What is the recommended prophylaxis for exposure to Neisseria (N.) meningitis?

Prophylaxis for Exposure to Neisseria Meningitidis

Ciprofloxacin is the preferred first-line prophylactic antibiotic for close contacts of patients with meningococcal meningitis, administered as a single 500 mg oral dose for adults, which is 90-95% effective in eradicating nasopharyngeal carriage. 1

Recommended Antibiotic Regimens

First-line option:

• Ciprofloxacin:
  • Adults: 500 mg orally as a single dose
  • Children 5-12 years: 250 mg orally as a single dose
  • Children under 5 years: 30 mg/kg orally as a single dose (maximum 125 mg) 2, 1

Alternative options (when ciprofloxacin is contraindicated or in areas with ciprofloxacin resistance):

• Rifampin:

  • Adults and children over 12 years: 600 mg orally twice daily for 2 days
  • Children 1-12 years: 10 mg/kg twice daily for 2 days
  • Infants under 12 months: 5 mg/kg twice daily for 2 days 2, 3

• Ceftriaxone:

  • Adults: 250 mg intramuscularly as a single dose
  • Children under 16 years: 125 mg intramuscularly as a single dose 1
  • Preferred option during pregnancy 1

Who Should Receive Prophylaxis

Prophylaxis should be administered to:

• Household members of the patient
• Child care center contacts
• Anyone directly exposed to the patient's oral secretions (e.g., through kissing, mouth-to-mouth resuscitation, endotracheal intubation)
• Healthcare professionals who handled the patient's airways or were exposed to respiratory secretions
• Passengers seated directly next to the patient on prolonged flights (≥8 hours) 2, 1

Timing of Prophylaxis

• Prophylaxis should be administered as soon as possible, ideally within 24 hours after identification of the index case
• Prophylaxis administered >14 days after onset of illness in the index patient is likely of limited or no value 2

Special Considerations

1. Areas with ciprofloxacin resistance:

   • Consider alternative antibiotics when both of the following criteria are met in a local area during a 12-month period:
     • Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains
     • ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains 4

2. Vaccination:

   • Unimmunized contacts of cases caused by vaccine-preventable non-B serogroups should be offered appropriate meningococcal vaccination 2
   • If two or more cases of serogroup B disease occur within the same family, vaccination against serogroup B should be offered to all household contacts 2

3. Index case management:

   • The index patient should receive chemoprophylactic antibiotics before hospital discharge if treated with antibiotics other than ceftriaxone or other third-generation cephalosporins 2
   • Patients should remain in respiratory isolation until they have received 24 hours of effective antibiotics 1

Effectiveness and Evidence

• The attack rate for household contacts exposed to meningococcal disease is estimated to be 4 cases per 1,000 people exposed, which is 500-800 times higher than the general population 2
• Ciprofloxacin, rifampin, and ceftriaxone are all 90-95% effective in reducing nasopharyngeal carriage of N. meningitidis 2, 5
• Rifampin is effective for up to 4 weeks after treatment, but resistant isolates can develop following prophylactic treatment 5, 6
• A recent study showed that village-wide distribution of ciprofloxacin during outbreaks in the African meningitis belt significantly reduced overall meningitis attack rates 7

Important Caveats

• Nasopharyngeal cultures are not helpful in determining the need for prophylaxis and might unnecessarily delay preventive measures 2
• Close contacts remain at increased risk for up to 6 months; their medical records should be labeled accordingly 2
• Rifampin can lead to circulation of resistant isolates during outbreaks, making ciprofloxacin or ceftriaxone potentially better choices in such situations 6
• Prophylaxis is not recommended for casual contacts or for contacts of patients with pneumococcal meningitis 1