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 10-14 days in children <5y 4. Use of antibiotics http://rehydrate.org/ors/low-osmolarity-ors.htm

7. Minimal to No Dehydration – Plan A Treatment http://www.bing.com/images/search?q=oral+r ehydration+solution&view=detailv2&&id=30D 455D47FD3B3D47C4581EA0BF9BAC77C58E18 9&selectedIndex=4&ccid=4t3j1PQK&simid=60 8010002184736627&thid=JN.D14JX5iNQaUYW N4MjbhutQ&ajaxhist=0

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 Source: CDC trainers of trainers presentation -Large bore 18 gauge IV needles -Can use nasogastric tube if IV cannot be placed (20ml/kg 1 st hour)

10. Putting IV Line

11. Antibiotic Therapy Recommended antibiotics – taken orally 1.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