Quantifying the population-level impact of expanded antibiotic treatment for cholera outbreak management

Since 2021, there has been a resurgence in the number of cholera cases, countries affected, and the case fatality rate. Because most cholera patients recover without antibiotic treatment, current cholera treatment guidelines only consider the tradeoffs between patient recovery and antibiotic stewardship. However, antibiotics also greatly reduce bacteria shedding, creating a potential role for antibiotics in cholera outbreak response through reduced transmission. We developed a compartmental model of cholera transmission in a non-endemic setting to quantify the potential impact of expanded antibiotic treatment on disease burden and antibiotic use. Through simulations, we evaluated different outbreak scenarios, by varying the reproductive number, care-seeking behavior, and proportion of non-severe cases receiving antibiotics. We found that expanding antibiotic treatment could significantly reduce the final outbreak size under certain outbreak characteristics. In these scenarios, treating non-severely symptomatic infections with antibiotics decreased cholera transmission and, in some cases, the total number of antibiotic doses used. We show that the effectiveness of expanded antibiotic treatment is highly dependent on achieving high care-seeking rates among non-severely symptomatic infections and tailoring the approach to specific outbreak conditions. While expanding antibiotic eligibility could enhance outbreak control in some settings, careful consideration of antibiotic resistance risks is necessary in high-transmission contexts.