What is the treatment for meningococcal encephalitis?

Treatment of Meningococcal Encephalitis

For confirmed meningococcal encephalitis, 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

Antibiotic Therapy

First-Line Treatment Options

• Ceftriaxone: 2 g IV every 12 hours 2, 1
• Cefotaxime: 2 g IV every 6 hours 1

Alternative Treatment Options

• Benzylpenicillin: 2.4 g IV every 4 hours (if organism is susceptible)
  • When using benzylpenicillin, add a single dose of ciprofloxacin 500 mg orally to eradicate throat carriage 2, 1
• Chloramphenicol: 25 mg/kg IV every 6 hours (for severe beta-lactam allergies) 1

Treatment Duration

• 5 days for meningococcal disease if the patient has clinically recovered 2, 1
• If no pathogen has been identified, antibiotics can be stopped after 10 days if the patient has clinically recovered 2

Adjunctive Therapy

Corticosteroids

• Dexamethasone 10 mg IV every 6 hours should be started with or before the first dose of antibiotics 2
• Continue for 4 days in confirmed cases

Not Recommended

• Routine adjuvant therapy with mannitol, acetaminophen, antiepileptic drugs, or hypertonic saline is not recommended 2
• Therapeutic hypothermia and glycerol are contraindicated in bacterial meningitis 2

Special Considerations

Outpatient Antibiotic Therapy (OPAT)

OPAT may be considered when the patient:

• Is afebrile and clinically improving
• Has received 5 days of inpatient therapy and monitoring
• Has reliable intravenous access
• Can access medical advice/care 24 hours a day
• Has no other acute medical needs 2

Regimens for OPAT

• Ceftriaxone 2 g twice daily IV (4 g once daily IV can be used after the first 24 hours of therapy)
• For penicillin-resistant pneumococci: Ceftriaxone 2 g twice daily IV and Rifampicin 600 mg twice daily PO 2

Chemoprophylaxis for Close Contacts

Close contacts of patients with meningococcal disease should receive prophylaxis to prevent secondary cases and eradicate carriage 2, 3:

• Ciprofloxacin: Single oral dose
• Ceftriaxone: Single intramuscular dose
• Rifampicin: Oral administration for 2 days 2

Monitoring and Follow-up

• All patients should be assessed for potential long-term sequelae, both physical and psychological, before discharge 2
• Hearing tests should be performed if hearing loss is suspected or if the patient cannot report hearing loss 2

Potential Complications and Pitfalls

• Delayed initiation of antibiotics can worsen mortality 4
• Treatment should be started promptly when meningococcal disease is suspected, especially if transfer, imaging, or lumbar puncture may delay diagnosis 4
• When using aciclovir for suspected concurrent viral encephalitis, monitor for renal impairment, particularly after 4 days of IV therapy 2
• Resistant isolates may emerge following rifampicin prophylaxis 3

Special Situations

• If meningococcal encephalitis is suspected along with HSV or VZV encephalitis, intravenous aciclovir should also be started within 6 hours of admission 2
• For patients with penicillin and cephalosporin-resistant organisms, consult with an infection specialist 2

The prompt recognition and treatment of meningococcal encephalitis is crucial for improving outcomes and reducing mortality. Early administration of appropriate antibiotics and consideration of adjunctive therapies like dexamethasone are key components of management.