What is the recommended post-exposure prophylaxis (PEP) regimen for Neisseria meningitis?

Post-Exposure Prophylaxis for Neisseria Meningitidis

Antibiotic chemoprophylaxis should be administered as soon as possible (ideally <24 hours after identification of the index patient) to all close contacts of patients with invasive meningococcal disease using rifampin, ciprofloxacin, or ceftriaxone. 1

Who Should Receive Prophylaxis

Close contacts requiring prophylaxis include:

• Household members 1, 2
• Child-care center contacts 1
• Anyone directly exposed to the patient's oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation, or endotracheal tube management) in the 7 days before symptom onset 1
• Healthcare workers who managed an airway or were exposed to respiratory secretions without wearing a mask 1
• Travelers seated directly next to an index-patient on a prolonged flight (≥8 hours) 1
• University students sharing kitchen facilities in halls of residence 2

Recommended Prophylactic Regimens

First-line options:

1. Rifampin:

   • Children <1 month: 5 mg/kg orally every 12 hours for 2 days 1, 2
   • Children ≥1 month: 10 mg/kg orally every 12 hours for 2 days (maximum 600 mg) 1, 2
   • Adults: 600 mg orally every 12 hours for 2 days 1, 2
   • Note: Not recommended for pregnant women in first trimester due to teratogenicity; may reduce effectiveness of oral contraceptives 1, 2

2. Ciprofloxacin:

   • Adults: 500 mg orally as a single dose 1, 2
   • Note: Generally not recommended for persons <18 years, pregnant or lactating women, but may be used when no acceptable alternative is available 1

3. Ceftriaxone:

   • Children <15 years: 125 mg intramuscular as a single dose 1, 2
   • Adults: 250 mg intramuscular as a single dose 1, 2
   • Note: Preferred option during pregnancy 2

Timing and Efficacy

• Prophylaxis should be administered as soon as possible, ideally within 24 hours after identification of the index patient 1, 2
• Prophylaxis administered >14 days after exposure has limited or no value 1
• Efficacy in eradicating nasopharyngeal carriage:
  • Ciprofloxacin: 96% reduction in carriage 2, 3
  • Rifampin: 83% reduction in carriage 2, 4
  • Ceftriaxone: More effective than rifampin at 1-2 weeks follow-up (97% vs 75-81%) 2, 5

Special Considerations

Emerging Resistance

In areas with documented ciprofloxacin resistance, consider alternative antibiotics when both of the following criteria are met in a local area during a 12-month period:

1. Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains
2. ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains 6

Patients Treated for Meningococcal Disease

• Patients treated with penicillin for meningococcal disease should receive clearance-effective antibiotics before discharge 2
• Patients who received ceftriaxone as treatment do not need additional prophylaxis 2

Isolation Precautions

• All patients with suspected meningococcal disease should be respiratory isolated until the condition is excluded or they have received 24 hours of effective antibiotics 1
• Droplet precautions should be taken until a patient has had 24 hours of antibiotics, including wearing surgical masks if likely to be in close contact with respiratory secretions 1

Important Caveats

• Oropharyngeal or nasopharyngeal cultures are not helpful in determining the need for chemoprophylaxis and might unnecessarily delay prophylaxis 1
• Prophylaxis is not recommended for contacts of patients with evidence of N. meningitidis only in nonsterile sites such as oropharyngeal swab, endotracheal secretions, or conjunctival swab 1
• There is no indication to treat asymptomatic nasopharyngeal carriers without exposure to a case 1
• In isolated cases, prophylaxis is not indicated for pupils in the same nursery, school, or class unless they are close contacts 2

By following these guidelines, healthcare providers can effectively prevent secondary cases of meningococcal disease among close contacts of infected individuals.