What is the recommended chemoprophylaxis for meningococcemia?

Recommended Chemoprophylaxis for Meningococcal Disease

Ciprofloxacin (500 mg as a single oral dose for adults) is the first-line chemoprophylactic agent for close contacts of patients with meningococcal disease due to its effectiveness, convenience, and high eradication rate of nasopharyngeal carriage. 1

Indications for Chemoprophylaxis

Chemoprophylaxis should be administered to close contacts of patients with invasive meningococcal disease, including:

• Household members
• Child-care center contacts
• Anyone directly exposed to the patient's oral secretions (kissing, mouth-to-mouth resuscitation)
• Healthcare workers exposed to respiratory secretions during procedures like intubation
• Travelers seated directly next to an index patient on prolonged flights (>8 hours) 2, 1

Timing of Administration

• Administer as soon as possible after identifying the index case, ideally within 24 hours
• Chemoprophylaxis given >14 days after exposure has limited or no value 2
• Do not delay chemoprophylaxis for nasopharyngeal cultures, as these are not helpful in determining the need for prophylaxis 2

Recommended Antibiotic Regimens

1. Ciprofloxacin

• Adults: 500 mg orally as a single dose
• Children 5-12 years: 250 mg orally as a single dose
• Children <5 years: 30 mg/kg orally as a single dose
• Effectiveness: 96% reduction in carriage 1
• Caution: Not generally recommended for persons <18 years or pregnant women, but may be used when no acceptable alternative is available 2

2. Rifampin

• Adults and children >12 years: 600 mg orally every 12 hours for 2 days
• Children 1 month-12 years: 10 mg/kg orally every 12 hours for 2 days
• Infants <1 month: 5 mg/kg orally every 12 hours for 2 days
• Effectiveness: 83% reduction in carriage 1, 3
• Caution: Not recommended in pregnancy (teratogenic in lab animals); affects reliability of oral contraceptives 2

3. Ceftriaxone

• Adults: 250 mg IM as a single dose
• Children <15 years: 125 mg IM as a single dose
• Pregnancy: First choice during pregnancy 2, 1

4. Azithromycin

• 500 mg orally as a single dose
• Effective in eradicating nasopharyngeal carriage of N. meningitidis
• Available in suspension form for children 2

Special Considerations

1. Pregnancy: Ceftriaxone is the first choice; rifampin may be used after the first trimester; avoid ciprofloxacin 1

2. Index patient treatment:

   • If treated with antibiotics other than ceftriaxone or third-generation cephalosporins, the index patient should receive chemoprophylaxis before hospital discharge 2
   • Patients treated with ceftriaxone do not need additional prophylaxis 1

3. Emerging resistance:

   • Monitor for ciprofloxacin resistance, which has been increasing since 2019 4
   • In areas with documented ciprofloxacin resistance (≥2 resistant cases AND ≥20% of cases resistant in a 12-month period), consider alternative antibiotics 4

4. Drug interactions:

   • Rifampin has numerous drug interactions and reduces effectiveness of hormonal contraceptives 1
   • Rifampin may lead to circulation of resistant isolates during outbreaks 5

Isolation Precautions

• Maintain respiratory isolation for patients with suspected meningococcal disease
• Continue droplet precautions until the patient has received 24 hours of effective antibiotics 1

Vaccination Considerations

• Unimmunized contacts of cases caused by vaccine-preventable serogroups should receive appropriate meningococcal vaccination 1
• Consider vaccination with Bexsero for household contacts if two or more cases of serogroup B disease occur in the same household 2

Chemoprophylaxis remains the primary means of preventing secondary cases of meningococcal disease, with the goal of reducing morbidity and mortality by eliminating nasopharyngeal carriage in close contacts of infected individuals.