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

Prophylaxis for Neisseria Meningitidis

Ciprofloxacin 500 mg as a single oral dose is the preferred first-line prophylactic antibiotic for close contacts of patients with meningococcal meningitis due to its effectiveness, ease of administration, and excellent compliance. 1

Who Should Receive Prophylaxis

Prophylaxis should be administered to:

• Household members
• Child care center contacts
• Individuals directly exposed to the patient's oral secretions
• Healthcare professionals who handled the patient's airways
• Passengers seated next to the patient on prolonged flights (≥8 hours) 1

Timing of Prophylaxis

Prophylaxis should be administered as soon as possible, ideally within 24 hours after identification of the index case, and no later than 14 days after exposure 2. Delayed prophylaxis (>14 days after exposure) is likely of limited or no value.

First-Line Prophylactic Regimens

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) 1

Alternative Regimens

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 1, 3

Ceftriaxone

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

Azithromycin

• A single 500-mg oral dose of azithromycin has been shown to be effective in eradicating nasopharyngeal carriage of N. meningitidis 2

Special Considerations

Areas with Ciprofloxacin Resistance

In areas where ciprofloxacin resistance has been documented, alternative antibiotics should be considered when:

• Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have occurred, AND
• ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains 4

In such cases, rifampin, ceftriaxone, or azithromycin should be used instead 4.

Pregnancy

Ceftriaxone is the preferred agent for pregnant women 1.

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, 1.

Efficacy and Rationale

• 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
• Close contacts remain at increased risk for up to 6 months, and their medical records should be labeled accordingly 1

Vaccination Considerations

• Unimmunized contacts of cases caused by vaccine-preventable non-B serogroups should be offered appropriate meningococcal vaccination 2, 1
• After a second confirmed serogroup B case occurs in a household, Bexsero should be considered in addition to chemoprophylaxis for all household contacts 2

Important Caveats

• Nasopharyngeal cultures are not helpful in determining the need for prophylaxis and might unnecessarily delay preventive measures 2, 1
• Rifampin may lead to the circulation of resistant isolates during outbreaks 5
• Systemic antimicrobial therapy of meningococcal disease with agents other than ceftriaxone or other third-generation cephalosporins might not reliably eradicate nasopharyngeal carriage of N. meningitidis 2
• The emergence of antibiotic-resistant N. meningitidis strains necessitates ongoing surveillance and appropriate antibiotic selection 6