eMedicine Specialties > Infectious Diseases > Bacterial Infections
Meningococcal Infections: Treatment & Medication
Updated: Mar 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- If the presentation is consistent with bacterial meningitis and/or the CSF findings are compatible with pyogenic meningitis, promptly start appropriate antimicrobial therapy. Some authors recommend initiation of appropriate antimicrobial therapy even before LP is performed in highly suspected cases.
- Gram-negative diplococci identified in the CSF with microscopy further suggest meningococcal meningitis.
- Fulminant meningococcemia is the most life-threatening form of meningococcal disease and may be the most difficult to recognize early. Patients with fulminant meningococcemia are likely to be hypotensive and have a severe coagulation abnormality consistent with disseminated intravascular clotting. Perform LP upon presentation, although most study findings other than the culture may be unremarkable.
- Patients with fulminant meningococcemia should be treated in an intensive care setting where frequent monitoring is readily available. Initiate appropriate antimicrobial therapy as soon as possible.
- Therapy is also directed at correcting circulatory collapse and maintaining renal function.
- Fulminant meningococcemia infrequently leads to adrenal insufficiency. If adrenal insufficiency occurs, corticosteroid replacement may be considered.
- Meningococci are susceptible to several antimicrobial agents.
- Penicillin G is more active against N meningitidis than other penicillins. The minimal inhibitory concentration (MIC) of penicillin usually ranges from 0.01-0.05 µg/mL against meningococcal isolates.
- Relative resistance to penicillin (MIC = 0.1-1 µg/mL) was not recognized in the United States until 1991, although it had previously been reported in Europe. The mechanism of resistance is decreased affinity of its penicillin-binding protein 2 for penicillin. Meningococci with relative resistance to penicillin made up only 3% of isolates in the United States in 1991. No isolates that are highly resistant to penicillin (MIC >1 µg/mL) have been found in the United States, although isolates producing beta-lactamase have been reported in South Africa.11
- Ceftriaxone, cefotaxime, and cefuroxime are cephalosporins that penetrate sufficiently into CSF from blood and are useful in the treatment of bacterial meningitis. These cephalosporins are known to have a potent action against meningococci, as do chloramphenicol, rifampin, erythromycin, and tetracyclines. Meningococci were found to be susceptible to ciprofloxacin at low concentrations.
- Meningococci resistant to sulfadiazine (MIC >0.128 µg/mL) have appeared. Surveillance studies in the last 10 years indicate that approximately one third of clinical isolates in the United States are resistant to sulfonamides.
- Meningococci are not inherently susceptible to vancomycin, polymyxin, or achievable serum levels of aminoglycoside antibiotics.
Surgical Care
Ischemic complications of fulminant meningococcemia may require surgical care for management.
Diet
Patients with meningitis or fulminant meningococcemia are at risk of vomiting and should be prevented from taking anything by mouth prior to substantial clinical improvement with antimicrobial therapy.
Activity
Bed rest is recommended for patients suspected of having meningococcal disease. Place patients with meningococcal disease on respiratory precautions for the first 24 hours of effective chemotherapy. Respiratory precautions generally include placement in a private room with proper air handling and the use of a respiratory mask by any person entering the patient's room.
Medication
Institute specific antimicrobial therapy promptly when clinical features suggest meningococcemia or meningococcal meningitis. The recommended drug for the treatment of meningococcal disease is intravenous penicillin G. Infections caused by organisms that are relatively resistant to penicillin seem to respond to this drug as well as fully susceptible organisms do.
Most authorities believe that ceftriaxone and cefotaxime are equally as efficacious as penicillin in the treatment of meningococcal meningitis. Ceftriaxone has the added advantage of having been proven able to eradicate the nasopharyngeal carriage of meningococci. Chloramphenicol is recommended for patients who are severely allergic to penicillin.
Most patients with uncomplicated meningococcemia defervesce within the first 24 hours of antibiotic therapy. Antibiotic therapy for uncomplicated meningococcemia needs to be administered for only 4-5 days after defervescence occurs, and, in adults, the dosage needed to complete the course of therapy can be reduced.
Corticosteroids are recommended for some types of meningitis, but they are not advocated for the treatment of meningococcal meningitis.
Other drugs used in the treatment of fulminant meningococcemia are those used to support the circulation, such as dopamine, and those used to treat DIC. The treatment of DIC with heparin is controversial.
Other drugs used to treat meningococcal meningitis are those that reduce ICP. Treatment of complications with steroids and mannitol is not very effective and is controversial.
Antimicrobial agents
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. People who come into household contact with patients who have meningococcal disease are at risk of acquiring this illness. Person-to-person transmission can be interrupted by chemoprophylaxis, which eradicates the asymptomatic nasopharyngeal carrier state. Rifampin, quinolones, and sulfonamides are the antimicrobials used to eradicate meningococci from the nasopharynx.
Penicillin G (Pfizerpen)
Patients suspected of having meningococcal disease should receive a high dosage of penicillin G for the initial 48 h of therapy because meningitis is a likely complication. Infections caused by organisms classified as relatively resistant to penicillin, based on a MIC = 0.1-1 µg/mL of penicillin, seem to respond to this drug as well as fully susceptible organisms do.
Adult
Initial: 4 million U intermittent IV q4h
Pediatric
250,000 U/kg/d IV/IM divided q4h
Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin
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
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 1 or more penicillin-binding proteins. Equally efficacious as penicillin in treatment of meningococcal disease; however, it is more expensive.
Adult
2 g IV q12h
Pediatric
50 mg/kg IV q12h
Probenecid may increase levels; coadministration with ethacrynic acid, 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 renal impairment; caution in breastfeeding women and in those with allergy to penicillin
Cefotaxime (Claforan)
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. More expensive than penicillin, but most authorities believe that it is equally efficacious as penicillin in the treatment of meningococcal disease
Adult
2 g IV q6h
Pediatric
50 mg/kg IV q6h
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 impairment; has been associated with severe colitis
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. Alternate therapy of meningococcal meningitis in patients who are allergic to penicillin.
Adult
75 mg/kg/d IV until defervescence; then 50 mg/kg/d for 7-10 d
Pediatric
Administer as in adults
Concurrently with barbiturates, chloramphenicol 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; levels may be increased or decreased
Documented hypersensitivity; history of previous toxic reaction
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
Concern about use relates to ability to induce an idiosyncratic reaction with persistent agranulocytosis (aplastic anemia); complication may occur when patients receive chloramphenicol PO; produces a dose-related transient agranulocytosis regardless of route of administration; for this reason, monitor WBC count
Cefuroxime (Kefurox, Zinacef)
Only second-generation cephalosporin approved for use in the treatment of meningitis. Has significant penetration into CSF and enhanced stability against beta-lactamases of Haemophilus influenzae, Neisseria gonorrhoeae, and some Enterobacteriaceae, compared to other first- and second-generation cephalosporins. Its pharmacologic properties most closely resemble those of cefotaxime. Condition of the patient, severity of the infection, and susceptibility of microorganism determines proper dose and route of administration.
Adult
2 g IV q6-8h
Pediatric
50 mg/kg IV q6h
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics, such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential
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
Reduce dosage by one half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy
Rifampin (Rifadin, Rimactane)
Commonly used for meningococcal prophylaxis of household contacts in United States, where one third of prevalent strains are sulfadiazine resistant.
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, 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 1 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 and baseline clinical chemistries 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
Sulfadiazine (Microsulfon)
Through a competitive antagonism of PABA, this agent interferes with microbial growth. Commonly used for meningococcal prophylaxis.
Adult
500 mg PO qid for 2 d
Pediatric
<1 years: 125 mg PO qid for 2 d
1-12 years: 250 mg PO qid for 2 d
>12 years: Administer as in adults
Increases effect of oral anticoagulants and oral hypoglycemic agents; effects are decreased when administered concurrently with PABA or PABA metabolites of drugs, such as proparacaine, tetracaine, sunscreens, and procaine
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
Caution in impaired renal function, impaired hepatic function, or G-6-PD deficiency; adjust dose in renal insufficiency
Ciprofloxacin (Cipro)
A single dose of 500 mg ciprofloxacin has been found to provide an effective alternative to rifampin for the eradication of meningococcal carriage in adults. Not recommended for persons younger than 18 y because it has caused cartilage damage in immature experimental animals.
Commonly used for meningococcal prophylaxis.
Adult
500 mg/d PO
Pediatric
Not recommended
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
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
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
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 1 or more penicillin-binding proteins. A single IM injection has been found to eradicate meningococcal carriage.
Commonly used for meningococcal prophylaxis.
Adult
250 mg/d IM
Pediatric
<5 years: 125 mg/d IM
>5 years: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
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
Adjust dose in renal impairment; caution in breastfeeding women and in those with allergy to penicillin
Minocycline (Minocin)
A member of the tetracycline class of antimicrobial agents. It is a broad-spectrum agent that inhibits susceptible organisms by blocking their protein synthesis. Although an oral form of the drug has been approved for chemoprophylactic use to eradicate the meningococcal carrier state, its use for these purposes was associated with a high incidence of general and gastrointestinal symptoms. Thus, it is now only of historic interest.
Commonly used for meningococcal prophylaxis.
Adult
100 mg PO q12h for 5 d
Pediatric
Not recommended for meningococcal prevention in children <8 y
Similar to other tetracyclines; may interact with other nephrotoxic or hepatotoxic drugs; increased risk of infection when used with corticosteroids
Documented hypersensitivity
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Numerous complications are possible, but the short course of use limits the number and types of complications; the most common problem with its use as a prophylactic agent was compliance because of the frequency of bothersome adverse effects; high incidence of GI symptoms; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth
Erythromycin (Erythrocin)
Antibiotic that interferes with protein synthesis of susceptible organisms. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest. Mostly used orally; however, a parenteral form is available. Although meningococci are susceptible to erythromycin, this drug is not recommended for use either as treatment for meningococcal infection or as a prophylactic agent.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.
Adult
250 mg erythromycin stearate/base (or 400 mg ethylsuccinate) PO q6h 1 h ac or 500 mg q12h
Alternatively, 333 mg PO q8h; increase to 4 g/d depending on severity of infection
Pediatric
30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occurs
Tetracycline (Achromycin)
A drug in a class of broad-spectrum agents that inhibits susceptible organisms by blocking protein synthesis. Inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunits. This drug class is not recommended for use as a treatment of meningococcal infection. One of the drugs in this class is minocycline; it has been used as a prophylactic agent.
Adult
250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Severe infections: 500 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Vasopressors
These agents are used to support circulation in patients with shock.
Dopamine (Intropin)
Stimulates both adrenergic and dopaminergic receptors. Hemodynamic effect is dependent on the dose. Lower doses predominantly stimulate dopaminergic receptors that, in turn, produce renal and mesenteric vasodilation. Cardiac stimulation and renal vasodilation produced by higher doses. After initiating therapy, increase dose by 1-4 mcg/kg/min q10-30min until optimal response is obtained. More than 50% of patients are satisfactorily maintained on doses less than 20 mcg/kg/min.
Adult
1-5 mcg/kg/min IV; not to exceed 50 mcg/kg/min
Pediatric
Administer as in adults
Phenytoin, alpha- and beta-adrenergic blockers, general anesthesia, and MAOIs increase and prolong effects; cyclopropane or halogenated hydrocarbon anesthetics increase cardiac irritability and may sensitize the myocardium to the effects; MAOIs reduce the degradation and potentiate the effects
Documented hypersensitivity; pheochromocytoma or ventricular fibrillation
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
Closely monitor urine flow, cardiac output, pulmonary wedge pressure, and blood pressure during the infusion; prior to infusion, correct hypovolemia with either whole blood or plasma, as indicated; monitoring central venous pressure or left ventricular filling pressure may be helpful in detecting and treating hypovolemia
More on Meningococcal Infections |
| Overview: Meningococcal Infections |
| Differential Diagnoses & Workup: Meningococcal Infections |
 Treatment & Medication: Meningococcal Infections |
| Follow-up: Meningococcal Infections |
| Multimedia: Meningococcal Infections |
| References |
| Further Reading |
| « Previous Page | Next Page » |
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Further Reading
Thompson MJ, Ninis N, Perera R, Mayon-White R, Phillips C, Bailey L, et al. Clinical recognition of meningococcal disease in children and adolescents. Lancet. Feb 4 2006;367(9508):397-403. [Medline].
Keywords
meningococcal infections, epidemic cerebrospinal fever, Waterhouse-Friderichsen syndrome, meningitis, meningococci, fulminant meningococcemia, acute meningococcemia, meningococcemia, meningococcal meningitis, bacterial meningitis, meningococcal disease, Neisseria meningitidis, N meningitidis, chronic meningococcemia
