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By Larry M. Bush, MD, Affiliate Professor of Clinical Biomedical Sciences;Affiliate Associate Professor of Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University;University of Miami-Miller School of Medicine ; Maria T. Perez, MD, Associate Pathologist, Department of Pathology and Laboratory Medicine, Wellington Regional Medical Center, West Palm Beach

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Cholera is an acute infection of the small bowel by Vibrio cholerae, which secretes a toxin that causes copious watery diarrhea, leading to dehydration, oliguria, and circulatory collapse. Infection is typically through contaminated water or seafood. Diagnosis is by culture or serology. Treatment is vigorous rehydration and electrolyte replacement plus doxycycline.

The causative organism, V. cholerae, serogroups 01 and 0139, is a short, curved, motile, aerobic bacillus that produces enterotoxin, a protein that induces hypersecretion of an isotonic electrolyte solution by the small-bowel mucosa. These organisms do not invade the intestinal wall; thus, few or no WBCs are found in stool.

Both the El Tor and classic biotypes of V. cholerae 01 can cause severe disease. However, mild or asymptomatic infection is much more common with the currently predominant El Tor biotype and with non-01, non-0139 serogroups of V. cholerae.

Cholera is spread by ingestion of water, seafood, or other foods contaminated by the excrement of people with symptomatic or asymptomatic infection. Household contacts of patients with cholera are at high risk of infection that probably occurs through shared sources of contaminated food and water. Person-to-person transmission is less likely to occur because a large inoculum of organism is needed to transmit the infection.

Cholera is endemic in portions of Asia, the Middle East, Africa, South and Central America, and the Gulf Coast of the US. Cases transported into Europe, Japan, and Australia have caused localized outbreaks. In endemic areas, outbreaks usually occur during warm months. The incidence is highest in children. In newly affected areas, epidemics may occur during any season, and all ages are equally susceptible.

A milder form of gastroenteritis is caused by noncholera vibrios.

Susceptibility to infection varies and is greater for people with blood type O. Because vibrios are sensitive to gastric acid, hypochlorhydria and achlorhydria are predisposing factors.

People living in endemic areas gradually acquire a natural immunity.

Symptoms and Signs

The incubation period for cholera is 1 to 3 days. Cholera can be subclinical, a mild and uncomplicated episode of diarrhea, or a fulminant, potentially lethal disease.

Abrupt, painless, watery diarrhea and vomiting are usually the initial symptoms. Significant nausea is typically absent. Stool loss in adults may exceed 1 L/h but is usually much less. Often, stools consist of white liquid void of fecal material (rice-water stool). The resultant severe water and electrolyte depletion leads to intense thirst, oliguria, muscle cramps, weakness, and marked loss of tissue turgor, with sunken eyes and wrinkling of skin on the fingers. Hypovolemia, hemoconcentration, oliguria and anuria, and severe metabolic acidosis with K+ depletion (but normal serum Na+ concentration) occur. If cholera is untreated, circulatory collapse with cyanosis and stupor may follow. Prolonged hypovolemia can cause renal tubular necrosis.

Most patients are free of V. cholerae within 2 wk after cessation of diarrhea; chronic biliary tract carriers are rare.


  • Stool culture and serotyping

Diagnosis of cholera is confirmed by stool culture (use of selective media is recommended) plus subsequent serotyping. Tests for V. cholerae are available in reference laboratories; PCR testing is also an option. Rapid dipstick testing for cholera is available for public health use in areas with limited access to laboratory testing.

Cholera should be distinguished from clinically similar disease caused by enterotoxin-producing strains of Escherichia coli and occasionally by Salmonella and Shigella.

Serum electrolytes, BUN, and creatinine should be measured.


  • Fluid replacement

  • Doxycycline, azithromycin, furazolidone, trimethoprim/sulfamethoxazole (TMP/SMX), or ciprofloxacin, depending on results of susceptibility testing

Fluid replacement

Replacement of fluid loss is essential. Mild cases can be treated with standard oral rehydration formulas. Rapid correction of severe hypovolemia is lifesaving. Prevention or correction of metabolic acidosis and hypokalemia is important. For hypovolemic and severely dehydrated patients, IV replacement with isotonic fluids should be used (for details on fluid resuscitation, see Intravenous Fluid Resuscitation and Oral Rehydration). Water should also be given freely by mouth. To replace potassium losses, KCl 10 to 15 mEq/L can be added to the IV solution, or KHCO3 1 mL/kg po of a 100-g/L solution can be given qid. Potassium replacement is especially important for children, who tolerate hypokalemia poorly.

Once intravascular volume is restored (rehydration phase), amounts for replacement of continuing losses should equal measured stool volume (maintenance phase). Adequacy of hydration is confirmed by frequent clinical evaluation (pulse rate and strength, skin turgor, urine output). Plasma, plasma volume expanders, and vasopressors should not be used in place of water and electrolytes.

Oral glucose-electrolyte solution is effective in replacing stool losses and may be used after initial IV rehydration, and it may be the only means of rehydration in epidemic areas where supplies of parenteral fluids are limited. Patients who have mild or moderate dehydration and who can drink may be rehydrated with the oral solution (about 75 mL/kg in 4 h). Those with more severe dehydration need more and may need to receive the fluid by nasogastric tube.

The oral rehydration solution (ORS) recommended by the WHO contains 13.5 g glucose, 2.6 g NaCl, 2.9 g trisodium citrate dihydrate (or 2.5 g NaHCO3), and 1.5 g KCl per liter of drinking water. This solution is best prepared using widely available, premeasured, sealed packets of glucose and salts; one packet is mixed with 1 L of clean water. Using such prepared ORS packets minimizes the possibility of error when untrained people mix the solution. If ORS packets are not available, a reasonable substitute can be made by mixing half a small spoon of salt and 6 small spoons of sugar in 1 L of clean water. The ORS should be continued ad libitum after rehydration in amounts at least equal to continuing stool and vomitus losses. Solid food should be given only after vomiting stops and appetite returns.


Early treatment with an effective oral antimicrobial eradicates vibrios, reduces stool volume by 50%, and stops diarrhea within 48 h. The choice of antimicrobial should be based on the susceptibility of V. cholerae isolated from the community.

Drugs effective for susceptible strains include

  • Doxycycline: For adults, a single dose of 300 mg po or 100 mg bid on day 1, then 100 mg once/day on days 2 and 3; or a single dose of azithromycin 1 g po (recommended for pregnant women) or 20 mg/kg for children

  • Furazolidone (not available in the US): For adults, 100 mg po qid for 72 h; for children, 1.5 mg/kg qid for 72 h

  • TMP/SMX: For adults, one double-strength tablet bid; for children, 5 mg/kg (of the TMP component) bid for 72 h

  • Ciprofloxacin: For adults, a single dose of 1 g po or 250 mg po once/day for 3 days


For control of cholera, human excrement must be correctly disposed of, and water supplies purified. In endemic regions, drinking water should be boiled or chlorinated, and vegetables and fish cooked thoroughly.

Vaxchora® is a live-attenuated oral vaccine that has been approved for use in the US for prevention of O1 in adults 18 to 64 yr of age traveling to cholera-affected areas.

Two killed whole-cell oral vaccines are currently available for use in children and adults internationally but not in the US:

  • Dukoral®: This monovalent vaccine contains only V. cholerae 01 and El Tor bacteria plus a small amount of nontoxic b subunit cholera toxin; it must be taken with a large amount of buffer fluid (buffer packet is dissolved in 5 oz of cool water) at the time of vaccine administration.

  • Shanchol®: This newer bivalent vaccine contains both 01 and 0139 strains of V. cholerae and has no added components, eliminating the requirement for excessive fluid ingestion at the time of vaccination.

Both vaccines provide 60 to 85% protection for up to 5 yr. Both require 2 doses, and booster doses are recommended after 2 yr for people with ongoing risk of cholera.

Injectable vaccines provide less protection for shorter periods of time with more adverse effects and are not recommended when an oral vaccine is available.

Antibiotic prophylaxis for household contacts of patients with cholera is not recommended because data supporting this measure are lacking.

Key Points

  • V. cholerae serogroups 01 and 0139 secrete an enterotoxin that can cause severe, sometimes fatal diarrheal illness that often occurs in large outbreaks caused by mass exposure to contaminated water or food.

  • Other V. cholerae serogroups can cause milder, nonepidemic disease.

  • Diagnose using stool culture and serotyping; a rapid dipstick test is helpful in identifying outbreaks in remote areas.

  • Rehydration is critical; oral rehydration solution is adequate for most cases, but patients with severe volume depletion require IV fluids.

  • Give infected adults doxycycline or azithromycin (TMP/SMX for children) pending results of susceptibility testing.

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