What is the recommended prophylaxis for meningitis?

Prophylaxis for Meningitis

For meningococcal meningitis prophylaxis, single-dose oral ciprofloxacin 500 mg is the first-line recommendation for adults, with ceftriaxone 250 mg IM or rifampin 600 mg twice daily for 2 days as alternatives. 1, 2

Meningococcal Meningitis Prophylaxis

Who Requires Prophylaxis

• Close contacts must receive prophylaxis within 24 hours of case identification, including household members, intimate kissing contacts, childcare center contacts, and anyone directly exposed to oral secretions. 1
• The risk of meningococcal disease increases 400-800 fold in close contacts, with secondary attack rates of 2-4 per 1000 population. 1, 3

First-Line Antibiotic Regimens

Adults (>16 years):

• Ciprofloxacin 500 mg oral single dose (preferred due to single-dose convenience and high street pharmacy availability) 1, 2
• Ceftriaxone 250 mg IM single dose 1, 2
• Rifampin 600 mg orally twice daily for 2 days 1, 4

Pediatric Dosing:

• Ciprofloxacin: 30 mg/kg for children <5 years; 250 mg for children 5-12 years 3
• Ceftriaxone: 125 mg IM single dose for children <16 years 2, 3
• Rifampin: 5 mg/kg twice daily for 2 days (<1 month); 10 mg/kg twice daily for 2 days (1-12 months and 3 months-12 years); 600 mg twice daily for 2 days (>12 years) 2, 4

Critical Considerations

• Ciprofloxacin is now preferred over rifampin because it requires only a single dose and avoids the emergence of rifampin-resistant isolates that can occur with rifampin use. 1, 5
• Patients who received IV ceftriaxone for treatment do not need additional prophylaxis before discharge. 1
• An increased risk persists for 6 months after exposure, even with prophylaxis; general practice records should be flagged accordingly. 1

Emerging Resistance Concerns

• In areas with ciprofloxacin resistance (≥2 cases with resistant strains AND ≥20% of cases resistant in a 12-month period), preferentially use rifampin, ceftriaxone, or azithromycin instead of ciprofloxacin. 6

Vaccination Considerations

• Contacts of vaccine-preventable non-B serogroups should receive meningococcal vaccination. 1
• After a second confirmed serogroup B case in a household, consider Bexsero vaccination in addition to chemoprophylaxis for all household contacts. 1

Haemophilus influenzae Type B Prophylaxis

Indications for Prophylaxis

• Prophylaxis is required only when households contain an at-risk individual (child <10 years or immunosuppressed person of any age). 1
• All household contacts and the index case should receive rifampin if an at-risk individual is present. 1

Dosing Regimen

• Adults and children >3 months: Rifampin 20 mg/kg once daily (maximum 600 mg) for 4 days 1, 4
• Infants <3 months: Rifampin 10 mg/kg once daily for 4 days 1

Vaccination

• All previously unvaccinated household contacts under age 10 should receive Hib vaccination. 1

Pneumococcal Meningitis

Prophylaxis Not Indicated

• Close contacts of pneumococcal meningitis do NOT require antibiotic prophylaxis, as they are not at increased risk. 1
• Clusters in elderly care homes should be discussed with local health protection authorities. 1

Vaccination Recommendations

• Patients who have had pneumococcal meningitis should receive pneumococcal vaccination to reduce recurrence risk (1-5% recurrence rate). 1
• Vaccination is particularly beneficial for patients with CSF leakage along with surgical repair of the dural barrier. 1

Implementation Pitfalls

• Do not delay prophylaxis—it must be initiated within 24 hours of case identification for maximum effectiveness. 1
• Droplet precautions should continue until contacts have received 24 hours of effective prophylaxis. 2
• Monitor contacts for symptoms for at least 10 days after exposure, even after receiving prophylaxis. 2
• Rifampin causes orange discoloration of body fluids and has multiple drug interactions; counsel patients accordingly. 4
• Ciprofloxacin is safe in pregnancy and all age groups, making it the most practical first-line choice. 1