Single Dose

Azithromycin Versus
Ciprofloxacin for
Cholera in Children:
A Randomized
Controlled Trial
Chairperson : Dr.ShivaSharanappa
Presenter: Dr.Mohan.T.Shenoy
5.5.2010
INDIAN PEDIATRICS- VOL 47 – APRIL
2010

JAYA SHANKAR KAUSHIK, PIYUSH

GUPTA, MMA FARIDI AND SHUKLA DAS

2
 REFERENCES
Nelson Textbook of Pediatrics – 18th Edition
IAP Textbook of Pediatrics – 6th Edition
Ghai Textbook of Pedatrics – 6th Edition
Management of Acute Diarrhea- IAP guidelines
WHO Guidelines for Cholera Control; 1993.

 http://www.who.int/topics/cholera/en/
 http://wwwnc.cdc.gov/travel/
3
 Diarrhea Causes
 Defn - Passage of >3 stools of greater fluidity than
normal/day

 Viruses-Rotavirus(15-25%)

 Bacteria-Escherichia coli(25%) esp. ETEC, shigella(10-15%),

camp. Jejuni (5-15%), Salmonella (non-typhoid) 1-5%, cholera

 Protozoa- Giardia duodenalis, Entamoeba histolytica,

Cryptosporidium

4
 CHOLERA
 Greek word for the “gutter of a roof”
comparing the deluge of water following a rainstorm to that of
the anus of an infected person.

Vibrios are highly motile, gram-negative,

curved or comma-shaped rods with a single polar flagellum,
whose natural habitat usually salt or fresh water.

More than 200 different serogroups of V.cholerae

5
Vibrio cholerae

6
 Vibrio spp. (Family
Vibrionaceae) Associated
with Human Disease

7
 History of Cholera
• For many centuries Cholera had been endemic in the
region of India.
• Epidemic cholera was described in 1563 by Garcia
del Huerto, a Portuguese physician at Goa, India.
• The mode of transmission of cholera by water was
proven in 1849 by John Snow, a London physician.
• In 1883, Robert Koch successfully isolated the
cholera vibrio from the intestinal discharges of
cholera patients and proved conclusively that it was
the agent of the disease.
8
 Epidemiology
• Recognized for more than 2 millennia with sporadic
disease and epidemics

• Endemic in Southern and Southeastern Asia; origin of

pandemic cholera outbreaks

• Generally in communities with poor sanitation

• Seven pandemics (possible 8th continuing) since 1817

attributable to increased world travel

• Cholera spread by contaminated water and food

• Human carriers and environmental reservoirs 9
10
11
 Classification Scheme

Toxigenic V. cholerae
Division into 2 epidemic serotypes

O1
Division into 2 biotypes O139

Classical El Tor
Each O1 biotype can have 3 serotypes

inaba ogawa hikojima

Division into ribotypes

A&B
A&C A, B, C
Antigens )A little C(

12
 Vibrio cholerae

 The O1 serogroup have caused the majority of

cholera outbreaks and are subdivided in to two
biotypes:

– Classical
– El Tor: relatively mild and asymptomatic.

This biotype produces hemolysins (exotoxins that

lyse red blood cells).
13
Where Cholera is Most Commonly
Found

14
 7th Cholera Pandemic: The El Tor Strain

 Up until the beginning of the 20th century all strains had

been classical.

 The 7th Pandemic began in Indonesia and devastated the

Philippines.

 Strain was not classical it was the El Tor Strain.

 The El Tor strain is more dangerous because the duration

of carriage after infection is longer in the El Tor Strain.

 El Tor also survives for longer periods of time in the

extraintestinal environment than does the classical strain. 15
The Evolution of the El Tor Strain

 The El Tor has evolved into an even more

dangerous strain.
 In 1992, people in Bangladesh were affected by a
large cholera epidemic.
 The strain of cholera was comparable to El Tor
but its antigenic structure changed.
 There are no existing immunities.
 The strain was called O139 “Bengal” 16
 Cholera
 A severe diarrhoeal illness with production of
‘rice water’ stools

 Abdominal pain,vomiting and nausea may

accompany

 Rapid onset of dehydration causing electrolyte

loss .. Hence severe weakness, prostration, poor
skin turgor, sunken eyes and cheeks, circulatory
and renal failure 17
• As more fluid is
lost, feces-
streaked stool
changes to

Rice-water
stools:

• Colorless
• Odorless
• No protein
• Speckled with
mucus
18
 Pathogenesis of V.cholerae
• Incubation period: 18 hr to 5 days.

• High infectious dose: >108 CFU

• 103 -105 CFU with achlorhydria or

hypochlorhydria (lack of or reduced stomach
acid)

• Abrupt onset of vomiting and life-threatening

watery diarrhea (15-20 litres/day) 19
 Cholera cont’d
 Typically water borne

 Short incubation period

 Colonization of the upper small intestine

attaches to epithelium and acts locally to
produce an enterotoxin which causes
increased cyclic AMP production with
outpouring of fluid and electrolytes
20
Mechanism of Action

21
22
Virulence Factors Asso with
Vibrio cholerae O1 and O139

23
 Laboratory Identification
•Transport medium - Cary-Blair semi-solid agar

•Enrichment medium - alkaline peptone broth

• Vibrios survive and replicate at high pH
• Other organisms are killed or do not multiply

•Selective/differential medium - TCBS agar

• V. cholerae grow as yellow colonies

•Biochemical and serological tests 24

25
26
Laboratory Methods (Contd.)

27
28
 MANAGEMENT OF
SUSPECTED CHOLERA
 Differs from other causes

1. occurs in large epidemics that involve both children and

adults;

2. voluminous watery diarrhoea leading rapidly to severe

dehydration with hypovolemic shock;

3. appropriate antibiotics may shorten the duration of the

illness
29
 When to suspect ??

 when a child older than 5 years develops

severe dehydration from acute watery
diarrhoea (usually with vomiting), or

 any patient older than 2 years has acute

watery diarrhoea when cholera is known to
be occurring in the area.

30
31
Treating Cholera

32
 Cholera contd..
 Amount of stool lost is greatest in 1st 24 hours of
illness- average requirement 200 ml/kg.

 Patients whose ongoing stool losses are in this range,

usually require IV maintenance therapy using Ringer's
Lactate Solution with added potassium chloride.

 Rice-based ORS is superior to standard ORS for adults

and children with cholera,

33
34
 Rehydration is the most important treatment.

 Oral rehydration given plenty is the treatment of

choice unless the child is obtunded, has an ileus,
or is in shock.

 Vomiting is not a contraindication to oral

rehydration

 However, antibiotics are useful in

– shortening the duration of illness,

– reducing the period of excretion of the organisms, and
– decreasing the requirements for fluid replacement. 35
 Rationale for antibiotics in
Cholera

 reduces the total volume of stool,

 causes diarrhoea to stop within 48 hours, and
 shortens the period of faecal excretion

 The 1ST dose given as soon as vomiting stops

 Antimicrobial therapy
 All cases of suspected cholera with severe
dehydration should receive an oral antimicrobial
effective against strains in the area

 Tetracycline 12.5 mg/kg 4 times a day x 3 days;

2nd choice- erythromycin same dose

 Nelson- Doxycycline is preferable in Asian

strains. 6 mg/ kg single dose

37
 Epidemic Control Measures
 Hygienic disposal of human waste

 Adequate supply of water

 Good food hygiene

– Thoroughly cooking food

– Eating food while it’s hot
– Preventing cooked foods from contacting raw foods
(including water or ice)
– Avoiding raw fruits or vegetables
– Washing hands after defecation & before cooking
38
http://www.who.int/mediacentre/factsheets/fs107/en/print.html
INDIAN PEDIATRICS- VOL 47 – APRIL
2010

JAYA SHANKAR KAUSHIK, PIYUSH

GUPTA, MMA FARIDI AND SHUKLA DAS

39
 WHO recommends a 3-5 day course of
furazolidone, trimethoprim-sulphamethoxazole
or erythromycin for treatment of cholera in
children; tetracycline may be used for those more
than 8 years of age.

 However, strains of V. cholerae resistant to these

drugs have been identified in Bangladesh and
elsewhere.

 Identification of clinically efficacious alternative

antibiotics is therefore necessary for use in children
with cholera.
40
 Azithromycin, a synthetic macrolide - an
emerging antibiotic with action against
V.cholerae.

 Single dose treatment with azithromycin has

a potential advantage of ease of
administration, good compliance, and
reduced cost of treatment.

 Studies on treatment of cholera in children

with single dose azithromycin are limited to
comparisons with erythromycin 41
 Objective
 To compare the clinical and bacteriological
success of single dose treatment with
Azithromycin and Ciprofloxacin in children
with cholera
Design: Randomized, open labelled, clinical controlled trial
from from March 2006 to February 2007.

Setting: Tertiary care hospital (University College of Medical

Sciences and Guru Teg Bahadur Hospital, Dilshad Garden,
Delhi, India.

Clearance was obtained from the institutional ethical committee

 Participants
 180 children

– between 2-12 years,

– having watery diarrhea for ≤24 hr and
– severe dehydration,
– who tested positive for Vibrio cholerae by
hanging drop examination or culture of stool

The study protocol was fully explained to the

parents/guardian, and informed written consent was obtained
43
 EXCLUSION

 Children with severe undernutrition (weight for

age less than 60% of 50th percentile of CDC 2000
standards)

 Coexisting systemic illness

 Blood in stool

 Received an antibiotic/antidiarrheal within

preceding 24 hours 44
 Data collection
 Baseline data were collected:

– name, age, address, telephone number

– Occupation, education and monthly income of

parents

– duration of illness, frequency of diarrhea and

vomiting prior to admission, and

– presence of associated symptoms including

abdominal pain,fever, and abdominal distension.45
 Data collection
 Evaluation was done for general hygiene, vitals,
and signs of dehydration

 The present weight was recorded on a standardized

weighing scale to the nearest 0.5 kg.

 Height was measured to the nearest 0.1 cm.

 The same observer obtained all the measurements

46
 Randomization and allocation
 Eligible children were allotted a study number.

 These numbers corresponded to the order of patients

entering the trial.

 Children were randomized to receive a single dose of

oral azithromycin (20 mg/kg) or ciprofloxacin
(20 mg/kg).

 A simple randomization was done using a computer

47
generated random number table on a master list.
 METHODS ( Contd.)
 Allocation of the treatment group was concealed by
having the names of both the study drug stored in
identical sealed envelope, which were opened after a
patient had been enrolled in the study and assigned a
study number.

 Randomized children were immediately rehydrated with

intravenous Ringer’s lactate solution 30 mL/kg in first ½
hour followed by 70 mL/kg over next 2½ hours.

 A stool sample was obtained for hanging drop

examination and culture for Vibrio cholerae, as soon as
the child passed stools after admission.

 The patient was reassessed for hydration after 3-4 hours 48

and managed further as per the WHO Guidelines.
 METHODS ( Contd.)

 The assigned Study drug was orally administered

after initial rehydration, under supervision.

 Eligible subjects received either a single dose of

azithromycin (20 mg/kg) or ciprofloxacin (20
mg/kg).

 Both the drugs were available in 100 mg, 250 mg and

500 mg tablets and the dose was rounded to nearest
50 mg.

 The dose was repeated if the child vomited within 10

49
minutes of drug administration.
 METHODS ( Contd.)
 Each Study day was defined as 24 hour counted from the
administration of study drug.

 Children remained in the Study center for 72 hours (day 3)

or until resolution of watery diarrhea, whichever was later.

 The parents were asked to bring their child back for a

follow-up visit on day 7.

 If the patient failed to return on the follow-up visit, the

parents were contacted by telephone and asked to come on
the next day.

 Clinical monitoring was performed on multiple occasions on

the day of admission and subsequently at the end of day 1,
50
2, 3 and 7.
 METHODS ( Contd.)

 A record was kept of frequency of stool and vomiting

for every 24 hrs.

 The amount of intravenous fluid and ORS administered

was also recorded at the end of each Study day.

 A stool sample or rectal swab was obtained at the end of

day 1, 2, 3 and at follow-up visit (day 7).

 Authors also noted for any possible adverse effects of

the drug administered like hypersensitivity reaction,
phototoxicity, tendinopathy and joint pain or swelling.
51
 Microbiological evaluation

 The motility of V. cholerae was seen by hanging

drop preparation.

 Stool sample was transported in alkaline peptone

water or Cary Blair media and processed.

 The stool samples were cultured in bile salt agar,

MacConkey agar and thiosulphate citrate bile
sucrose agar

 Plates were incubated at 37ºC for 24 hours 52

 Microbiological evaluation
 The samples were inoculated in fresh alkaline
peptone water for enrichment and subseqent plating

 Bacteriological analysis was done by standard

laboratory techinques and V. cholerae isolates were
serotyped by slide agglutination test using specific
antisera (Denca Saken).

 Antimicrobial susceptibility testing of the strains

was performed by standard methods.
53
 Primary Outcome measures

(i) clinical success: defined as resolution of diarrhea

within 72 hours after the start of therapy; and

(ii) bacteriological success: defined as absence of

Vibrio cholerae in the stool sample from day 3
onwards.

Resolution of diarrhea was considered when

• child has passed two consecutive formed stools

or
54
• had not passed stool for 12 hours.
 Secondary outcome variables
 (i) total duration of diarrhea (recovery time) defined as time elapsed
from the entry into study till resolution of diarrhea in hrs;

 (ii) total requirement of ORS and / or intravenous therapy;

 (iii) duration of excretion of V. cholerae in stool;

 (iv) proportion of children with clinical relapse defined as cessation of

diarrhea
 for 1 day or longer followed by return of
diarrhea

or bacteriological relapse defined as a positive stool culture following

negative culture report.
55
 Statistical analysis
 Data were analysed using SPSS version 13.0.

 All quantitative variables (between the groups)

were compared by unpaired t-test; categorical
variables were compared by Chi-square test or
Fisher’s exact test.

 P<0.05 was considered as significant.

 Variables which were measured repeatedly were

analysed with repeated measure ANOVA at 1%
level of significance to allow for multiple
comparisons 56
 A total of 89 Study subjects received
ciprofloxacin and 91 received
azithromycin

 Baseline characteristics of the study

subjects were comparable between the
groups

57
 RESULTS
 407 children were included in the study and were
randomized to receive azithromycin (n=205) or
ciprofloxacin (n=202).

 Of these, 180 children who tested positive for V.

cholerae by hanging drop examination or culture
of the stool were finally included in the analysis,
and designated as “Study subjects”

58
 Baseline
comparison

59
 DISCUSSION

 Rate of clinical success significantly more in

Azithromycin gp as compared to Ciprofloxacin,
although the rate of bacteriological success was
comparable in the two groups.

 Subjects who received Azithromycin had a

significantly lesser duration of diarrhea, shorter
duration of excretion of V. cholerae, and lower
requirement of intravenous fluids.

 Rate of bacteriological relapse was found to be

comparable and none of the subjects in either group
had clinical relapse. 60
Outcome variables

61
 Symptomatic improvement was assessed by
comparing the frequency of diarrhea and
vomiting.

 The frequency of stool and vomiting was

significantly lower in children who received
azithromycin as compared to ciprofloxacin
group during the first 72 hours.

 The rate of decline in frequency of stool and

vomiting was however comparable between
ciprofloxacin and azithromycin groups 62
The follow-up loss in first 72 hours of hospital stay was only 3.3%.

However, the follow-up loss beyond day 3 was 18.8%, which was
significant.
63
 Clinical and bacteriological success with
azithromycin are much higher in this study

 Discrepancy in the success rates could be attributed

to differing definitions of success adopted in these
trials and differences in baseline characteristics of
the enrolled population.

 Ciprofloxacin resistance might have emerged in

direct response to selective pressure exerted by
nalidixic acid coupled with disproportionate use of
fluoroquinolones for all bacterial infections in our
country. 64
 CONCLUSION FROM
THE STUDY
 Single dose azithromycin is a useful alternative
for treating cholera in children.

 Considering the clinical efficacy and lack of

resistance to azithromycin, authors advocate
that it should be considered as an option for
first line treatment of childhood cholera in
areas where V.cholerae infection are caused by65
susceptible strains.
If you haven’t heard of cholera,
be thankful for clean water.

66
Pathogenesis: Mechanism of
Action: Overview

67
 68
Sack, David, et al. 2004. Seminar: Cholera. The Lancet. 363: 223-233.