eMedicine Specialties > Infectious Diseases > Bacterial Infections
Meningococcemia: Treatment & Medication
Updated: Feb 24, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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Treatment
Medical Care
Hospitalization is required for severely ill patients with fever, headache, and petechial rash.
- Promptly begin antibiotic treatment.
- Suspect fulminant meningococcemia in patient with hypotension and severe coagulation abnormalities. In such cases, monitoring in an intensive care setting is required.
- Other than antimicrobial treatment, supportive measures may be needed to correct circulatory collapse.
- Any adrenal insufficiency requires corticosteroid replacement.
Surgical Care
- Arterial occlusion caused by intravascular clotting in the extremities may require amputation.
- Pericardiocentesis may be required if pericarditis is complicated by tamponade.
Consultations
- Consult an infectious diseases specialist.
- Consultation with a surgeon is needed in gangrene of the extremities.
- Consultation with a hematologist may be needed to manage coagulopathy.
- Consultation with a cardiologist may be needed upon evidence of heart failure or pericarditis.
Activity
Activity is determined by the severity of the presentation. In most severe cases, patients are bed bound.
Medication
Antimicrobial therapy is directed toward treatment of active infection or used prophylactically to protect those exposed to N meningitidis through close contact.
Drugs effective in treating active meningococcal infection include penicillin G, chloramphenicol in patients who are allergic to penicillin, and some cephalosporins (ie, cefotaxime, ceftriaxone, cefuroxime) used to treat pediatric patients. Meningococcal resistance to penicillins has occurred; the mechanism of resistance involves altered penicillin-binding proteins. Sulfonamides have a limited role in meningococcal infections because of the resistance of serogroups A, B, and C; these are not discussed further in this article. The duration of treatment is dictated by clinical response and manifestation of disease, although 10-14 days should be sufficient with a sensitive organism.
Individuals with at least 4 hours of close contact with an index patient during the week before onset of illness are at an increased risk of infection. Individuals at risk include housemates, daycare contacts, cellmates, or individuals exposed to infected nasopharyngeal secretions (eg, through kissing, mouth-to-mouth resuscitation, intubation, suctioning).
Rifampin and ciprofloxacin are commonly used for chemoprophylaxis. Other agents include ceftriaxone and azithromycin. A single dose of intramuscular ceftriaxone may be used in children or adults. Spiramycin is the primary prophylactic regimen used in many European countries. Vaccination with monovalent A; monovalent C; bivalent A-C; or quadrivalent A, C, Y, and W-135 vaccine should be adjunctive to antibiotic chemoprophylaxis in susceptible contacts in epidemics.
The Centers for Disease Control and Prevention (CDC) has issued new (2007) guidelines for the use of meningococcal vaccinations. In addition, in June 2007, the Advisory Committee on Immunization Practices (ACIP) revised its guidelines and advises routine immunization of individuals aged 11-18 years with the quadrivalent conjugate meningococcal vaccine (MCV4), which was first licensed in 2005 in the United States (Menactra, Sanofi Pasteur, Inc.)
Guillain-Barré syndrome has been associated with its use, and this is a relative contraindication.11
The eradication of carriage is also indicated in the index case unless third-generation cephalosporins have been used.
A single intramuscular dose of an oily suspension of chloramphenicol has been shown to be as effective as 5 days of penicillin in persons with meningococcal meningitis, and this may be useful in resource-poor countries.
Antimicrobial agents
These agents are used to treat active meningococcal infection.
Penicillin G (Pfizerpen)
Treat suspected meningococcal disease with a high dose in the initial 48 h of therapy because meningitis is a likely complication.
Adult
4 million U IV q4h initial
Pediatric
250,000 U/kg/d IV 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
Chloramphenicol (Chloromycetin)
Used in patients with penicillin allergy. Chloramphenicol binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. Chloramphenicol-resistant strains are found in Southeast Asia but are rare in the United States.
Adult
100 mg/kg/d IV divided q6h; not to exceed 4 g/d
Pediatric
50-100 mg/kg/d IV divided q6h
Concurrent use with barbiturates may decrease chloramphenicol serum levels, while barbiturate levels may increase and cause toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol 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
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 (ie, 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
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity. Lower efficacy against gram-positive organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
2 g IV q12h initial; 1 g IV q24h for infections other than meningitis
Pediatric
50 mg/kg IV q12h
Probenecid may increase ceftriaxone 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 with breastfeeding and penicillin allergy
Cefotaxime (Claforan)
Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. Has been used successfully in pediatric meningococcal meningitis
Adult
2 g IV q6h
Pediatric
50 mg/kg IV q6h
Probenecid may increase cefotaxime 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; associated with severe colitis; caution in patients with penicillin allergy
Antimicrobial agents, chemoprophylaxis
These agents protect individuals who are at risk because of close contact with patients who have meningitis.
Rifampin (Rifadin, Rimactane)
Semisynthetic derivative of rifamycin B that inhibits bacterial and mycobacterial RNA synthesis by binding to beta-subunit of DNA-dependent RNA polymerase, thus inhibiting binding to DNA and blocking RNA transcription.
Adult
600 mg PO bid 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, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO 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 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
Ciprofloxacin (Cipro)
Fluoroquinolone. Inhibits bacterial DNA synthesis and, consequently, growth.
Adult
500 mg PO single dose prophylaxis
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; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin 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
Seizures; 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. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins. Has successfully treated pediatric meningococcal meningitis. Useful in special circumstances (ie, relatively penicillin-resistant organisms, hypersensitivity reactions to penicillin or chloramphenicol).
Adult
250 mg IM single dose prophylaxis
Pediatric
<15 years: 125 mg IM single dose
>15 years: Administer as in adults
Probenecid may increase ceftriaxone 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 and in penicillin allergy
Azithromycin (Zithromax)
Semisynthetic antibiotic structurally similar to erythromycin. Inhibits protein synthesis in bacterial cells by binding to 50S subunit of bacterial ribosomes.
Adult
500 mg PO single dose prophylaxis
Pediatric
Not established
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; coadministration with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution with impaired hepatic function and prolonged QT intervals; caution in patients who are hospitalized, geriatric, or debilitated
Spiramycin (Rovamycine)
Macrolide antibiotic with antimicrobial activity similar to erythromycin and clindamycin. Not commercially available in the United States.
Adult
500 mg PO q6h for 5 d
Pediatric
10 mg/kg PO q6h for 5 d
May potentiate effects of corticosteroids, digoxin, antihistamines, theophylline, and carbamazepine; may decrease effectiveness of PO contraceptives
Documented hypersensitivity (including hypersensitivity to related medications, eg, erythromycin, azithromycin, clarithromycin, troleandomycin)
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 liver disease or bile duct obstruction; associated with rash, itching, bleeding, bloody stools, chest pain, fever, GI distress, and jaundice
Vaccines
These agents may be used to prevent and control outbreaks of serogroup C meningococcal disease.
Meningococcal polysaccharide (Menactra A, C, Y, W-135 diphtheria toxoid conjugate vaccine)
Diphtheria toxoid conjugate vaccine induces the production of bactericidal antibodies specific to capsular polysaccharides of serogroups A, C, Y, and W-135.
Adult
0.5 mL IM once, preferably in deltoid region
Pediatric
Not established
Immunosuppressive therapies, including irradiation, antimetabolites, cytotoxic drugs, alkylating agents and corticosteroids may reduce immune response to vaccines
Documented hypersensitivity; during course of any acute illness; Guillain-Barré syndrome (GBS) reported following administration of vaccine; persons previously diagnosed with GBS should not receive Menactra vaccine
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
If vaccine administered in persons receiving immunosuppressive therapy, expected immune response may not be obtained; obtain previous immunization history of vaccinee
Meningococcal vaccine (Menomune A/C/Y/W-135)
Quadrivalent vaccine for meningitis prophylaxis. Considered an adjunct to antibiotic chemoprophylaxis.
Adult
0.5 mL SC once
Pediatric
<2 years: Do not administer
>2 years: Administer as in adults
Immunosuppressive therapies, including irradiation, antimetabolites, cytotoxic drugs, alkylating agents and corticosteroids may reduce immune response to vaccines
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
If vaccine administered in persons receiving immunosuppressive therapy, expected immune response may not be obtained; obtain previous immunization history of vaccinee; caution in acute illness, asplenic patients, and pregnancy
More on Meningococcemia |
| Overview: Meningococcemia |
| Differential Diagnoses & Workup: Meningococcemia |
 Treatment & Medication: Meningococcemia |
| Follow-up: Meningococcemia |
| Multimedia: Meningococcemia |
| References |
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Further Reading
Keywords
meningococcemia, Waterhouse-Friderichsen syndrome, Neisseria meningitidis infection, N meningitidis, meningitis with meningococcemia, acute meningococcal infection, meningitis, meningococci, fulminant meningococcemia, meningococci A, meningococci B, meningococci C, meningococci Y, meningococci W-135, immunoglobulin G2 subclass deficiency, purpura fulminans, meningococcal disease, occult meningococcemia, chronic meningococcemia, meningococcal sepsis
