Meningococcal Infections Treatment & Management

  • Author: Darvin Scott Smith, MD, MSc, DTM&H; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Oct 17, 2011
 

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.[12]

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.

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Surgical Care

Ischemic complications of fulminant meningococcemia may require surgical care for management.

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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.

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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.

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Contributor Information and Disclosures
Author

Darvin Scott Smith, MD, MSc, DTM&H  Adjunct Assistant Professor, Department of Microbiology and Immunology, Stanford University School of Medicine; Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Redwood City Hospital

Darvin Scott Smith, MD, MSc, DTM&H is a member of the following medical societies: American Medical Association, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and International Society of Travel Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas A Hoffman, MD  Professor, Department of Internal Medicine, Division of Infectious Diseases, Jackson Memorial Hospital, University of Miami

Thomas A Hoffman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Joanna L Chan, MD  Mohs Fellow, California Skin Institute

Joanna L Chan, MD is a member of the following medical societies: American Academy of Dermatology and American Society for Dermatologic Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Joseph Richard Masci, MD  Professor of Medicine, Professor of Preventive Medicine, Mount Sinai School of Medicine; Director of Medicine, Elmhurst Hospital Center

Joseph Richard Masci, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, Association of Professors of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Aaron Glatt, MD  Professor of Clinical Medicine, New York Medical College; President and CEO, Former Chief Medical Officer, Departments of Medicine and Infectious Diseases, St Joseph Hospital (formerly New Island Hospital)

Aaron Glatt, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physician Executives, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, American Thoracic Society, American Venereal Disease Association, Infectious Diseases Society of America, International AIDS Society, and Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Eleftherios Mylonakis, MD  Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital

Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD  Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

References

  1. Tappero JW, Reporter R, Wenger JD, et al. Meningococcal disease in Los Angeles County, California, and among men in the county jails. N Engl J Med. Sep 19 1996;335(12):833-40. [Medline].

  2. Brundage JF, Ryan MA, Feighner BH, Erdtmann FJ. Meningococcal disease among United States military service members in relation to routine uses of vaccines with different serogroup-specific components, 1964-1998. Clin Infect Dis. Dec 1 2002;35(11):1376-81. [Medline].

  3. Christensen H, May M, Bowen L, Hickman M, Trotter CL. Meningococcal carriage by age: a systematic review and meta-analysis. Lancet Infect Dis. Dec 2010;10(12):853-61. [Medline].

  4. Kaplan SL, Schutze GE, Leake JA, Barson WJ, Halasa NB, Byington CL, et al. Multicenter surveillance of invasive meningococcal infections in children. Pediatrics. Oct 2006;118(4):e979-84. [Medline].

  5. Periappuram M, Taylor MR, Keane CT. Rapid detection of meningococci from petechiae in acute meningococcal infection. J Infect. Nov 1995;31(3):201-3. [Medline].

  6. Arend SM, Lavrijsen AP, Kuijken I, van der Plas RN, Kuijper EJ. Prospective controlled study of the diagnostic value of skin biopsy in patients with presumed meningococcal disease. Eur J Clin Microbiol Infect Dis. Oct 2006;25(10):643-9. [Medline].

  7. Bryant PA, Li HY, Zaia A, et al. Prospective study of a real-time PCR that is highly sensitive, specific, and clinically useful for diagnosis of meningococcal disease in children. J Clin Microbiol. Jul 2004;42(7):2919-25. [Medline].

  8. de Filippis I, do Nascimento CR, Clementino MB, et al. Rapid detection of Neisseria meningitidis in cerebrospinal fluid by one-step polymerase chain reaction of the nspA gene. Diagn Microbiol Infect Dis. Feb 2005;51(2):85-90. [Medline].

  9. Lin HW, Yin JH, Lo JP, et al. Use of universal polymerase chain reaction assay and endonuclease digestion for rapid detection of Neisseria meningitides. J Microbiol Immunol Infect. Dec 2004;37(6):371-4. [Medline].

  10. Richardson DC, Louie L, Louie M, Simor AE. Evaluation of a rapid PCR assay for diagnosis of meningococcal meningitis. J Clin Microbiol. Aug 2003;41(8):3851-3. [Medline].

  11. Parmentier L, Garzoni C, Antille C, Kaiser L, Ninet B, Borradori L. Value of a novel Neisseria meningitidis--specific polymerase chain reaction assay in skin biopsy specimens as a diagnostic tool in chronic meningococcemia. Arch Dermatol. Jun 2008;144(6):770-3. [Medline].

  12. Hart CA, Cuevas LE. Meningococcal disease in Africa. Ann Trop Med Parasitol. Oct 1997;91(7):777-85. [Medline].

  13. [Guideline] CDC. Updated recommendations for use of meningococcal conjugate vaccines --- Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep. Jan 28 2011;60(3):72-6. [Medline]. [Full Text].

  14. [Guideline] CDC. Recommendation of the Advisory Committee on Immunization Practices (ACIP) for Use of Quadrivalent Meningococcal Conjugate Vaccine (MenACWY-D) Among Children Aged 9 Through 23 Months at Increased Risk for Invasive Meningococcal Disease. MMWR Morb Mortal Wkly Rep. Oct 14 2011;60:1391-2. [Medline]. [Full Text].

  15. Centers for Disease Control and Prevention (CDC). Update: Guillain-Barré syndrome among recipients of Menactra meningococcal conjugate vaccine--United States, June 2005-September 2006. MMWR Morb Mortal Wkly Rep. Oct 20 2006;55(41):1120-4. [Medline].

  16. Vienne P, Ducos-Galand M, Guiyoule A, et al. The role of particular strains of Neisseria meningitidis in meningococcal arthritis, pericarditis, and pneumonia. Clin Infect Dis. Dec 15 2003;37(12):1639-42. [Medline].

  17. Wong JS, Balakrishnan V. Neisseria meningitidis endogenous endophthalmitis: case report and literature review. J Pediatr Ophthalmol Strabismus. May-Jun 1999;36(3):145-52. [Medline].

  18. Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. May 27 2005;54(RR-7):1-21. [Medline].

  19. Childers BJ, Cobanov B. Acute infectious purpura fulminans: a 15-year retrospective review of 28 consecutive cases. Am Surg. Jan 2003;69(1):86-90. [Medline].

  20. de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med. Nov 14 2002;347(20):1549-56. [Medline].

  21. Durand ML, Calderwood SB, Weber DJ, et al. Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med. Jan 7 1993;328(1):21-8. [Medline].

  22. Giraud T, Dhainaut JF, Schremmer B, et al. Adult overwhelming meningococcal purpura. A study of 35 cases, 1977-1989. Arch Intern Med. Feb 1991;151(2):310-6. [Medline].

  23. Hansen L, Christensen JJ, Breum L. Chronic meningococcaemia. Scand J Infect Dis. 2003;35(6-7):418-9. [Medline].

  24. Harrison LH. Preventing meningococcal infection in college students. Clin Infect Dis. Apr 2000;30(4):648-51. [Medline].

  25. Harrison LH, Pass MA, Mendelsohn AB, et al. Invasive meningococcal disease in adolescents and young adults. JAMA. Aug 8 2001;286(6):694-9. [Medline].

  26. Quagliarello V, Scheld WM. Bacterial meningitis: pathogenesis, pathophysiology, and progress. N Engl J Med. Sep 17 1992;327(12):864-72. [Medline].

  27. Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med. Mar 6 1997;336(10):708-16. [Medline].

  28. Rosenstein NE, Perkins BA, Stephens DS, et al. Meningococcal disease. N Engl J Med. May 3 2001;344(18):1378-88. [Medline].

  29. Rosenstein NE, Perkins BA, Stephens DS, et al. The changing epidemiology of meningococcal disease in the United States, 1992-1996. J Infect Dis. Dec 1999;180(6):1894-901. [Medline].

  30. Ross SC, Densen P. Complement deficiency states and infection: epidemiology, pathogenesis and consequences of neisserial and other infections in an immune deficiency. Medicine (Baltimore). Sep 1984;63(5):243-73. [Medline].

  31. Schildkamp RL, Lodder MC, Bijlmer HA, et al. Clinical manifestations and course of meningococcal disease in 562 patients. Scand J Infect Dis. 1996;28(1):47-51. [Medline].

  32. Schuchat A, Robinson K, Wenger JD, et al. Bacterial meningitis in the United States in 1995. Active Surveillance Team. N Engl J Med. Oct 2 1997;337(14):970-6. [Medline].

  33. Stephens DS, Hajjeh RA, Baughman WS, et al. Sporadic meningococcal disease in adults: results of a 5-year population-based study. Ann Intern Med. Dec 15 1995;123(12):937-40. [Medline].

  34. 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].

  35. Tunkel AR, Wispelwey B, Scheld WM. Bacterial meningitis: recent advances in pathophysiology and treatment. Ann Intern Med. Apr 15 1990;112(8):610-23. [Medline].

  36. van de Beek D, de Gans J, McIntyre P, Prasad K. Steroids in adults with acute bacterial meningitis: a systematic review. Lancet Infect Dis. Mar 2004;4(3):139-43. [Medline].

  37. van de Beek D, de Gans J, Spanjaard L, et al. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med. Oct 28 2004;351(18):1849-59. [Medline].

  38. Wall RA. Meningococcal disease: treatment and prevention. Ann Med. 2002;34(7-8):624-34. [Medline].

  39. Yazdankhah SP, Caugant DA. Neisseria meningitidis: an overview of the carriage state. J Med Microbiol. Sep 2004;53(Pt 9):821-32. [Medline].

 
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Scattered petechial lesions in a patient with acute meningococcemia.
Purpuric lesions in a young adult with fulminant meningococcemia.
The legs of a 22-year-old woman in septic shock with a rapidly evolving purpuric rash. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
A 9-month-old baby in septic shock with purpuric Neisseria meningitis skin lesions. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
The leg of a 9-month-old infant in septic shock with a rapidly evolving purpuric rash. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Neisseria meningitis purpuric lesions on the ear and cheek of a 9-month-old infant who is in septic shock. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Lesions caused by Neisseria meningitis bacteremia on the palm of the hand of a 9-month-old infant. Photo by D. Scott Smith, MD, taken at Stanford University Hospital.
Areas with frequent epidemics of meningococcal disease. This is known as the Meningitis Belt of Africa, and visitors to these locales may benefit from meningitis vaccine. Image courtesy of CDC.
 
 
 
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