What are the recommended methods for Neisseria meningitis prophylaxis?

Neisseria Meningitidis Prophylaxis

Antimicrobial chemoprophylaxis should be administered to close contacts of patients with meningococcal disease as soon as possible, ideally within 24 hours after identification of the index case, using ciprofloxacin, rifampin, or ceftriaxone as first-line agents. 1

Close Contacts Requiring Prophylaxis

Close contacts who should receive prophylaxis include:

• Household members
• Child-care center contacts
• Anyone directly exposed to the patient's oral secretions (e.g., kissing, mouth-to-mouth resuscitation)
• Healthcare workers who performed endotracheal intubation or managed endotracheal tubes
• Passengers seated directly next to an index patient on prolonged flights (≥8 hours) 2, 1

The attack rate for household contacts is approximately 4 cases per 1,000 persons exposed, which is 500-800 times higher than the general population risk 2, 1.

Timing of Prophylaxis

• Administer as soon as possible, ideally within 24 hours after identifying the index case
• Prophylaxis administered >14 days after onset of illness in the index patient has limited or no value 2, 1

Recommended Antimicrobial Regimens

Population	Ciprofloxacin	Rifampin	Ceftriaxone
Adults	500 mg orally as a single dose	600 mg orally twice daily for 2 days	250 mg IM as a single dose
Children 5-12 years	250 mg orally as a single dose	10 mg/kg twice daily for 2 days	125 mg IM as a single dose
Children <5 years	30 mg/kg orally as a single dose (max 125 mg)	10 mg/kg twice daily for 2 days	125 mg IM as a single dose
Infants <1 year	Not recommended	5 mg/kg twice daily for 2 days	125 mg IM as a single dose

All three antibiotics are 90-95% effective in reducing nasopharyngeal carriage of N. meningitidis 2, 1.

Special Considerations

1. Areas with ciprofloxacin resistance: Consider alternative antibiotics (rifampin, ceftriaxone, or azithromycin) when:

   • Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have occurred in a local area
   • ≥20% of all reported invasive meningococcal disease cases are caused by ciprofloxacin-resistant strains 3

2. Index patient treatment: If systemic antimicrobial therapy for the index patient used agents other than ceftriaxone or other third-generation cephalosporins, the patient should receive chemoprophylactic antibiotics before hospital discharge 2, 1

3. Nasopharyngeal cultures: Not helpful in determining the need for prophylaxis and might unnecessarily delay preventive measures 2, 1

Vaccination Recommendations

Vaccination is recommended in addition to chemoprophylaxis in certain situations:

1. Outbreak control: Consider vaccination when three or more confirmed cases of serogroup A, C, W, or Y meningococcal disease occur within ≤3 months, with a primary attack rate of >10 cases/100,000 population 2

2. High-risk groups: Routine vaccination is recommended for:

   • Persons with complement component deficiencies
   • Persons with anatomic or functional asplenia
   • Laboratory personnel routinely exposed to N. meningitidis
   • First-year college students living in residence halls
   • Military recruits
   • Travelers to countries where meningococcal disease is hyperendemic or epidemic 2

3. Vaccine types:

   • MenACWY vaccines for serogroups A, C, W, and Y
   • MenB vaccines for serogroup B 2, 4

Public Health Response

• All cases of meningococcal meningitis must be reported to public health authorities
• Contact tracing and prophylaxis should be coordinated by public health officials 1
• In outbreak settings, public health officials will determine the need for broader vaccination campaigns 2

Common Pitfalls to Avoid

1. Delayed prophylaxis: Effectiveness decreases significantly if not administered within 24 hours
2. Incomplete contact identification: Ensure all close contacts are identified and treated
3. Relying on cultures: Do not wait for nasopharyngeal culture results before initiating prophylaxis
4. Inadequate treatment of index case: Ensure index patients treated with antibiotics other than third-generation cephalosporins receive prophylaxis before discharge
5. Overlooking vaccination: Consider vaccination for unimmunized contacts in addition to chemoprophylaxis when appropriate

By promptly identifying close contacts and administering appropriate antimicrobial prophylaxis, the risk of secondary cases of meningococcal disease can be significantly reduced.