What is the treatment for Neisseria meningitidis infections?

Treatment of Neisseria meningitidis Infections

For invasive meningococcal disease, initiate immediate empiric treatment with a third-generation cephalosporin—specifically ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours—without waiting for diagnostic confirmation, as delays in antibiotic administration directly increase mortality. 1

Empiric Antibiotic Selection

First-Line Therapy

• Ceftriaxone 2g IV every 12 hours is the preferred empiric agent for suspected or confirmed meningococcal meningitis or sepsis 2
• Cefotaxime 2g IV every 6 hours is equally effective as an alternative third-generation cephalosporin 2
• Third-generation cephalosporins must be used empirically due to increasing rates of penicillin resistance in N. meningitidis strains, with some regions reporting up to 80% reduced penicillin susceptibility 2, 3

Alternative Agents (When Cephalosporins Cannot Be Used)

• Penicillin G 2.4g IV every 4 hours may be used only if local susceptibility patterns confirm penicillin sensitivity and the patient has no risk factors for resistance 2, 4
• Chloramphenicol 25 mg/kg IV every 6 hours is reserved for patients with severe beta-lactam allergies 2
• Penicillin G is highly active against N. meningitidis in vitro, but resistance patterns now limit its empiric use 4

Treatment Duration

• Continue antibiotics for 5-7 days for confirmed meningococcal meningitis 5, 2
• The standard duration is 7 days for meningococcal meningitis per IDSA recommendations 5
• A 5-day course is sufficient if clinical improvement is documented and the infection is confirmed as meningococcal 2

Critical Management Considerations

Do Not Delay Treatment

• Administer antibiotics immediately upon clinical suspicion—do not wait for lumbar puncture, imaging, or culture results 1
• Mortality increases significantly with each hour of delayed antibiotic administration in meningococcal disease 1
• Blood cultures should be obtained before antibiotics when possible, but this should not delay treatment 1

Resistance Surveillance

• Increasing fluoroquinolone resistance has been documented since 2005, mediated by gyrA mutations 3
• Fully penicillin-resistant isolates have increased notably since 2016, mediated by mosaic penA alleles or β-lactamase genes (blaROB-1 and blaTEM-1) 3
• Four cases of third-generation cephalosporin resistance have been identified globally since 2011, though this remains exceptionally rare 3

Chemoprophylaxis for Close Contacts

Indications and Timing

• Administer prophylaxis within 24 hours of identifying the index case for maximum effectiveness 1, 5
• Prophylaxis given >14 days after exposure has limited or no value 1, 5
• Close contacts include household members, childcare contacts, and persons directly exposed to oral secretions (kissing, mouth-to-mouth resuscitation, intubation) 5

Prophylaxis Regimens

In areas WITHOUT ciprofloxacin resistance:

• Ciprofloxacin 500mg PO single dose (not for pregnant women) 1
• Ceftriaxone 250mg IM single dose (safe in pregnancy) 1
• Rifampin (600mg PO twice daily for 2 days in adults; not for pregnant women due to teratogenicity) 1

In areas WITH ciprofloxacin resistance:

• Avoid ciprofloxacin when ≥2 ciprofloxacin-resistant cases AND ≥20% of all cases are resistant in the past 12 months 6
• Preferentially use rifampin, ceftriaxone, or azithromycin in these settings 6
• Azithromycin 500mg PO single dose is effective for eradicating nasopharyngeal carriage and is available in suspension form for children 1

Index Patient Considerations

• The index patient requires prophylaxis before hospital discharge if treated with antibiotics other than ceftriaxone or third-generation cephalosporins, as these may not reliably eradicate nasopharyngeal carriage 1, 5
• Patients treated with ceftriaxone do not require additional prophylaxis 5

Infection Control

Healthcare Worker Exposure

• Healthcare workers have a 25-fold increased risk compared to the general population when exposed to meningococcal patients 1, 5
• Postexposure prophylaxis is indicated for intensive, unprotected contact (intubation, resuscitation, close oropharyngeal examination without mask) 1
• Adherence to respiratory droplet precautions significantly reduces transmission risk 1

Contagious Period

• Patients remain contagious from 7 days before symptom onset until 24 hours after starting effective antibiotics 5
• Household contacts have an attack rate of 4 cases per 1,000 exposed—500-800 times higher than the general population 1, 5

Common Pitfalls to Avoid

• Never use rifampin or fosfomycin as monotherapy due to rapid resistance development 2
• Do not perform oropharyngeal or nasopharyngeal cultures to determine prophylaxis need—this unnecessarily delays intervention 1
• Do not discontinue therapy prematurely even with rapid clinical improvement, as this may lead to relapse 2
• Do not assume penicillin susceptibility—empiric third-generation cephalosporins are mandatory until susceptibility confirmed 2, 3