What is the latest guidance for antibiotic prophylaxis in Neisseria (N.) meningitis contacts, including adults, children, pregnant women, and lactating women?

From the Guidelines

For close contacts of individuals with Neisseria meningitidis infection, antibiotic prophylaxis should be administered as soon as possible, ideally within 24 hours of case identification, with ciprofloxacin being the preferred option for adults and children, given as a single 500 mg oral dose for adults, and 250 mg or 30 mg/kg (up to a maximum of 125 mg) for child contacts aged 5-12 years and under 5 years, respectively, as recommended by the most recent guideline 1. The choice of antibiotic prophylaxis depends on the age and condition of the contact, with rifampicin being an alternative option for those unable to take ciprofloxacin, given as 600 mg twice a day for 2 days for contacts over 12 years, 10 mg/kg twice a day for 2 days for contacts aged 1-12 years, and 5 mg/kg twice a day for 2 days for contacts under 1 year 1. For pregnant women, ceftriaxone is the preferred option, given as a single 250 mg intramuscular dose, due to potential risks associated with rifampicin and ciprofloxacin 1. Lactating women can receive any of these antibiotics, although rifampicin may cause orange discoloration of breast milk 1. Prophylaxis should be offered to household contacts, intimate kissing contacts, healthcare workers with direct exposure to respiratory secretions, and those who shared sleeping quarters with the index case, and contacts should be monitored for symptoms including fever, headache, stiff neck, and rash for at least 10 days after exposure, even after receiving prophylaxis 1. Some key points to consider when administering antibiotic prophylaxis include:

• The importance of prompt administration, ideally within 24 hours of case identification
• The need to consider the age and condition of the contact when choosing an antibiotic
• The potential risks and benefits associated with each antibiotic option
• The importance of monitoring contacts for symptoms of meningococcal disease, even after receiving prophylaxis. It is also worth noting that vaccine can be given to any unvaccinated contacts of cases caused by any non-B serogroup, and that wider vaccination may be offered in line with national guidance in certain circumstances, such as when two or more cases of probable/confirmed IMD due to the same vaccine preventable strain occur in the same educational or residential setting within a four-week period 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 recommended antibiotic prophylaxis for Neisseria meningitidis contacts is:

• Adults: Rifampin (PO)
• Children: Rifampin (PO)
• Pregnant: Rifampin (PO) is recommended, but the decision should be made on a case-by-case basis, considering the risks and benefits.
• Lactating: Rifampin (PO) is recommended, but the decision should be made on a case-by-case basis, considering the risks and benefits. Key considerations:
• Risk assessment: The risk of meningococcal disease should be high to justify the use of rifampin.
• Susceptibility testing: Diagnostic laboratory procedures, including serotyping and susceptibility testing, should be performed to establish the carrier state and the correct treatment.
• Resistance: Rifampin should not be used indiscriminately to reduce the development of drug-resistant bacteria. 2

From the Research

Antibiotics Prophylaxis for Neisseria Meningitis Contacts

• The following antibiotics have been studied for prophylaxis against Neisseria meningitis: ciprofloxacin, rifampin, minocycline, ampicillin, penicillin, and ceftriaxone 3, 4, 5, 6.
• Ciprofloxacin, rifampin, minocycline, and penicillin have been shown to be effective in eradicating N. meningitidis one week after treatment compared to placebo 3, 4, 5, 6.
• Rifampin, ciprofloxacin, and penicillin have been shown to still be effective at one to two weeks after treatment 3, 4, 5, 6.
• Ceftriaxone has been shown to be more effective than rifampin after one to two weeks of follow-up 3, 4, 5, 6.

Special Considerations

• Pregnant Women: Ceftriaxone is recommended for pregnant women, as well as children under 2 years old or lactating women 7.
• Children: Ciprofloxacin has been shown to be safe and effective in children 2-18 years old 7.
• Lactating Women: Ceftriaxone is recommended for lactating women 7.
• Adults: Ciprofloxacin, rifampin, and penicillin have been shown to be effective in adults 3, 4, 5, 6.

Adverse Events and Resistance

• Mild adverse events have been associated with treatment, including abdominal pain and other side effects 3, 4, 5, 6, 7.
• The use of rifampin may lead to the circulation of resistant isolates, and alternative antibiotics such as ciprofloxacin, ceftriaxone, or penicillin should be considered 3, 4, 5, 6.