Treatment of Meningococcal Meningitis and Meningococcemia
Administer ceftriaxone 2 grams IV every 12 hours immediately upon clinical suspicion, even before lumbar puncture or imaging, and continue for 5 days if the patient has recovered by day 5. 1, 2
Immediate Antibiotic Administration
- Start empiric antibiotics within 60 minutes of hospital arrival, as delays in treatment are strongly associated with death and poor outcomes 2
- Draw blood cultures immediately, but never delay antibiotic administration while awaiting culture results 2
- Treatment should begin on clinical suspicion alone, before any diagnostic procedures 2
First-Line Antibiotic Regimen
Ceftriaxone is the preferred agent because it both treats the infection and reliably eradicates meningococcal carriage in the oropharynx, preventing transmission 1, 2
- Ceftriaxone 2 grams IV every 12 hours (or cefotaxime 2 grams IV every 6 hours as an alternative) 1, 2
- Continue for 5 days if the patient has recovered by day 5 1, 2
- Extend treatment duration if clinical response is delayed 1, 2
Alternative Regimen
- Benzylpenicillin 2.4 grams IV every 4 hours may be used as an alternative 1, 2
- However, ceftriaxone remains preferred due to superior oropharyngeal eradication 2
Penicillin Allergy
Critical Adjunctive Measure: Eradication of Carriage
If benzylpenicillin or any beta-lactam other than ceftriaxone is used, you must add carriage eradication therapy to prevent transmission 1, 2:
- Ciprofloxacin 500 mg orally as a single dose (preferred) 1, 2
- OR rifampicin 600 mg orally twice daily for 2 days if ciprofloxacin is contraindicated 2
- This step is not needed if ceftriaxone is used for treatment, as it reliably eradicates oropharyngeal carriage 1, 2
Treatment Algorithm by Clinical Presentation
Meningococcemia WITH Meningitis
- Use the same ceftriaxone regimen (2 grams IV every 12 hours) 1, 2
- Continue for 5 days if recovered 1, 2
- The twice-daily dosing is essential to maintain adequate CSF concentrations throughout the dosing interval 3
Meningococcemia WITHOUT Meningitis (Sepsis Only)
- Ceftriaxone 2 grams IV every 12 hours (or cefotaxime 2 grams IV every 6 hours) 1, 2
- Continue for 5 days if recovered by day 5 1, 2
- Benzylpenicillin 2.4 grams IV every 4 hours is an acceptable alternative 1, 2
Probable Meningococcemia (Typical Petechial/Purpuric Rash, No Identified Pathogen)
- Treat as confirmed meningococcemia with the same regimen 1
- Stop treatment by day 5 if the patient has recovered and the clinical picture is consistent with meningococcal disease 1
Common Pitfalls and How to Avoid Them
Pitfall #1: Delaying antibiotics for diagnostic procedures
- Never delay antibiotics for lumbar puncture or imaging 2
- Blood cultures can be drawn simultaneously but should not delay treatment 2
Pitfall #2: Forgetting carriage eradication when using penicillin
- Beta-lactams other than ceftriaxone do not reliably eradicate oropharyngeal carriage 1, 2
- Always add ciprofloxacin or rifampicin if benzylpenicillin is used 1, 2
Pitfall #3: Using once-daily ceftriaxone dosing
- Meningococcal meningitis requires twice-daily dosing (every 12 hours) to maintain adequate CSF concentrations 1, 3
- Once-daily dosing is insufficient for CNS infections 3
Pitfall #4: Extending treatment unnecessarily
- If the patient has recovered by day 5, treatment can be safely discontinued 1, 2
- Prolonged courses are not beneficial and increase risk of adverse effects and C. difficile infection 1
Outpatient Transition Criteria
Outpatient IV therapy should be considered in patients who meet all of the following criteria 1, 2:
- Clinically well and afebrile 1, 2
- Completed at least 5 days of inpatient therapy and monitoring 2
- Reliable IV access 2
- 24-hour access to medical advice and care from the outpatient parenteral antibiotic therapy (OPAT) team 2
Supportive Care Considerations
While antibiotic therapy is the definitive treatment, aggressive supportive care is critical in meningococcemia 4: