution using a nasogastric tube.

Children with moderate diarrhea can be given a drinking solution in which 1 teaspoon of sugar, 4 teaspoons of sugar, 3/4 teaspoon of table salt and 1 teaspoon of baking soda with pineapple or orange juice. In case of vomiting, the solution is given more often and in small portions.

Water-salt therapy is stopped after the appearance of feces, in the absence of vomiting and the prevalence of urine over the number of bowel movements in the last 6-12 hours.

Antibiotics, as an additional tool, reduce the duration of clinical manifestations of cholera and accelerate the purification of vibrios. Tetracycline is prescribed in 0.3-0.5 g after 6 hours for 3-5 days or doxycycline 300 mg once. If they are absent or intolerant, treatment with trimethoprim with sulf-metaxazole (cotrimoxazole) 160 and 800 mg twice a day for 3 days or furazolidone 0.1 g every 6 hours for 3-5 days can be carried out. Children are prescribed trimethoprim-sulfometaxazole at 5 and 25 mg / kg body weight
2 times a day for 3 days. Promising in the treatment of cholera, fluoroquinolones, in particular, ofloxacin (tarid), which is currently widely used for intestinal infections, the causative agents of which are resistant to traditional antibiotics. It is prescribed 200 mg orally twice a day for 3-5 days. Vibrion carriers carry out a five-day course of antibiotic therapy. Taking into account the positive experience of US military doctors who used streptomycin inside Vietnam with persistent vibration, it is possible to recommend the administration of kanamycin 0.5 g 4 times a day for 5 days in these cases.

A special diet for cholera patients is not required. Having recovered from severe cholera during the convalescence period, products containing potassium salts (dried apricots, tomatoes, potatoes) are indicated.

Patients who have undergone cholera, as well as vibriocarriers, are discharged from the hospital after clinical recovery and three negative bacteriological studies of bowel movements. Feces are examined 24-36 hours after the end of antibiotic therapy for 3 consecutive days. Bile (portions B and C) is examined once. Workers in the food industry, water supply, children’s and health care facilities examine bowel movements five times (over five days) and bile once.

The prognosis for timely and adequate treatment is usually favorable. Under ideal conditions, with urgent and adequate rehydration with isotonic polyionic solutions, mortality reaches zero, and serious consequences are rare. However, experience shows that at the beginning of epidemic outbreaks, the mortality rate can reach 60% due to the lack of pyrogen-free solutions for intravenous administration in remote areas, difficulties in organizing emergency treatment in the presence of a large number of patients.