What is the recommended prophylaxis for meningococcal (Neisseria meningitidis) infection?

Recommended Prophylaxis for Meningococcal Infection

For prophylaxis of meningococcal infection, ciprofloxacin 500 mg as a single oral dose is the first-line recommendation for adults, with rifampin or ceftriaxone as alternatives when ciprofloxacin cannot be used. 1

Who Should Receive Prophylaxis

• Prophylaxis should be administered to close contacts of patients with meningococcal disease, including:

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

• Close contacts have a 400-800 fold increased risk of developing meningococcal disease compared to the general population 2

Timing of Prophylaxis

• Prophylaxis should be administered as soon as possible, ideally within 24 hours of identifying the index case 2
• Prophylaxis given more than 14 days after onset of illness in the index patient has limited or no value 2

Recommended Prophylactic Antibiotics

For Adults:

• First-line: Ciprofloxacin 500 mg orally as a single dose 1, 2
• Alternatives:
  • Rifampin 600 mg orally twice daily for 2 days 2, 3
  • Ceftriaxone 250 mg intramuscularly as a single dose 1, 2
  • Ceftriaxone is the preferred option during pregnancy 4

For Children:

• For children under 1 month: Rifampin 5 mg/kg orally twice daily for 2 days 4, 3
• For children 1 month to 12 years: Rifampin 10 mg/kg (not to exceed 600 mg per dose) orally twice daily for 2 days 3, 1
• For children over 12 years: Adult dosing 3
• Alternative: Ceftriaxone 125 mg intramuscularly as a single dose for children 1

Special Considerations

• Nasopharyngeal cultures are not helpful in determining the need for prophylaxis and may unnecessarily delay treatment 2
• If the index patient was treated with antibiotics other than ceftriaxone or other third-generation cephalosporins, they should also receive prophylactic antibiotics before hospital discharge to eradicate nasopharyngeal carriage 2
• Emerging ciprofloxacin resistance should be considered when selecting prophylaxis. In areas with documented ciprofloxacin resistance, alternative antibiotics (rifampin, ceftriaxone, or azithromycin) should be used 5
• Droplet precautions should be implemented for exposed individuals until they have received 24 hours of effective antibiotic prophylaxis 4
• Monitor contacts for symptoms of meningococcal disease for at least 10 days after exposure, even after receiving prophylaxis 4

Vaccination Considerations

• Unvaccinated contacts of cases caused by vaccine-preventable non-B serogroups should be offered vaccination 2
• After a second confirmed serogroup B case occurs in a household, vaccination against serogroup B should be considered for all household contacts 2
• Any unimmunized index case under 25 years should be offered vaccination according to the national schedule 2

Efficacy of Prophylaxis

• Rifampin, ciprofloxacin, and ceftriaxone are 90-95% effective in reducing nasopharyngeal carriage of N. meningitidis 2
• A Cochrane meta-analysis confirmed that ceftriaxone, rifampin, and ciprofloxacin are the most effective agents for eradicating N. meningitidis 6
• Despite prophylaxis, an increased risk persists for at least 6 months in contacts of patients with invasive infection 2

Potential Pitfalls

• Rifampin may lead to circulation of resistant isolates during outbreaks 6
• Ciprofloxacin is contraindicated in pregnancy 4
• Rifampin can cause orange discoloration of body fluids and may interfere with hormonal contraceptives 3
• Failure to provide prophylaxis within 24 hours significantly reduces effectiveness 2
• Increasing ciprofloxacin resistance in some regions necessitates monitoring local resistance patterns 5, 7