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4.1: Bacterial Infections

Table of Contents

4.1.1 Cholera

Cholera is an acute gastrointestinal infection caused by Vibrio cholerae. Infection occurs through ingestion of contaminated water or food by human faeces leading to severe diarrhoea and emesis associated with body fluid and electrolyte depletion.

Note: When a case of cholera is suspected at home, advise to rehydrate the patient using ORS if available while preparing to take a patient to the nearest health facility or Cholera Treatment Centre

Diagnostic Criteria

  • A sudden onset of painless watery diarrhoea that may quickly become severe with profuse watery stools, vomiting, severe dehydration and muscular cramps, leading to hypovolemic shock and death
  • The stool has a characteristic “rice water” appearance (non-bilious, grey, slightly cloudy fluid with flecks of mucus, no blood and inoffensive odour)


  • Laboratory evidence of dark field microscopic isolation of motile curved bacillus on a wet mount of fresh stool specimen. OR
  • Isolation of bacteria through stool culture on TCBS agar.
For confirmation at the beginning of an outbreak, rectal swab or stool specimen should be taken from first 5 to 10 suspected cases.
If any are positive, every tenth case will be sampled for specimen throughout the outbreak
Manage a suspected cholera case in an isolation ward or in an established Cholera Treatment Centre


  • Drink water from safe sources (taps, decontaminated deep wells, bottles)
  • Boil water or treat it to kill bacteria and make it safe for drinking and other domestic uses
  • Wash hands with liquid soap and running water after visiting the toilet, before preparing foods, and before eating
  • DO NOT eat uncooked street food and do not eat cooked food that is no longer hot.
  • DO NOT eat street prepared fresh fruits. Always eat home prepared fresh fruits


  • Assess the patient’s level of dehydration as per National Guidelines for Prevention and Control of Cholera. It is of paramount importance to make correct diagnosis and administer the right treatment according to the Treatment
    o plan A: No dehydration,
    o plan B: Moderate dehydration and
    o plan C: Severe dehydration.

Pharmacological Treatment:

For Severe dehydration:

  • Administer intravenous (IV) fluid immediately to replace fluid deficit; Use Ringer Lactate solution or, if that is not available, 0.9% sodium chloride solution. Give 100 ml/kg IV in 3 hours, 30 ml/kg as rapidly as possible (within 30 min) then 70 ml/kg in the next 2.5 hours.
  • After the initial 30 ml/kg has been administered, the radial pulse should be strong and blood pressure should be normal. If the pulse is not yet strong, continue to give IV fluid rapidly. Administer ORS solution (about 5 ml/kg/hour) as soon as the patient can drink, in addition to IV fluid.
  • If the patient can drink, begin giving A: oral rehydration salt solution (ORS) by mouth while the drip is being set up; ORS can provide the potassium, bicarbonate, and glucose that saline solution lacks. Give an oral antibiotic to patients with severe dehydration as follows:

Adults (Not for pregnant women)

A: Doxycycline (PO) 300 mg as a single dose or 5mg/kg single dose


A: Ciprofloxacin (PO) 1g stat or 15mg/kg 12 hourly for 3 days


A: Folic acid (PO) 5mg once daily for the duration of the treatment.

Expectant mothers:

A: Erythromycin (PO) 500mg 8 hourly for 5 days


A: Erythromycin syrup (PO) 12.5mg/kg 6 hourly for 3 days


A: Co-trimoxazole 48mg/kg once a day for 3 days

For adolescents:

A: Ciprofloxacin (PO) 12mg/kg 2 times for 3 days


A: Doxycycline (PO) 300mg as single dose or 5mg/kg single dose


A: Folic acid (PO) 2.5mg once daily for children < 6 months, or 5mg once daily for children >6 months for the duration of the treatment


A: Zinc (PO) 10mg once daily for children <6months, or 20mg once daily for children >6 months for duration of 10 days

Ciprofloxacin was previously contraindicated to children under 12 years. Recent studies have shown it to be safe for use in children
Start feeding 3-4 hours after oral rehydration begins. Preferably, give antibiotics with food to minimize vomiting

For moderate Dehydration

  • Give oral rehydration, approximately 75-100ml/kg in the first four hours
  • Reassess after four hours; if improved, continue giving WHO based ORS, in quantity corresponding to losses (eg. after each stool) or 10 to 20ml/kg. If not improved, treat as severe

If no signs of dehydration

  • Patients who have no signs of dehydration when first observed can be treated at home
  • Give these patients ORS packets to take home, enough for 2 days
  • Demonstrate how to prepare and give the solution
  • Instruct the patient or the caretaker to return if any of the following signs develop; increased number of watery stools repeated vomiting or any signs indicating other problems (eg, fever, blood in stool)


Prophylaxis of cholera contacts is not recommended. Routine treatment of a community with antibiotics, or mass chemoprophylaxis, has no effect on the spread of cholera, can have adverse effects by increasing antimicrobial resistance and provides a false sense of security.

4.1.2 Anthrax

Anthrax is a bacterial disease caused by the spore forming Bacillus anthracis, a Gram positive, rod-shaped bacterium. It is a zoonotic disease whereby man is infected directly through contact with infected hides or inhalation of spores in the lungs or ingestion of infected meat. It can be cutaneous, pulmonary and/or intestinal.

Diagnostic Criteria:

  • Itching
  • A malignant pustule,
  • Pyrexia
  • Pulmonary and gastrointestinal signs.

Pharmacological Treatment

A: Benzylpenicillin. Adult 0.6 MU I.V every 6 hours until local oedema subsides then continue with

A: Phenoxymethylpenicillin 250 mg 6 hourly for 7 days

A: Paracetamol 15mg/kg 8 hourly for 3 days

4.1.3 Plague

An infectious disease caused by the bacteria Yersinia pestis, usually found in small mammals and their fleas. It is transmitted between animals from their fleas. Humans can be contaminated by the bite of infected fleas, through direct contact with infected materials or by inhalation.

Diagnostic Criteria

  • Sudden onset of fever, chills, head and body aches  Weakness, vomiting and nausea.
  • Yersinia pestis is identified by laboratory testing from a sample of pus from a bubo, blood or sputum.
  • A specific Y. pestis antigen can be detected by different techniques.

There are 3 forms of plague infection, depending on the route of infection:

  • Bubonic plague is the most common, caused by the bite of an infected flea. pestis, enters at the bite and travels through the lymphatic system to the nearest lymph node, replicates itself and causes the lymph node to be inflamed, tense and painful, turning into open sores with pus.
  • Septicaemic plague occurs when infection spreads through the bloodstream, following untreated bubonic plague causing bleeding, tissue necrosis and shock.
  • Pneumonic plague is the most virulent form and is rare. It is typically caused by spread to the lungs from advanced bubonic plague. However, any person with pneumonic plague may transmit the disease via droplets to other humans. Untreated pneumonic plague can be fatal.


  • Inform people of the presence of zoonotic plague and advised to take precautions against flea bites
  • Do not handle animal carcasses and avoid direct contact with infected body fluids and tissues
  • Apply standard precautions when handling potentially infected patients and while collecting specimens

Vaccination: Not recommended expect for high-risk groups (such as laboratory personnel who are constantly exposed to the risk of contamination, and health care workers).

Pharmacological Treatment

  • C. Streptomycin 30 mg/kg/day (up to a total of 2 g/day) in divided doses IM, to be continued for 10 days of therapy or until 3 days after the temperature has returned to normal.

4.1.4 Cerebro-Spinal Meningitis

Further information on Meningitis refer Nervous system (chapter eight). Note that for epidemics, N. Neisseria meningitidis is the one with the potential to cause large epidemics.

Diagnostic Criteria

  • Sudden fever
  • Neck stiffness,
  • Intense headache, nausea and vomiting,
  • Altered consciousness and convulsions,
  • Bulged anterior fontanelle (in infants)

4.1.5 Neonatal Tetanus

Usually occurs through introduction of tetanus spores via the umbilical cord during delivery through the use of an unclean instrument to cut the cord, or after delivery by “dressing” the umbilical stump with substances heavily contaminated with tetanus spores.

Diagnostic Criteria

  • Sudden inability of a newborn to suck/feed between 2nd and 28th day after birth
  • Generalized stiffness
  • Convulsions


  • Immunize women of reproductive age with TTCV, either during pregnancy or outside of pregnancy. This protects the mother and also her baby through the transfer of tetanus antibodies to the fetus.
  • Good hygienic practices when the mother is delivering a child are also important to prevent neonatal and maternal tetanus.

To be protected throughout life, WHO recommends that an individual receives 6 doses (3 primary plus 3 booster doses) of TTCV through routine immunization.


  • Rigorously cleanse the umbilical stump to stop the production of toxin at the site of infection
  • Antibiotic therapy:
    A: Amoxycillin via Nasal Gastric Tube 20–30 mg/kg/day every 8 hours
    A: Metronidazole 7.5 mg/kg For postnatal age ≤7 days: 1200–2000 g: 7.5 mg/kg/day given every 24 hours >2000 g: 15 mg/kg/day in divided doses every 12 hours. Postnatal age >7 days: 1200-2000 g: 15 mg/kg/day in divided doses every 12 hours >2000 g: 30 mg/kg/day in divided doses every 12 hours
  • Immunotherapy, to neutralise circulating toxin
    B: Administer human antitetanus immunoglobulin (TIG), 100–300 IU/kg intramuscularly stat, with the dose divided into two different muscle masses
  • To provide effective management of muscle spasm, give a sedative cocktail of ALL the following via NGT: B: Diazepam 0.5 mg/kg every 6 hours
  • A: Chlorpromazine 2 mg/kg every 6 hours
  • B: Phenobarbitone 6 mg/kg every 12 hours


Table 4.1: Guidelines for Dosage Administration**

Time (hours) 0 3 6 9 1










Diazepam * * * * * *
Chlorpromazine * * *
Phenobarbitone * * *

** These are general guidelines. Frequency of drug administration should be titrated vs clinical condition

  • Airway / respiratory control
    o Provide mechanical ventilation.
  • Provide adequate fluids and nutrition, as tetanus spasms result in high metabolic demands and a catabolic state.

4.1.6 Tick-Borne Relapsing Fever

A bacterial infection caused by Borrelia bacteria, transmitted to humans through the bite of infected “soft ticks”, that live within rodent burrows, feeding on the rodent. Humans typically come into contact with soft ticks when they sleep in rodent-infested cabins.

Diagnostic Criteria

  • Recurring episodes of high fever, headache, muscle and joint aches, and nausea
  • Reccurring symptoms, producing a telltale pattern of fever lasting roughly 3 days, followed by 7 days without fever, followed by another 3 days of fever. Without antibiotic treatment, this process can repeat several times.


  • Peripheral blood smear reveals a long and spiral-shaped bacterium.


  • Avoid sleeping in rodent-infested buildings whenever possible. Although rodent nests may not be visible, other evidence of rodent activity (e.g., droppings) are a sign that a building may be infested.
  • Prevent tick bites. Use insect repellent (on skin or clothing) or permethrin (applied to clothing or equipment).
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