What is the recommended protocol for meningitis (inflammation of the meninges) prophylaxis?

Meningitis Prophylaxis Protocol

Prophylaxis for meningococcal meningitis should be administered as soon as possible after identification of an index case, ideally within 24 hours and no later than 14 days after exposure, with ciprofloxacin as the first-line agent for most contacts. 1

Notification and Coordination

• All cases of meningitis (regardless of etiology) must be notified to the relevant public health authority 2
• Contact the local public health team/Consultant in Communicable Disease Control early 2
• Prophylaxis of contacts should be initiated by public health authorities, not the admitting clinicians 2

Identifying Contacts Requiring Prophylaxis

Prophylaxis should be offered to:

• Household members (highest risk group - 500-800 times higher risk than general population) 1
• Child care center contacts 1
• Individuals directly exposed to the patient's oral secretions 1
• Healthcare professionals who handled the patient's airways 1
• Passengers seated next to the patient on prolonged flights (≥8 hours) 1

Antibiotic Prophylaxis Regimens

First-line: Ciprofloxacin (single oral dose) 2, 1

• Adults: 500 mg
• Children 5-12 years: 250 mg
• Children under 5 years: 30 mg/kg (maximum 125 mg)

Alternative: Rifampin 2, 1

• Adults and children >12 years: 600 mg twice daily for 2 days
• Children 1-12 years: 10 mg/kg twice daily for 2 days
• Infants <12 months: 5 mg/kg twice daily for 2 days

Other alternatives 1

• Ceftriaxone: 250 mg IM single dose for adults, 125 mg IM single dose for children
• Azithromycin: 500 mg oral single dose (effective in eradicating nasopharyngeal carriage)

Special Considerations

• Antibiotic resistance: In areas with ciprofloxacin resistance, consider alternative antibiotics when two or more cases caused by resistant strains occur and ≥20% of all reported cases are caused by resistant strains 3
• Index patient prophylaxis: The index patient should receive chemoprophylactic antibiotics before hospital discharge if treated with antibiotics other than ceftriaxone or other third-generation cephalosporins 1
• Infection control: Maintain respiratory isolation and droplet precautions until the patient has received 24 hours of effective antibiotics 1

Vaccination Recommendations

• Offer appropriate meningococcal vaccination to unimmunized contacts of cases caused by vaccine-preventable non-B serogroups 2, 1
• If two or more cases of serogroup B disease occur in the same household, consider Bexsero vaccination in addition to chemoprophylaxis for all household contacts 2, 1
• Any unimmunized index case under 25 years should be offered vaccination according to the national schedule 2
• Cases of confirmed serogroup C disease who were previously immunized should be offered a booster dose of Meningococcal C conjugate vaccine around hospital discharge 2

Important Clinical Pearls

• Prophylaxis effectiveness: Ciprofloxacin, rifampin, and ceftriaxone are all 90-95% effective in reducing nasopharyngeal carriage of N. meningitidis 1
• Timing is critical: The highest risk period for secondary cases is within the first week after identification of the index case 1, 4
• Close contacts remain at increased risk for up to 6 months, and their medical records should be labeled accordingly 1
• Nasopharyngeal cultures are not helpful in determining the need for prophylaxis and might unnecessarily delay preventive measures 1
• Rifampin use during an outbreak may lead to the circulation of resistant isolates, so ciprofloxacin, ceftriaxone, or azithromycin may be preferable in outbreak settings 4, 3

Haemophilus influenzae Meningitis Prophylaxis

While this protocol focuses primarily on meningococcal meningitis, it's worth noting that close contacts of H. influenzae type b meningitis may also require prophylaxis, particularly in household settings with vulnerable individuals 5, 6.