eMedicine Specialties > Dermatology > Bacterial Infections
Meningococcemia: Treatment & Medication
Updated: Sep 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- The most important measure in treating meningococcemia is early detection and rapid administration of antibiotics. Penicillin G is the antibiotic of choice for susceptible isolates. A third-generation cephalosporin (eg, cefotaxime, ceftriaxone) can be used initially in septic patients while the diagnosis is being confirmed or in countries such as the United Kingdom or Spain, where penicillin-resistant strains of N meningitidis have been isolated.6
- Intensive supportive care is required for patients with fulminant meningococcemia. Components of treatment include antibiotic therapy, ventilatory support, inotropic support, and intravenous fluids. Central venous access facilitates the administration of massive amounts of volume expanders and inotropic medications needed for adequate tissue perfusion. If disseminated intravascular coagulation (DIC) is present, fresh frozen plasma may be indicated. Treatment is individualized depending on the severity of hemodynamic compromise of the patient.
- Many experimental and alternate therapies have been tried with varying success.7 Currently under study are treatments to inhibit inflammatory mediators (eg, monoclonal antibodies to endotoxin, tumor necrosis factor, interleukin 1, interleukin 6, and interferon-gamma). Anecdotal reports show removal of inflammatory mediators by dialysis may offer some benefit. Fibrinolytic treatment using recombinant tissue plasminogen activator or the administration of highly purified protein C concentrate may prove to be helpful adjuncts to conventional therapy to improve tissue perfusion in the presence of DIC.8
- Several clinical guideline summaries related to meningococcal disease are available, as follows:
- American Academy of Pediatrics Committee on Infectious Diseases - Prevention and control of meningococcal disease: recommendations for use of meningococcal vaccines in pediatric patients9
- Centers for Disease Control and Prevention Advisory Committee on Immunization Practices - Revised recommendations of the Advisory Committee on Immunization Practices to Vaccinate all Persons Aged 11-18 Years with Meningococcal Conjugate Vaccine10
- Scottish Intercollegiate Guidelines Network -Management of invasive meningococcal disease in children and young people. A national clinical guideline11
Surgical Care
Patients who survive the initial acute phase of fulminant meningococcemia are at increased risk for serious complications as a result of poor tissue perfusion.12
- Early in the course of tissue injury, conservative therapy is recommended until a distinct line of demarcation is apparent between viable and nonviable tissue.
- Once the patient is stable, debridement of all necrotic tissue is essential and may necessitate extensive removal of skin, subcutaneous tissue, and muscle.
- Large defects may be covered using microvascular free flaps or skin grafts.
- The use of artificial skin can spare the patient immediate use of autograft sites, which frequently are limited.13
- Avoid amputation whenever useful function of a limb can be salvaged.
- Poor tissue perfusion may also lead to dental complications that require extensive extraction of severely affected teeth.14
Consultations
- Infectious disease specialist - To assist in management and provide guidance in antimicrobial therapy
- Preventive medicine specialist - To evaluate the community risk associated with an index case and initiate reporting to local and regional health authorities if indicated
Medication
The goals of pharmacotherapy are to eradicate the microorganism, to reduce morbidity, and to prevent complications.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Penicillin G (Pfizerpen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Adult
300,000 U/kg/d up to 24 million U/d IV in divided doses q4h until 5-7 d after temperature has returned to normal
Pediatric
Administer as in adults
Probenecid can increase effects; coadministration of tetracyclines can decrease effects; may increase methotrexate toxicity; may decrease contraceptive efficacy; may interfere with immunological response to live typhoid vaccine; concurrent administration with aminoglycoside therapy may result in inactivation of aminoglycoside (amikacin appears to possess greatest stability in presence of penicillins; in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice)
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function, preexisting seizure disorder, or patients with electrolyte abnormalities (contains 1.7 mEq of potassium per million U)
Chloramphenicol (Chloromycetin)
Binds to 50-S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. Use if patient is allergic to penicillin.
Adult
1 g IV q6h until 5-7 d after temperature has returned to normal
Pediatric
12.5-25 mg/kg IV q6h until 5-7 d after temperature has returned to normal; not to exceed 2-4 g/d
If administered concurrently with barbiturates, serum levels may decrease while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity (chloramphenicol levels may be increased or decreased); may antagonize effect of beta-lactam antibiotics; dosing adjustments of cyclosporine or tacrolimus may be required with concurrent penicillin administration; may interfere with immunological response to live typhoid vaccine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Use only for indicated infections or as prophylaxis for bacterial infections; serious and fatal blood dyscrasias (eg, aplastic anemia, hypoplastic anemia, thrombocytopenia, granulocytopenia) can occur; evaluate baseline and perform periodic blood studies approximately every 2 d while in therapy; discontinue upon appearance of reticulocytopenia, leukopenia, thrombocytopenia, anemia, or findings attributable to chloramphenicol; adjust dose in liver or kidney dysfunction; caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray syndrome); may result in false-positive reaction for urine glucose using copper reduction methods (Clinitest, Benedict solution, or Fehling solution)
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.
Use for penicillin-resistant strains.
Adult
2 g IV/IM q12h until 5-7 d after temperature has returned to normal
Pediatric
50-100 mg/kg/d IV/IM divided q12h until 5-7 d after temperature has returned to normal; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity; hyperbilirubinemic neonates (increased risk of bilirubin encephalopathy [kernicterus])
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breastfeeding; caution in history of gastrointestinal disease, particularly colitis; may interfere with immunological response to live typhoid vaccine
Rifampin (Rimactane, Rifadin)
Inhibits DNA-dependent bacterial but not mammalian RNA polymerase.
Use for chemoprophylaxis after contact. Regimen below does not treat active infection.
Adult
600 mg PO bid for 2 d
Pediatric
10 mg/kg PO bid for 2 d
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Obtain CBC counts and baseline clinical chemistry values prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur
Cefotaxime (Claforan)
Arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
Use for penicillin-resistant strains.
Adult
Bacterial septicemia (for life-threatening infections): 2 g IV q4h
Pediatric
Neonates, premature and normal gestational age: 0-1 week: 50 mg/kg IV q12h;
1-4 week: 50 mg/kg IV q8h
1 month to 12 years and <50 kg: 50-180 mg/kg/d IV divided into 4-6 doses depending on type and severity of infection; not to exceed 12 g/d
1 month to 12 years and >50 kg: 2 g IV q6-8h
Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; has been associated with severe colitis; caution in history of gastrointestinal disease, especially colitis; may result in falsely elevated theophylline serum levels as measured by HPLC (EMIT, TDx) theophylline assay methods do not appear to be subject to cefotaxime interference); may interfere with immunological response to live typhoid vaccine
More on Meningococcemia |
| Overview: Meningococcemia |
| Differential Diagnoses & Workup: Meningococcemia |
 Treatment & Medication: Meningococcemia |
| Follow-up: Meningococcemia |
| References |
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References
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Further Reading
Keywords
meningococcemia, meningococcal sepsis, meningococcal disease, meningococcal infection, meningitis, bacteremia, meningococcemia, acute meningococcal septicemia, adrenal hemorrhage, Waterhouse-Friderichsen syndrome, meningococcal septicemia
