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 ³gutter 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.
5

More than 200 different serogroups of

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
Division into ribotypes

hikojima

A& C

A& B
(A little C) Antigens

A, B, C 12

Vibrio cholerae 
The O1 serogroup have caused the majority of cholera outbreaks and are subdivided in to two biotypes:
² Classical ² 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 ´Bengalµ
16

Cholera 
A severe diarrhoeal illness with production of µrice 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, fecesstreaked 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 29 the illness

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
http://www.who.int/mediacentre/factsheets/fs107/en/print.html 38

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 41 comparisons with erythromycin

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
² between 2-12 years, ² having watery diarrhea for ”24 hr and ² severe dehydration, ² 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:
² name, age, address, telephone number ² Occupation, education and monthly income of parents ² duration of illness, frequency of diarrhea and vomiting prior to

admission, and
² 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 generated random number table on a master list.
47

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 and managed further as per the WHO Guidelines.

48

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 minutes of drug administration.
49

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, 2, 3 and 7.

50

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 had not passed stool for 12 hours.
54

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 a 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 ³Study 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 by susceptible strains.
65

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.