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After many years of progress in reducing the burden of Vibrio cholerae, the causative agent of cholerae, recent upsurges threaten this and highlight a worrying trend for future infection rates. From 2022 to 2024, rates of cholera increased by around 40% globally (), with the rates in 2022 already being double that of 2021 (). 

This surge is a result of several factors such as increases in natural disasters due to climate change, along with conflict and humanitarian crises. Events like these can result in flooding or breakdowns in access to clean water, resulting in individuals and communities coming into contact with contaminated water, increasing their risk of V. cholerae infection (). 

Antibiotics are recommended for use in severe cases of cholera, for example, when oral rehydration therapy is failing. The recommended antibiotics are broad spectrum agents like doxycycline, azithromycin and ciprofloxacin (). The rise in V. cholerae infections has undoubtedly resulted in the increased use and, in turn, misuse of antibiotics. Additionally, these recent infections have been associated with a higher case fatality rate (). This is likely due to a culmination of factors such as lack of access to oral rehydration therapy treatments or vaccination, but it may also be highlighting a trend of more severe infections and thus further antibiotic use. V. cholerae, is already known to be multi-drug resistant (), and the poor sanitation and hygiene associated with V. cholerae infection allows for resistant bacteria to proliferate and spread through communities. The surge in cholera rates over the past 3 years therefore may have resulted in an increased spread of resistant bacteria through affected communities and beyond. 

Three oral cholera vaccines are approved by the WHO and these are key in mitigating the effects of outbreaks and increased infection rates. However, the vaccines are produced in a limited capacity such that when surges occur, as in recent years, a supply gap is created. Data has suggested that ~50% of requests for vaccines are denied (). In early 2024, a simplified vaccine formulation was approved by the WHO allowing production to begin to increase to meet demand (). In turn the vaccine stockpile was able to reach 5.9 million doses by December 2024, exceeding the 5 million dose threshold suggested for effective outbreak response (). 

Ultimately however, to prevent infection and the unnecessary use of antibiotics, investing in sustainable water, sanitation and hygiene (WASH) infrastructures is crucial. Ensuring that communities, for example, have easy access to clean water can greatly reduce the risk of transmission. In displaced populations, the rapid establishment of WASH services is also key in preventing large scale outbreaks within refugee camps which can often be devastating. 

As natural disasters and flooding are only set to increase in the coming years, working towards implementing effective WASH measures will allow for an infrastructure which can prevent the spread and outbreaks of many infectious disease agents. Ultimately, allowing for increased prevention of widespread morbidity and the reduced use and conservation of remaining effective antibiotics.