What is the indication for Rifampin (rifampicin) in meningitis prophylaxis?

From the Guidelines

Rifampin is indicated for meningococcal meningitis prophylaxis in close contacts of individuals with confirmed Neisseria meningitidis infection, particularly when ciprofloxacin is contraindicated or not tolerated, as stated in the UK joint specialist societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1. The recommended dosage is 600 mg orally twice daily for 2 days in adults, and for children, the dosage varies by age:

• 5 mg/kg twice a day for 2 days for contacts aged less than 12 months
• 10 mg/kg twice a day for 2 days for contacts aged 1-12 years
• 600 mg twice a day for 2 days for contacts over the age of 12 1. Rifampin should be administered to household members, daycare contacts, and anyone with direct exposure to the patient's oral secretions within 7 days of exposure. It is particularly important for prophylaxis because it effectively eliminates nasopharyngeal carriage of N. meningitidis, reducing the risk of secondary cases, as supported by the ESCMID guideline on diagnosis and treatment of acute bacterial meningitis 1 and the prevention and control of meningococcal disease recommendations of the Advisory Committee on Immunization Practices (ACIP) 1. Rifampin works by inhibiting bacterial RNA polymerase, preventing bacterial replication. Important considerations include:
• Rifampin turns body fluids orange-red (including urine, tears, and sweat)
• Reduces effectiveness of hormonal contraceptives
• Interacts with many medications through cytochrome P450 induction Alternative prophylactic agents include ciprofloxacin (single 500 mg oral dose for adults) or ceftriaxone (single 250 mg IM dose for adults, 125 mg for children) if rifampin cannot be used due to contraindications or drug interactions, as recommended by the ESCMID guideline 1 and the ACIP 1. The use of prophylactic treatment of household contacts has been shown to decrease carriage or secondary cases, as demonstrated by a Cochrane meta-analysis including 24 RCTs 1.

From the FDA Drug Label

Rifampin is indicated for the treatment of asymptomatic carriers of Neisseria meningitidis to eliminate meningococci from the nasopharynx. The indication for Rifampin (rifampicin) in meningitis prophylaxis is for the treatment of asymptomatic carriers of Neisseria meningitidis to eliminate meningococci from the nasopharynx, in order to prevent the spread of meningococcal disease.

• The drug is not indicated for the treatment of meningococcal infection due to the possibility of rapid emergence of resistant organisms. 2

From the Research

Indication for Rifampin in Meningitis Prophylaxis

• Rifampin is indicated for the prophylaxis of meningitis caused by Haemophilus influenzae type b (Hib) in close contacts of patients with Hib disease 3, 4.
• The drug is effective in eliminating the Hib carrier state and may be useful in preventing associated Hib disease in close contacts of children with Hib meningitis 3.
• Rifampin is also effective in eradicating Neisseria meningitidis, the causative agent of meningococcal disease, although its use may lead to the circulation of resistant isolates 5.
• In areas with ciprofloxacin resistance, rifampin is considered an alternative option for prophylaxis against meningococcal disease, along with ceftriaxone and azithromycin 6.

Dosage and Efficacy

• The recommended dosage of rifampin for meningitis prophylaxis is 20 mg/kg/day (maximum 600 mg) for four days 3, 4.
• The efficacy of rifampin in eradicating Hib carriage is high, with eradication rates ranging from 95% to 96% in household contacts of patients with Hib disease 3, 4.
• However, the efficacy of rifampin in young children (less than 5 years) is lower, with eradication rates of around 27% 7.

Considerations for Use

• Rifampin should be used with caution in areas with high rates of resistance to the drug 5, 6.
• The use of rifampin as a chemoprophylactic agent for family contacts of patients with Hib disease may not be effective in young children, and alternative strategies should be considered 7.