What antibiotic regimen is used for meningococcal infection prophylaxis in patients receiving ravulizumab (Complement inhibitor)

Antibiotic Prophylaxis for Meningococcal Infection in Patients Receiving Ravulizumab

Patients receiving ravulizumab require continuous antibiotic prophylaxis with penicillin or a macrolide throughout the duration of complement inhibitor therapy due to their markedly increased risk of invasive meningococcal disease.

Primary Prophylaxis Regimen

While the provided evidence focuses on post-exposure prophylaxis for meningococcal contacts rather than prophylaxis for complement inhibitor recipients, the standard approach for patients on ravulizumab (a C5 complement inhibitor) requires:

• Penicillin V 250-500 mg orally twice daily as the preferred continuous prophylaxis regimen
• Azithromycin 250 mg orally once daily as an alternative for penicillin-allergic patients

Critical Context for Complement Inhibitor Patients

Patients on ravulizumab face a fundamentally different risk profile than typical meningococcal contacts. The complement system is essential for defense against encapsulated organisms, particularly Neisseria meningitidis. Complement inhibition creates a persistent immunocompromised state requiring ongoing prophylaxis, not just post-exposure treatment.

Vaccination Requirements

• Meningococcal vaccination is mandatory before initiating ravulizumab, ideally at least 2 weeks prior to first dose
• Quadrivalent meningococcal conjugate vaccine (MenACWY) is required 1, 2
• Serogroup B meningococcal vaccine (MenB) should also be administered 2, 3
• Vaccination alone is insufficient protection; antibiotic prophylaxis must continue despite vaccination status

Post-Exposure Prophylaxis (If Exposure Occurs Despite Prophylaxis)

Should a patient on ravulizumab be exposed to a confirmed meningococcal case, standard post-exposure prophylaxis regimens apply:

First-Line Options:

• Ciprofloxacin 500 mg oral single dose (preferred for convenience and efficacy) 1, 2, 3
• Ceftriaxone 250 mg IM single dose (alternative, equally effective) 1, 2

Alternative Regimen:

• Rifampin 600 mg orally twice daily for 2 days 1, 2, 3

Important Caveat on Ciprofloxacin Resistance:

Recent surveillance data shows increasing ciprofloxacin resistance among N. meningitidis isolates 4, 5. In areas where ≥20% of meningococcal cases are ciprofloxacin-resistant during a 12-month period, alternative antibiotics (rifampin, ceftriaxone, or azithromycin) should be preferentially used 4.

Key Clinical Pitfalls

• Never discontinue prophylactic antibiotics while the patient remains on ravulizumab, even if they are fully vaccinated
• Prophylaxis must continue for the duration of complement inhibitor therapy and typically for several months after discontinuation (specific duration depends on drug pharmacokinetics)
• Patients who received IV ceftriaxone for treatment of confirmed meningococcal disease do not need additional prophylaxis before discharge 2
• Monitor for breakthrough infections despite prophylaxis, as vaccination and antibiotics reduce but do not eliminate risk in complement-deficient states

Monitoring and Patient Education

• Patients must be educated to seek immediate medical attention for fever, headache, or signs of meningitis 2, 3
• Even with prophylaxis and vaccination, the risk of invasive meningococcal disease remains elevated compared to the general population
• Healthcare providers should maintain high clinical suspicion for meningococcal disease in any febrile patient on complement inhibitors