Treatment of Neisseria Meningitis
The recommended first-line treatment for Neisseria meningitis is ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours for a duration of 5-7 days, provided there is clinical improvement. 1
Initial Antibiotic Therapy
First-line Treatment
- Ceftriaxone: 2g IV every 12 hours (or 4g every 24 hours)
- Cefotaxime: 2g IV every 6 hours (or every 4-6 hours)
Alternative Options (for patients with cephalosporin allergy)
- Chloramphenicol: 25 mg/kg IV every 6 hours
- Benzylpenicillin: 2.4g IV every 4 hours (only if organism is known to be penicillin-sensitive)
Treatment Duration
- 5 days for Neisseria meningitidis with clinical improvement 1
- Extend treatment if clinical response is delayed
Special Considerations
Antibiotic Resistance
- In areas with suspected penicillin resistance:
- Continue with third-generation cephalosporins (ceftriaxone or cefotaxime)
- Consider adding vancomycin or rifampicin if high-level resistance is suspected 1
Age-Specific Considerations
- Adults >50 years or immunocompromised: Add amoxicillin/ampicillin (2g every 4 hours) to cover Listeria monocytogenes 1
- Children: Dosing adjustments required
- Cefotaxime: 75 mg/kg every 6-8 hours
- Ceftriaxone: 50 mg/kg every 12 hours (maximum 2g every 12 hours) 1
Adjunctive Therapy
Corticosteroids
- Dexamethasone: 10mg IV every 6 hours for 4 days
- Should be started with or before the first antibiotic dose
- Consider discontinuing if pathogens other than S. pneumoniae or H. influenzae are identified
- For N. meningitidis specifically, there appears to be no clear harm or benefit from dexamethasone, and the decision to continue or stop can be made on an individual basis 1
Prophylaxis for Close Contacts
Antimicrobial prophylaxis should be administered to close contacts within 24 hours of identifying the index case 1:
| Drug | Age Group | Dosage | Duration |
|---|---|---|---|
| Rifampin | Adults | 600 mg every 12 hours | 2 days (oral) |
| Children ≥1 month | 10 mg/kg every 12 hours | 2 days (oral) | |
| Infants <1 month | 5 mg/kg every 12 hours | 2 days (oral) | |
| Ciprofloxacin | Adults | 500 mg | Single oral dose |
| Ceftriaxone | Adults | 250 mg | Single IM dose |
| Children <15 years | 125 mg | Single IM dose |
Monitoring and Follow-up
- Monitor clinical response within the first 24-48 hours
- If no improvement after 48 hours, consider:
- Repeat lumbar puncture to confirm CSF sterilization
- Evaluation for complications (e.g., subdural empyema, brain abscess)
- Reassessment of antibiotic regimen
Common Pitfalls to Avoid
- Delayed treatment: Initiate antibiotics immediately after obtaining CSF samples; do not wait for results
- Inadequate prophylaxis: Ensure all close contacts receive appropriate prophylaxis within 24 hours
- Inappropriate antibiotic selection: Consider local resistance patterns when selecting empiric therapy
- Overlooking adjunctive therapy: Consider dexamethasone for all suspected bacterial meningitis cases
- Insufficient duration: Complete the full course of antibiotics even if rapid clinical improvement occurs
The evidence strongly supports third-generation cephalosporins as the cornerstone of treatment for Neisseria meningitis, with excellent CSF penetration and bactericidal activity against meningococci 2, 3, 4. While penicillin was historically used, increasing resistance concerns have made cephalosporins the preferred first-line agents in most settings.