eMedicine Specialties > Neurology > Neurological Infections

Meningococcal Meningitis: Treatment & Medication

Author: Francisco de Assis Aquino Gondim, MD, MSc, PhD, Professor Adjunto II, Departments of Physiology and Pharmacology, Neurology Residency Program Director, Faculdade de Medicina, Universidade Federal do Ceará, Brazil
Coauthor(s): Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience; Sidney E Croul, MD, Director of Neuropathology, Professor, Department of Pathology and Laboratory Medicine, Medical College of Pennsylvania Hahnemann University
Contributor Information and Disclosures

Updated: Aug 11, 2009

Treatment

Medical Care

Meningococcal disease is potentially fatal and always should be viewed as a medical emergency. Admission to a hospital is necessary. To prevent serious neurological morbidity and death, prompt institution of antibiotic therapy is essential when the diagnosis of bacterial meningitis is suspected.

  • Institute antimicrobial therapy as soon as possible after the lumbar puncture is performed.
  • If imaging studies are indicated before lumbar puncture, draw blood for culture and begin administration of empiric antibiotics. Administration of empiric antibiotics is unlikely to decrease diagnostic sensitivity if CSF is tested for bacterial antigens early in the course of the illness.
  • Long delays may occur in the emergency department before initiation of antibiotics in patients with suspected bacterial meningitis. In general, these delays appear to be physician generated and, to a great extent, potentially avoidable.12
  • In children and adults, the recommended initial empiric therapy consists of third-generation cephalosporins, but the addition of ampicillin is required in patients in whom a Listeria species pathogen is suspected (eg, patients older than 50 years, neonates). Once the organism is identified, the antibiotic regimen can be changed appropriately.
  • A recent study has suggested that at least in children, CSF sterilization may occur more rapidly after initiation of parenteral antibiotics than previously suggested, with complete sterilization of meningococcus within 2 hours and the beginning of sterilization of pneumococcus by 4 hours.

Surgical Care

Surgical interventions may be necessary for the management of complications such as subdural effusions, empyema, and hydrocephalus.

Medication

At presentation, meningitis due to N meningitidis may be impossible to differentiate from other types of meningitis. Thus, empirical treatment with an antibiotic with effective CNS penetration should be based on age and underlying disease status, since delay in treatment is associated with adverse clinical outcome.

Standard empirical therapy varies according to age, as follows:

  • In infants younger than 4 weeks, it consists of ampicillin plus cefotaxime or an aminoglycoside.
  • Infants aged 4-12 weeks should be treated with ampicillin plus a third-generation cephalosporin.
  • In children aged 12 weeks to 18 years, a third-generation cephalosporin or ampicillin plus chloramphenicol is an appropriate combination.
  • Adults aged 18-50 years and individuals with basilar skull fracture should be treated with a third-generation cephalosporin, while individuals older than 50 years should be treated with ampicillin plus a third-generation cephalosporin.

Once the accurate diagnosis of meningococcal meningitis is established, appropriate changes can be made. Currently, penicillin is the drug of choice for the treatment of meningococcal meningitis and septicemia. Unresponsiveness to penicillin has not been observed in the United States. Routine testing for susceptibility of meningococcal isolates is not necessary, unless the patient does not exhibit appropriate clinical response.

Therapy should be changed to ceftriaxone (or cefotaxime) if the isolate is resistant to penicillin.

The use of dexamethasone in the management of bacterial meningitis in adults remains controversial. It may be used in children, especially in those with meningitis caused by Haemophilus influenzae. In adults with suspected bacterial meningitis, especially in high-risk cases, the adjunctive use of dexamethasone may be beneficial.

Person-to-person transmission can be interrupted by chemoprophylaxis, which eradicates the asymptomatic nasopharyngeal carrier state. Rifampin, quinolones, and ceftriaxone are the antimicrobials used to eradicate meningococci from the nasopharynx.

Antibiotics

Penicillin is the drug of choice for the treatment of meningococcal meningitis and septicemia. Chemoprophylactic antimicrobials most commonly used to eradicate meningococci include rifampin, quinolones (eg, ciprofloxacin), and sulfonamides. (Also included in this category are ceftriaxone, minocycline, and spiramycin.)


Penicillin G (Pfizerpen)

Patients in whom meningococcal disease is suspected should receive a high dose of this drug, which interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Adult

4 million U initially through intermittent IV q4h

Pediatric

250,000 U/kg/d IV in divided doses

Probenecid can increase effectiveness

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in patients with impaired renal function


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms.

Adult

Treatment: 2 g IV q12h
Chemoprophylaxis: 250 mg IM (single dose)

Pediatric

Treatment: 50 mg/kg IV q12h; not to exceed 4 g/d
Chemoprophylaxis
<15 years: 125 mg IM (single dose)
>15 years: 250 mg IM (single dose)

Probenecid may increase levels; ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in patients with renal impairment; caution in breastfeeding women


Rifampin (Rifadin, Rimactane)

Inhibits DNA-dependent bacterial but not mammalian RNA polymerase. For chemoprophylactic use only.

Adult

600 mg PO for 2 d

Pediatric

<1 month: 5 mg/kg PO q12h for 2 d
>1 month: 10 mg/kg PO q12h for 2 d

Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, cyclosporine, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; enalapril may increase blood pressure; isoniazid may result in higher chances of hepatotoxicity than with either agent alone

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

Caution in hepatic disease, as drug may cause further hepatic damage; serious thrombocytopenia may occur, which is reversible if therapy discontinued; if treatment continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur


Ciprofloxacin (Cipro)

Single dose (500 mg) may be effective for eradication of meningococcal carriage in adults. For chemoprophylactic use only.

Adult

500 mg PO qd

Pediatric

<18 years: Not recommended; has caused cartilage damage in immature experimental animals

Reduces therapeutic effects of phenytoin; antacids, iron salts, and zinc salts may reduce serum levels; may increase toxicity of theophylline, cyclosporine, and digoxin; may increase effects of anticoagulants

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

With long-term use, may need periodic renal, hepatic, and hematologic evaluations; adjust dose in patients with impaired renal function

More on Meningococcal Meningitis

Overview: Meningococcal Meningitis
Differential Diagnoses & Workup: Meningococcal Meningitis
Treatment & Medication: Meningococcal Meningitis
Follow-up: Meningococcal Meningitis
Multimedia: Meningococcal Meningitis
References
Further Reading
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Keywords

Neisseria meningitidis, N meningitidis, meningococcal disease, meningococci, meningococcal infections, Neisseria lactamica, N lactamica, bacterial meningitis, Waterhouse-Friderichsen syndrome, meningococcal septicemia

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Contributor Information and Disclosures

Author

Francisco de Assis Aquino Gondim, MD, MSc, PhD, Professor Adjunto II, Departments of Physiology and Pharmacology, Neurology Residency Program Director, Faculdade de Medicina, Universidade Federal do Ceará, Brazil
Francisco de Assis Aquino Gondim, MD, MSc, PhD is a member of the following medical societies: American Academy of Neurology and Movement Disorders Society
Disclosure: Boehringer-Ingelheim Honoraria Speaking and teaching

Coauthor(s)

Manish K Singh, MD, Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience
Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Association of Physicians of Indian Origin, American Headache Society, American Medical Association, and American Society of Regional Anesthesia and Pain Medicine
Disclosure: Nothing to disclose.

Sidney E Croul, MD, Director of Neuropathology, Professor, Department of Pathology and Laboratory Medicine, Medical College of Pennsylvania Hahnemann University
Sidney E Croul, MD is a member of the following medical societies: American Academy of Neurology, American Association of Neuropathologists, and Society for Neuroscience
Disclosure: Nothing to disclose.

Medical Editor

Norman C Reynolds Jr, MD, Neurologist, Veterans Affairs Medical Center of Milwaukee; Professor Medical College of Wisconsin (retired)
Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Nicholas Y Lorenzo, MD, Chief Editor, eMedicine Neurology; Consulting Staff, Neurology Specialists and Consultants
Nicholas Y Lorenzo, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Neurology
Disclosure: Nothing to disclose.

 
 
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