What is the treatment for Neisseria meningitidis?

Treatment for Neisseria Meningitidis Infection

For confirmed Neisseria meningitidis infection, the recommended first-line treatment is ceftriaxone 2 g IV every 12 hours or cefotaxime 2 g IV every 6 hours for 5 days in patients who have clinically recovered. 1

Definitive Antibiotic Treatment Algorithm

First-line Options:

• Ceftriaxone: 2 g IV every 12 hours
• Cefotaxime: 2 g IV every 6 hours
• Duration: 5 days (if patient has clinically recovered) 1

Alternative Options (if allergies or resistance):

• Benzylpenicillin: 2.4 g IV every 4 hours 1
  • Note: If benzylpenicillin is used instead of ceftriaxone, add a single dose of ciprofloxacin 500 mg orally 1
• Chloramphenicol: 25 mg/kg IV every 6 hours (for severe beta-lactam allergies) 1

Special Considerations

Penicillin Resistance

Recent surveillance data shows increasing rates of reduced susceptibility to penicillin in N. meningitidis globally, with up to 27.2% of isolates showing non-sensitivity to penicillin 2. A UK study identified 113 penicillin-resistant isolates among 4,122 invasive meningococcal disease cases from 2010-2019 3. Therefore:

• Third-generation cephalosporins (ceftriaxone/cefotaxime) are preferred over penicillin due to increasing resistance patterns
• Resistance to third-generation cephalosporins remains extremely rare (only one cefotaxime-resistant isolate identified in the UK study) 3

Pediatric Dosing

For children 3 months and older with meningococcal meningitis:

• Meropenem: 40 mg/kg IV every 8 hours (maximum 2 g every 8 hours) 4
• Ceftriaxone/Cefotaxime: Same as adult dosing but weight-adjusted

Antibiotic Duration

• Stop treatment after 5 days if the patient has clinically recovered 1
• The European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recommends 7 days of treatment 1
• For culture-negative meningitis with clinical suspicion, continue empiric treatment for at least 2 weeks 1

Prophylaxis for Close Contacts

Close contacts of patients with meningococcal disease should receive chemoprophylaxis to eradicate carriage:

• Ciprofloxacin: Single 500 mg oral dose (most effective at eradicating carriage) 5
• Rifampin: Alternative option, but resistant isolates may emerge during outbreaks 5
• Ceftriaxone: More effective than rifampin after 1-2 weeks of follow-up 5

Monitoring and Follow-up

• Monitor clinical response within the first 24-48 hours
• If no improvement or clinical deterioration, consider:
  1. Repeat lumbar puncture
  2. Evaluation for complications (e.g., subdural empyema, brain abscess)
  3. Assessment for antibiotic resistance (though still rare for N. meningitidis)

Emerging Concerns

Recent data indicates a progressive increase in antibiotic-resistant N. meningitidis isolates worldwide, particularly since the COVID-19 pandemic, with increasing resistance to penicillin and fluoroquinolones 6. While still exceptionally rare, four N. meningitidis isolates with third-generation cephalosporin resistance have been identified since 2011 6, highlighting the importance of continued surveillance and appropriate antibiotic selection.

Common Pitfalls to Avoid

1. Delaying treatment: Empiric therapy should be started immediately when meningococcal disease is suspected
2. Using penicillin as first-line empiric therapy: Due to increasing resistance, third-generation cephalosporins are preferred
3. Inadequate contact tracing: Ensure all close contacts receive appropriate prophylaxis
4. Stopping antibiotics too early: Complete the full course even if rapid clinical improvement occurs
5. Failing to provide ciprofloxacin when using benzylpenicillin instead of ceftriaxone for definitive therapy