Medication Summary
The role of antibiotics in managing meninogococcemia is to treat an active infection, provide prophylaxis to protect those with significant exposure to cases of N meningitidis, and eliminate the carrier state in asymptomatic individuals.
Drugs effective in treating active meningococcal infection include 3rd generation cephalosporins like ceftriaxone, penicillin G, and chloramphenicol (in penicillin-allergic). Meningococcal resistance to penicillins has occurred; the mechanism of resistance involves altered penicillin-binding proteins. Chloramphenicol is less effective and should be avoided if other options are there. Antimicrobial susceptibility testing should be obtained prior to penicillin and ampicillin use. Resistance to ceftriaxone is rare.
The duration of antimicrobial treatment is dictated by the clinical response. It should be no less than 7 days
Individuals with greater than 4 hours of close contact with an index patient during the week before the onset of illness are at an increased risk for infection. Individuals at risk include housemates, daycare contacts, cellmates, or individuals exposed to infected nasopharyngeal secretions (eg, through kissing, mouth-to-mouth resuscitation, intubation, and suctioning).
Rifampin and ciprofloxacin commonly are used for chemoprophylaxis. Ciprofloxacin should be avoided in pregnant and lactating women. Ciprofloxacin-resistant strains have been reported, and susceptibility testing should be used to guide prophylaxis based on local prevalence. [110] Rifampin may eradicate carriage in up to 80-90% of individuals, but resistant strains have occurred. [111] Other agents that can be used include ceftriaxone and azithromycin. A single dose of intramuscular ceftriaxone may be used in children or adults. During epidemics, vaccination should be adjunctive to antibiotic chemoprophylaxis for susceptible contacts. The eradication of carriage is also indicated in the index case unless third-generation cephalosporins have been used.
See the Treatment Section for more detail.
Antimicrobial agents
Class Summary
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, ciprofloxacin and ceftriaxone are the antimicrobials used to eradicate meningococci from the nasopharynx.
Mortality in meningococcal infections may be reduced with early antibiotic therapy. Regarding community management, because mortality may be reduced with early antibiotic therapy, patients with a meningococcal rash should receive parenteral benzyl penicillin by means of an IV or IM route as soon as the diagnosis is suspected. IM antibiotic injections may be less effective in a patient with shock and poor tissue perfusion. Give cefotaxime, ceftriaxone, or chloramphenicol to patients who are allergic to penicillin. Empiric antibiotic therapy for meningitis based on age is as follows:
- Neonates - Ampicillin and cefotaxime
- Infants aged 1-3 months - Ampicillin and cefotaxime
- Older infants, children, and adults - Cefotaxime or ceftriaxone
Penicillin G
Penicillin G interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. It should not be used empirically, against N Meningitidis.
Infections caused by organisms classified as relatively resistant to penicillin, based on a minimum inhibitory concentration (MIC) of 0.1-1 µg/mL of penicillin, seem to respond to this drug as well as fully susceptible organisms do.
Chloramphenicol
Chloramphenicol can be used in patients with penicillin and cephalosporin allergies. It binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. It is effective against gram-negative and gram-positive bacteria. Chloramphenicol-resistant strains are found in Southeast Asia but are rare in the United States.
Ceftriaxone
Ceftriaxone is a third-generation cephalosporin with broad-spectrum, gram-negative activity. It has lower efficacy against gram-positive organisms. Ceftriaxone arrests bacterial growth by binding to 1 or more penicillin-binding proteins. It has successfully been used to treat pediatric meningococcal meningitis. It is useful in special circumstances (ie, relatively penicillin-resistant organisms, hypersensitivity reactions to penicillin or chloramphenicol).
Ceftriaxone is a first-line antibiotic for empiric therapy of meningitis or sepsis while culture and susceptibility data are pending. Cefotaxime or ceftriaxone are the preferred agents for the treatment of confirmed meningococcal disease.
Cefotaxime (Claforan)
Cefotaxime is a third-generation cephalosporin with a gram-negative spectrum. It has lower efficacy against gram-positive organisms. Cefotaxime has been used successfully in pediatric meningococcal meningitis
The drug is more expensive than penicillin, but most authorities believe that it is as efficacious as penicillin in the treatment of meningococcal disease.
Cefotaxime arrests bacterial cell wall synthesis, which, in turn, inhibits bacterial growth. It is used for penicillin-resistant strains.
Cefotaxime is used as a first-line antibiotic for the empiric therapy of meningitis or sepsis while culture and susceptibility data are pending. Cefotaxime or ceftriaxone are the preferred agents for the treatment of confirmed meningococcal disease.
Ampicillin
A broad-spectrum penicillin that interferes with bacterial cell-wall synthesis during active replication, causing bactericidal activity against susceptible organisms.
Rifampin (Rifadin)
Rifampin is a semisynthetic derivative of rifamycin B that inhibits bacterial and mycobacterial RNA synthesis by binding to the beta subunit of deoxyribonucleic acid (DNA)–dependent RNA polymerase, thus inhibiting binding to DNA and blocking RNA transcription.
Rifampin is commonly used for meningococcal prophylaxis of household contacts in United States, where one third of prevalent strains are sulfadiazine resistant.
Ciprofloxacin (Cipro, Cipro XR)
Ciprofloxacin is a fluoroquinolone. It inhibits bacterial DNA synthesis and, consequently, growth. A single dose of 500mg has been found to provide an effective alternative to rifampin for the eradication of meningococcal carriage in adults. Ciprofloxacin is commonly used for meningococcal prophylaxis. It is not recommended for persons younger than 18 years because it has caused cartilage damage in immature experimental animals. Resistance has been reported, and it should only be used if the strain is known to be susceptible.
Corticosteroids
Class Summary
These agents elicit anti-inflammatory and immunosuppressive properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.
Dexamethasone (Decadron)
Dexamethasone may reduce sensorineural hearing loss in children and infants with H influenzae type B meningitis. Administer this agent to all children with suspected bacterial meningitis (the pathophysiology is likely to be similar). Dexamethasone does not reduce CNS clearance of bacteria or cause treatment failure. It is of no proven benefit in meningococcal meningitis and may be stopped following microbiologic confirmation.
Vaccines, Inactivated, Bacterial
Class Summary
These agents may be used to prevent and control outbreaks of serogroup C meningococcal disease.
Meningitis group A C Y and W-135 vaccine diphtheria conjugate vaccine (Menactra, Menveo)
Diphtheria toxoid conjugate vaccine induces the production of bactericidal antibodies specific to capsular polysaccharides of serogroups A, C, Y, and W-135.
Meningococcal C and Y/haemophilus influenza type B vaccine (MenHibrix)
Contains antigenic capsular polysaccharides (ie, meningococcal serogroups A and C, Haemophilus influenzae type b) that convey active immunity by stimulating endogenous antibody production; antibodies have been associated with protection from invasive meningococcal disease.
Meningococcal Polysaccharide Vaccine A/C/Y/W-135
This is a quadrivalent vaccine for meningitis prophylaxis. It is considered an adjunct to antibiotic chemoprophylaxis.
Meningococcal group B vaccine (Bexsero, Trumenba)
Protection against invasive meningococcal disease is conferred mainly by complement-mediated antibody-dependent killing of N meningitidis.
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Dorsum of the hand showing petechiae. Courtesy of Professor Chien Liu.
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Petechiae on the palm. Courtesy of Professor Chien Liu.
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Petechiae on lower extremities. Courtesy of Professor Chien Liu.
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Conjunctival petechiae. Courtesy of Professor Chien Liu.
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Gram-negative intracellular diplococci. Courtesy Professor Chien Liu.
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Scattered petechiae in a patient with acute meningococcemia.
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Purpura in a young adult with fulminant meningococcemia.
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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.
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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.
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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.
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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.
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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.
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Areas with frequent epidemics of meningococcal disease. This is known as the meningitis belt of Africa; visitors to these locales may benefit from meningitis vaccine. Image courtesy of CDC.
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Child with severe meningococcal disease and purpura fulminans.
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Flow chart shows guidelines for the emergency management of meningococcal disease in children. These guidelines may be reprinted for use in clinical areas and are available at Meningitis.org.
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Flow chart shows guidelines for the emergency management of meningococcal disease in adult patients. These guidelines may be reprinted for use in clinical areas and are available from Meningitis.org.
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Chart for family practice recognition and management of meningococcal disease (courtesy of Meningitis.org).
Tables
Patient population |
Conditions |
Vaccine Regimen |
Persons aged 10 years or older at increased risk for serogroup B meningococcal disease |
In high-risk persons and during serogroup B meningococcal disease outbreaks |
3 doses of MenB-FHbp at 0, 1-2, and 6 months to provide earlier protection and maximize short-term immunogenicity. If the second dose of MenB-FHbp is administered at an interval of 6 months or greater, a third dose need not be given. |
Adolescents and young adults aged 16-23 years |
Healthy adolescents and young adults |
2 doses of MenB-FHbp at 0 and 6 months. If the second dose of MenB-FHbp is given less than 6 months after the first dose, give a third dose at least 4 months after the second dose. |
Pregnant or lactating individuals |
Defer vaccination unless the person is at increased risk for serogroup B meningococcal disease and their healthcare provider determines benefits outweigh potential risks. |
Type of patient |
Vaccine type |
Regimen |
11-18 years old |
Quadrivalent ACWY vaccines |
One dose at age 11-12 years and booster at 16 years |
19–21 years old |
Quadrivalent ACWY vaccines +/- serogroup B vaccines |
Freshman in college dormitories should receive serogroup B vaccines |
Patient population |
Conditions |
Vaccine Regimen |
Persons aged 10 years or older at increased risk for serogroup B meningococcal disease |
In high-risk persons and during serogroup B meningococcal disease outbreaks |
3 doses of MenB-FHbp at 0, 1-2, and 6 months to provide earlier protection and maximize short-term immunogenicity. If the second dose of MenB-FHbp is administered at an interval of 6 months or greater, a third dose need not be given. |
Adolescents and young adults aged 16-23 years |
Healthy adolescents and young adults |
2 doses of MenB-FHbp at 0 and 6 months. If the second dose of MenB-FHbp is given less than 6 months after the first dose, give a third dose at least 4 months after the second dose. |
Pregnant or lactating individuals |
Defer vaccination unless the person is at increased risk for serogroup B meningococcal disease and their healthcare provider determines benefits outweigh potential risks. |
