Chemoprophylaxis for meningococcal disease

People are worried about the many meningitis outbreaks. The incidence of meningococcal meningitis is increasing in teens and young adults possibly due to new strains of Neisseria meningitidis. The bacteria are spread by direct contact with respiratory or throat secretions such as by coughing, kissing or sharing drinks or cigarettes. Patients initially have a headache and flu-like symptoms. But they can go downhill fast, about 10% die despite early antibiotics. And others develop significant disabilities like mental retardation, hearing loss, and amputations.

Prescribe prophylactic antibiotics for close contacts, household members, close friends, etc. Start them as soon as possible, ideally within 24 hours after a case of meningococcal meningitis is identified. For adults, give rifampin 600 mg BID for 2 days or a single dose of ciprofloxacin 500 mg or IM ceftriaxone 250 mg, (see table 1).

Table (1). Chemoprophylaxis Regimens for Protection against Meningococcal Disease
Drug	Age group	Dose	Duration and route of administration
Preferred regimens
Rifampin	Infants age <1 month	5 mg/kg every 12 hours	2 days (4 doses) of oral therapy
	Infants and children age ≥1 month	15 to 20 mg/kg (maximum 600 mg) every 12 hours	2 days (4 doses) of oral therapy
	Adults	600 mg every 12 hours	2 days (4 doses) of oral therapy
Ciprofloxacin	Infants and children age ≥1 month	20 mg/kg (maximum 500 mg)	Single oral dose
	Adults	500 mg	Single oral dose
Ceftriaxone	Children age <15 years	125 mg	Single IM dose
	Adults and adolescents age ≥15 years	250 mg	Single IM dose
Alternative regimen (e.g., if rifampin or ceftriaxone cannot be used in the setting of ciprofloxacin-resistant Neisseria meningitidis exposure)
Azithromycin	Infants and children	10 mg/kg (maximum 500 mg)	Single oral dose
	Adults	500 mg	Single oral dose
Rifampin is not recommended for pregnant women because the drug is teratogenic in laboratory animals. Because the reliability of oral contraceptives might be affected by rifampin therapy, consideration should be given to using alternative contraceptive measures while rifampin is being administered. Ciprofloxacin should not be used if fluoroquinolone-resistant strains of N. meningitidis have been identified in the community. In addition, ciprofloxacin is not recommended for pregnant women (single dose can be given). Although systemic fluoroquinolones are not routinely used as a first-line agent in children less than 18 years of age, it is reasonable to use a single dose of ciprofloxacin for chemoprophylaxis for meningococcal disease. Although azithromycin has activity against meningococcus, it has not been well studied for this indication.
Reference, American Academy of Pediatrics. Meningococcal infections. In: Kimberlin DW, Jackson MA, Long SS, Brady MT (eds). Red Book: 2018–2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics; 2018:550.

Use the meningococcal vaccine (Mencevax ACWY, see NOTE below) to help control outbreaks and to prevent meningitis in high-risk groups such as immunocompromised patients, college students, and military recruits. Tell patients the vaccine is protective within 7 to 10 days, but there are some limitations. It's not very effective in kids under age 2, it doesn't protect against all strains of N. meningitidis and immunity only lasts 3 to 5 years. GET OUR NOTE "Antibiotic protocol for bacterial meningitis or suspected meningococcal disease", for more information about antibiotic treatment.

Note...

The recommended dose of the vaccine (Mencevax) contained in 0.5 ml must be administered. In adults and children over 5 years of age immunity will persist for up to 3 years. Children who were aged under 5 years when first vaccinated should be considered for revaccination after 2-3 years if they remain at high risk. ACWY is for subcutaneous use only.

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References

1. Lyczko K, Borger J. Meningococcal Prophylaxis. [Updated 2022 Feb 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537338
2. Bamberger DM. Diagnosis, initial management, and prevention of meningitis. Am Fam Physician. 2010 Dec 15;82(12):1491-8. Available at: https://www.aafp.org/afp/2010/1215/p1491.html
3. Mayon-White RT, Heath PT. Preventative strategies on meningococcal disease. Arch Dis Child. 1997 Mar;76(3):178-81. Available at: https://adc.bmj.com/content/76/3/178
4. Sanford R. K. Prevention of Meningococcal Disease. Am Fam Physician. 2005 Nov 15;72(10):2049-2056. Available at: https://www.aafp.org/afp/2005/1115/p2049.html

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