From the Guidelines
Rifampin is indicated for the treatment of pneumococcal meningitis when the pneumococcus is both penicillin and cephalosporin resistant, in combination with ceftriaxone or cefotaxime and vancomycin, at a dose of 600 mg IV/orally 12-hourly. This recommendation is based on the UK Joint Specialist Societies guideline on the diagnosis and management of acute meningitis and meningococcal sepsis in immunocompetent adults 1. The guideline suggests that for patients with pneumococcal meningitis who have not recovered by day 10, treatment should be continued for 14 days, and rifampin should be added to the treatment regimen if the pneumococcus is resistant to both penicillin and cephalosporin.
Some key points to consider when using rifampin for the treatment of meningitis include:
- The dose of rifampin for adults is 600 mg IV/orally 12-hourly, as recommended by the guideline 1
- Rifampin should be used in combination with other antibiotics, such as ceftriaxone or cefotaxime and vancomycin, for the treatment of resistant pneumococcal meningitis
- The treatment duration for pneumococcal meningitis is typically 14 days, as recommended by the guideline 1
- Rifampin has numerous drug interactions due to cytochrome P450 enzyme induction, and its ability to turn body fluids orange-red, and the need to monitor liver function during treatment, as noted in other studies 1
It's worth noting that rifampin is also used for meningococcal meningitis prophylaxis, as an alternative to ciprofloxacin, at a dose of 600 mg twice daily for 2 days in adults, as recommended by the ESCMID guideline 1. However, this is not the primary indication for rifampin in the context of meningitis treatment.
From the FDA Drug Label
Rifampin is indicated for the treatment of asymptomatic carriers of Neisseria meningitidis to eliminate meningococci from the nasopharynx. Rifampin is not indicated for the treatment of meningococcal infection because of the possibility of the rapid emergence of resistant organisms
The indication for Rifampin (rifampicin) treatment in meningitis is not supported for the treatment of meningococcal infection, including meningitis, due to the risk of rapid emergence of resistant organisms. It is only indicated for the treatment of asymptomatic carriers of Neisseria meningitidis to eliminate meningococci from the nasopharynx 2.
From the Research
Indication for Rifampin Treatment in Meningitis
- Rifampin is used as a prophylactic treatment to prevent meningococcal disease in close contacts of people with a meningococcal infection and populations with known high carriage rates 3, 4, 5.
- The effectiveness of rifampin in preventing meningococcal disease cannot be directly assessed as there were no cases of meningococcal disease during follow-up in the trials 3, 4, 5.
- Rifampin has been shown to be effective in eradicating N. meningitidis from the pharynx in healthy carriers 3, 4, 5.
- In the context of acute community-acquired meningitis, rifampin use has been associated with lower mortality in the ICU, particularly in patients with pneumococcal meningitis 6.
- A pilot randomized controlled trial suggested that pretreatment with rifampin may reduce inflammation and neuronal damage in childhood bacterial meningitis 7.
Mechanism of Action
- Rifampin has been shown to attenuate the inflammatory response in experimental models of bacterial meningitis 7.
- Pretreatment with rifampin has been found to reduce the CSF concentrations of markers of inflammation and neuronal damage in children with bacterial meningitis 7.
Clinical Use
- Rifampin is often used in combination with other antibiotics, such as ceftriaxone, to treat bacterial meningitis 6, 7.
- The use of rifampin in an outbreak setting may lead to the circulation of resistant isolates, and alternative antibiotics such as ciprofloxacin or ceftriaxone should be considered 3, 4, 5.