What is the prophylaxis for meningococcal meningitis?

Prophylaxis for Meningococcal Meningitis

Antibiotic prophylaxis with ceftriaxone, ciprofloxacin, or rifampin should be given to all close contacts of patients with invasive meningococcal disease to prevent secondary cases and eradicate nasopharyngeal carriage. 1

Who Should Receive Prophylaxis

Prophylaxis should be administered to:

• Household members
• Child care center contacts
• Anyone directly exposed to oral secretions of the patient
• Dormitory roommates
• Boyfriends/girlfriends
• University students sharing kitchen facilities in halls of residence 1

Close contacts have a 400-800 fold increased risk of developing meningococcal disease, with the highest risk occurring within the first week after exposure 1.

Recommended Prophylactic Antibiotics

First-line options:

1. Rifampin:

   • Children <3 months: 5 mg/kg orally twice daily for 2 days
   • Children 3 months-12 years: 10 mg/kg orally twice daily for 2 days (max 600 mg)
   • Children >12 years and adults: 600 mg orally twice daily for 2 days
   • Pregnancy: 600 mg twice daily for 2 days (only after first trimester) 1

2. Ciprofloxacin:

   • Adults >16 years: 500 mg orally as a single dose
   • Not recommended during pregnancy 1

3. Ceftriaxone:

   • Children <16 years: 125 mg intramuscular as a single dose
   • Adults ≥16 years: 250 mg intramuscular as a single dose
   • Pregnancy: 250 mg intramuscular as a single dose (first choice during pregnancy) 1

Alternative option:

1. Azithromycin: Consider in areas with ciprofloxacin resistance 2, 3

Timing and Administration

• Prophylaxis should be commenced within 24 hours of case identification 1
• Patients treated with penicillin for meningococcal disease should also receive clearance-effective antibiotics before discharge
• Patients who received ceftriaxone as treatment do not need additional prophylaxis 1

Special Considerations

1. Ciprofloxacin resistance: In areas where both of the following criteria are met in a 12-month period, consider alternatives to ciprofloxacin:

   • Two or more cases caused by ciprofloxacin-resistant strains
   • ≥20% of all cases caused by ciprofloxacin-resistant strains 2

2. Pregnancy: Ceftriaxone is the first choice during pregnancy. Rifampin can be used after the first trimester. Ciprofloxacin should be avoided 1

3. Vaccine considerations: After an episode of meningococcal disease, vaccination with meningococcal C vaccine should be offered before discharge 1

Effectiveness of Prophylaxis

High-quality evidence from a Cochrane meta-analysis of 24 RCTs confirms that ciprofloxacin, rifampin, and ceftriaxone are effective at eradicating N. meningitidis from the nasopharynx 1, 4:

• Ciprofloxacin: 96% reduction in carriage (RR 0.04; 95% CI 0.01 to 0.12)
• Rifampin: 83% reduction in carriage (RR 0.17; 95% CI 0.13 to 0.24)
• Ceftriaxone: More effective than rifampin at 1-2 weeks follow-up 4

Potential Pitfalls

1. Resistance development: Using rifampin during outbreaks may lead to circulation of resistant isolates 4

2. Inappropriate prophylaxis: In isolated cases, prophylaxis is not indicated for pupils in the same nursery, school, or class unless they are close contacts 1

3. Delayed administration: Effectiveness is highest when prophylaxis is given promptly after case identification 1

4. Failure to monitor resistance patterns: Ongoing surveillance for antimicrobial resistance is essential to guide prophylaxis recommendations 2, 5

By following these evidence-based guidelines, the risk of secondary cases of meningococcal disease can be significantly reduced among close contacts of infected individuals.