WHO 2024 Cholera Antibiotic Treatment Guidelines

Antibiotic Selection

Azithromycin is the WHO‑recommended first‑line oral antibiotic for cholera (single‑dose 20 mg/kg for children, 1 g for adults) because it shortens diarrhea duration and improves clinical success compared with other agents【1】.
Doxycycline (single 300 mg dose for adults or 4 mg/kg up to 300 mg for children > 8 years) is listed as a second‑line option when azithromycin is unavailable or contraindicated【1】.
Ciprofloxacin is an alternative second‑line agent alongside doxycycline【1】.

Antibiotics should be administered only to patients with severe dehydration; rapid fluid replacement remains the primary therapy for all cholera patients【1】.
Patients with mild‑to‑moderate dehydration do not require antibiotics and should receive rehydration alone【1】.

Increasing prevalence of tetracycline‑resistant Vibrio cholerae O1 strains has reduced the effectiveness of doxycycline, prompting its relegation to second‑line status【1】.

Single‑dose azithromycin reduces the duration of diarrhoea by more than 1 day versus ciprofloxacin and by about 0.5 day versus erythromycin【1】.
Clinical success is higher with azithromycin (risk ratio 1.34; 95 % CI 1.16–1.54)【1】.
In epidemic settings, the single‑dose regimen of azithromycin improves compliance, making it especially valuable【1】.

Do not use doxycycline as empiric first‑line therapy in regions where tetracycline resistance is documented【1】.
Do not prescribe antibiotics without first ensuring adequate rehydration; fluid therapy is the cornerstone of cholera management【1】.
Azithromycin should be the default treatment; reserve doxycycline or ciprofloxacin only when azithromycin cannot be used【1】.