What is the recommended therapy for suspected meningococcal infection?

Recommended Therapy for Suspected Meningococcal Infection

For suspected meningococcal infection, immediately administer ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours within 1 hour of presentation, without waiting for lumbar puncture or imaging. 1, 2, 3

Immediate Empirical Treatment

Standard Adult Regimen (<60 years, immunocompetent)

• Ceftriaxone 2g IV every 12 hours OR cefotaxime 2g IV every 6 hours 1, 2, 3
• Third-generation cephalosporins provide bactericidal activity against Neisseria meningitidis and Streptococcus pneumoniae with excellent CSF penetration 1
• Benzylpenicillin 2.4g IV every 4 hours is an acceptable alternative if meningococcal disease is confirmed and the organism is susceptible 1

Modified Regimen for Older Adults (≥60 years)

• Add ampicillin 2g IV every 4 hours to the cephalosporin regimen to cover Listeria monocytogenes 1, 2, 3
• This addition is critical as Listeria becomes increasingly prevalent in older adults 2, 3

Modified Regimen for Immunocompromised Patients

• Add ampicillin 2g IV every 4 hours to the cephalosporin regimen 1, 2
• Risk factors include diabetes, alcohol misuse, immunosuppressive drugs, and cancer 2

Special Circumstances Requiring Additional Coverage

Recent Travel to Areas with Penicillin-Resistant Pneumococci

• Add vancomycin 15-20 mg/kg IV every 12 hours (targeting trough 15-20 μg/mL) OR rifampicin 600mg IV/PO every 12 hours if the patient traveled within the past 6 months to high-resistance areas 1, 2
• Check European Centre for Disease Prevention and Control or WHO websites for current resistance patterns 1

Severe Penicillin/Cephalosporin Allergy

• Chloramphenicol 25 mg/kg IV every 6 hours if there is a clear history of anaphylaxis 1, 3

Critical Timing Principles

• Antibiotics must be administered within 1 hour of hospital presentation 2
• Never delay treatment for lumbar puncture, CT imaging, or any other diagnostic procedure 1, 2
• Obtain blood cultures before antibiotics, but do not delay treatment beyond the 1-hour window 2
• Delays in antibiotic administration are strongly associated with increased mortality and poor neurological outcomes 2

Definitive Therapy After Culture Confirmation

Confirmed Meningococcal Meningitis

• Continue ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours for 5-7 days total 1, 2, 3
• Treatment can be discontinued after 5 days if the patient has clinically recovered 1
• Give a single dose of ciprofloxacin 500mg orally if ceftriaxone was not used, to eliminate nasopharyngeal carriage 1

Confirmed Meningococcal Sepsis (without meningitis)

• Continue ceftriaxone 2g IV every 12 hours or cefotaxime 2g IV every 6 hours 1
• Treatment can be discontinued after 5 days if the patient has recovered 1
• Benzylpenicillin 2.4g IV every 4 hours may be used as an alternative 1

Common Pitfalls to Avoid

• Never delay antibiotics while waiting for imaging or lumbar puncture—if CT is indicated due to focal neurologic deficits, new-onset seizures, severely altered mental status (GCS <10), or severe immunocompromise, start antibiotics immediately before imaging 1, 2
• Do not omit ampicillin in patients ≥60 years or immunocompromised—Listeria coverage is essential and frequently missed in these populations 2, 3
• Avoid inadequate dosing—use high doses (ceftriaxone 2g every 12 hours, not lower doses) to ensure adequate CSF penetration 2
• Do not stop antibiotics prematurely—complete the full 5-7 day course for meningococcal disease even if clinical improvement occurs earlier 1, 2
• Meropenem offers no advantage over ceftriaxone/cefotaxime for meningococcal infections and should not be used as first-line therapy 4

Adjunctive Carriage Eradication

• Single dose ciprofloxacin 500mg orally should be given to patients with confirmed or probable meningococcal disease who were not treated with ceftriaxone, to eliminate nasopharyngeal carriage and prevent transmission 1
• Ceftriaxone reliably eradicates meningococcal carriage, so additional prophylaxis is not needed if ceftriaxone was used 1