Meningococcal Infections Follow-up

Patients with meningococcal disease must complete a course of antimicrobial therapy.

Any complications of meningococcal disease must also be treated. One of the most common complications that occur during the course of treatment is arthritis, which has been found in about 10% of patients with meningococcal disease. This complication usually occurs within the first few days of treatment and manifests as effusion of a large joint, often the knee. Joint effusions usually resolve without a change in therapy; occasionally, repeated arthrocentesis is needed to control symptoms.

Other possible complications include ischemic conditions caused by the coagulation abnormality and neurologic complications of meningitis. The patient must be observed for any neurologic sequelae. The frequency of neurologic abnormalities seems to be related to the severity of the acute disease. Some neurologic sequelae can develop in the absence of meningitis.

Respiratory precautions may be discontinued once the patient has received 24 hours of effective antimicrobial therapy.

Household contacts and close respiratory contacts of a patient should undergo chemoprophylaxis to eliminate the carrier state and to prevent the spread of infection or reinfection.

Observe patients for any late neurologic sequelae. Abnormal findings on electroencephalography, epileptogenic activity, sensorineural hearing loss, impaired vestibular function, abnormal findings on cerebral CT scan, and neuropsychological impairment have been found in up to 30% of survivors 1 year after an episode of meningococcal disease. The frequency of serious neurologic sequelae in individuals who survive an episode is 3%.

Rifampin is used for chemoprophylaxis (see Medications). Single-dose ciprofloxacin has also been recommended for contact prophylaxis in adults.

Sulfadiazine can be used for chemoprophylaxis when the causative meningococcal isolate is known to be susceptible to this antimicrobial (see Medications).

Promptly transfer any patient who is acutely ill with fever, headache, and petechial rash to a hospital for medical evaluation. This evaluation should include an LP for examination of the CSF.

^[13] Antimicrobial chemoprophylaxis of close contacts is the primary means of preventing secondary cases of sporadic meningococcal disease. Person-to-person transmission can be interrupted by administration of an antimicrobial that eradicates the asymptomatic nasopharyngeal carrier state. Sulfonamides, rifampin, minocycline, ciprofloxacin, and ceftriaxone are the drugs that have been shown to eradicate meningococci from the nasopharynx.

Meningococcal infection is probably introduced into families by asymptomatic adults and then spread through one or more household contacts to infect younger family members. Household contacts are defined as individuals who live in the same house with a person who has a meningococcal disease. An operational definition commonly used by public health authorities includes persons eating and sleeping under the same roof with the index case. The attack rate of meningococcal disease among household contacts has been estimated to be several hundred times greater than that in the general population. The secondary attack rate is inversely proportional to age and is estimated to be approximately 10% in household contacts aged 1-4 years.

The risk of acquiring meningococcal disease may also be increased in other closed populations, such as those of daycare facilities and nursery schools. The American Academy of Pediatrics recommends antimicrobial chemoprophylaxis for contacts of persons with invasive meningococcal disease, including household members, individuals at daycare centers and nursery schools, and persons directly exposed to the patient's oral secretions (eg, kissing, sharing food or beverages) within 7 days preceding the onset of the illness in the index case. The decision to administer chemoprophylaxis to other populations should be reached only after consultation with public health authorities who have a better understanding of the patterns of disease that currently exist in the community.

Consider antimicrobial chemoprophylaxis in hospital personnel who have direct exposure to the oral secretions of a patient with meningococcal disease from such activities as mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management. Patients with meningococcal disease who are hospitalized should be placed on respiratory precautions for the first 24 hours of effective antimicrobial therapy. When this is done, the risk for hospital personnel with casual or indirect contact is believed to be negligible. Antimicrobial chemoprophylaxis is not recommended in hospital personnel who have only casual or indirect contact with a patient with meningococcal disease.

For travelers, antimicrobial chemoprophylaxis should be considered for any passenger who had direct contact with respiratory secretions from an index patient or for anyone seated directly next to an index patient on a prolonged flight (ie, one that lasts ≥8 h).

Rifampin is commonly used for meningococcal prophylaxis of household contacts in the United States, where one third of the prevalent strains are sulfadiazine resistant. A 2-day course of rifampin is recommended. The rapid emergence of rifampin-resistant meningococci precludes the use of this drug in large populations. Chemoprophylaxis of sulfadiazine-resistant meningococci by rifampin should be accompanied by close observation of household contacts for signs of disease. A single dose of ciprofloxacin has been found to provide an effective alternative to rifampin for the eradication of meningococcal carriage in adults.

Ciprofloxacin is not recommended in persons younger than 18 years because it has caused cartilage damage in immature experimental animals. A single intramuscular injection of ceftriaxone has been found to eradicate meningococcal carriage. The chemoprophylactic dose of ceftriaxone is 250 mg IM in adults and 125 mg IM in children.

Meningococcal isolates that are susceptible to sulfadiazine can be eradicated by a 2-day course of sulfadiazine. The high incidence of adverse effects has limited acceptance of minocycline as a means of eradicating the carrier state.

Meningococcal disease can be prevented by vaccination with group-specific meningococcal capsular polysaccharides. The CDC has issued an updated 2010 guideline for meningococcal conjugate vaccines (ie, Menactra, Menveo).^[13]

Purified polysaccharides of groups A, C, Y, and W135 meningococci have been used to stimulate group-specific humoral bactericidal antibodies.

A meningococcal polysaccharide vaccine (MPSV4), which is quadrivalent, has been a highly effective means of preventing disease caused by these serogroups of meningococci. A single dose of vaccine does not protect younger children, especially those younger than 2 years. Menactra has been approved for high-risk children aged 9-23 months.^[14] Use of the vaccine is indicated for the at-risk population whenever an outbreak caused by one of these serogroups of meningococci occurs and for terminal complement deficiency and anatomic asplenia patients. In 2005, a tetravalent meningococcal polysaccharide-protein conjugate (MCV4) was licensed for use among persons aged 2-55 years. This vaccine has the advantage of producing a longer duration of protective antibodies.

The ACIP recommends vaccination with MCV4 before high-school entry as an effective strategy to reduce meningococcal disease incidence among adolescents and young adults. MCV4 is also recommended for at-risk populations, including college freshmen living in dormitories, military recruits, travelers to areas where meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to meningococci, patients with anatomic or functional asplenia, and patients with terminal complement deficiency. Other adolescents, college students, and persons infected with HIV who wish to decrease their risk for meningococcal disease may elect to receive this vaccine.

The risk of Guillain-Barré Syndrome (GBS) seems to be slightly increased among recipients of the MCV4 (Menactra) vaccine.^[15] The CDC estimates the rate to be 0.2 per 100,000 person-months in individuals aged 11-19 years who received the vaccine. The background rate was estimated at 0.11 per 100,000 person-months in this population group. The CDC recommends that persons with a history of GBS not receive MCV4, although persons with a history of GBS at especially high risk for meningococcal disease (eg, microbiologists routinely exposed to isolates of N meningitidis) might consider vaccination. The ACIP is in the process of reviewing the current recommendations for MCV4.

Although the capsular polysaccharide of group B meningococci is not immunogenic, progress has been made in obtaining a satisfactory vaccine for group B meningococcal disease. A vaccine for group B organisms was developed in Cuba and consists of outer-membrane proteins that are capable of inducing group-specific bactericidal antibody. Clinical trials with this vaccine in the United States have not been completed.

Vaccination with the meningococcal polysaccharides has also been used effectively in military recruit populations to control disease caused by group A and group C N meningitidis.

The increased incidence of meningococcal disease in adolescents and college-aged young adults has prompted consideration of a policy of routine vaccination in this population. The ACIP recommends college freshmen and their parents be provided information about the risk of meningococcal disease and the availability of MCV4 so they can make an informed decision regarding vaccination. Routine vaccination with MCV4 of all children is recommended by ACIP beginning at age 11 years.

Many complications occur in fulminant meningococcemia. Patients with fulminant meningococcemia may develop respiratory insufficiency and need mechanical ventilation. Patients with severe DIC may develop a hemorrhagic diathesis with bleeding into the lungs, urinary tract, and gastrointestinal tract. Ischemic complications of DIC have been reported in up to 50% of survivors of fulminant meningococcemia.

Meningococcal meningitis may progress to mental obtundation, stupor, or coma, which may be related to increased ICP, and such patients are prone to herniation. Other rare complications of meningitis include acute and delayed venous thrombosis, which usually manifests as a focal neurologic deficit.

Meningococcal infection may spread through the bloodstream and localize in other parts of the body, where it can cause suppurative complications. Septic arthritis, purulent pericarditis^[16] , and endophthalmitis^[17] can occur but are uncommon. Meningococcal pneumonia has been described and probably results from aspiration of N meningitidis. The W135 serogroup of meningococci was found to be more likely to cause this form of meningococcal disease, as well as pericarditis or septic arthritis.

Approximately 10% of patients with meningococcal disease develop nonsuppurative arthritis, usually of the knee joints. This usually becomes evident within the first 48 hours of treatment. Nonsuppurative arthritis is believed to occur on an immunologic basis.

Meningococcal disease may progress very quickly and can result in loss of life, neurologic impairment, or peripheral gangrene.

Recurrent meningococcal disease has been associated with hereditary deficiencies of various terminal components of the complement system.

The prognosis of fulminant meningococcemia is guarded. Approximately one half of patients who present with this form of meningococcal disease do not survive, even with prompt administration of appropriate antimicrobial therapy.

The prognosis of meningococcal meningitis is relatively good if the patient is neither comatose nor has focal neurologic findings. Most patients with this form recover completely when appropriate antimicrobial therapy is administered promptly upon presentation.

For patient education resources, see the Brain and Nervous System Center, as well as Meningitis in Adults and Meningitis in Children.