What is the treatment for Neisseria meningitidis infection?

Treatment for Neisseria meningitidis Infection

Initiate ceftriaxone 2 grams IV every 12 hours immediately upon suspicion of meningococcal disease, even before lumbar puncture or imaging, and continue for 5 days if the patient has clinically recovered. 1

Immediate Antibiotic Therapy

• Start empiric antibiotics within 60 minutes of hospital arrival, as delays in treatment are strongly associated with death and poor outcomes 1
• Draw blood cultures immediately, but never delay antibiotic administration while awaiting results 1
• Administer ceftriaxone 2 grams IV every 12 hours (or cefotaxime 2 grams IV every 6 hours as an alternative) 2, 1

Treatment Duration

• Continue ceftriaxone for 5 days if the patient has clinically recovered by day 5 3, 1
• Extend treatment duration to 7 days if clinical response is delayed 2, 3
• Ceftriaxone can be safely discontinued after 5 days in patients with meningococcal meningitis who have clinically recovered 4

Alternative Antibiotic Options

• Benzylpenicillin 2.4 grams IV every 4 hours may be used as an alternative, but ceftriaxone is preferred because it reliably eradicates meningococcal carriage in the oropharynx 1
• For patients with penicillin allergy, chloramphenicol 25 mg/kg IV every 6 hours is an alternative 1

Critical Adjunctive Measure: Eradication of Nasopharyngeal Carriage

If ceftriaxone is NOT used as the primary treatment agent, add a single dose of ciprofloxacin 500 mg orally to eliminate throat carriage, as no beta-lactams other than ceftriaxone reliably eradicate meningococcal carriage 1, 5

• Alternative for carriage eradication: rifampin 600 mg orally twice daily for 2 days if ciprofloxacin is contraindicated 1
• In areas with ciprofloxacin resistance (≥20% of invasive meningococcal disease cases caused by ciprofloxacin-resistant strains in a rolling 12-month period), preferentially use rifampin, ceftriaxone, or azithromycin for prophylaxis of close contacts 6
• Rifampin is effective at eradicating N. meningitidis for up to four weeks after treatment, though resistant isolates have been observed 7

Adjunctive Corticosteroid Therapy

• Administer dexamethasone together with the first dose of antibiotics in all cases of suspected bacterial meningitis 2
• Dexamethasone can still be started up to 4 hours after the first dose of antibiotics if not given initially 2
• For meningococcal meningitis specifically, there appears to be no harm or benefit from dexamethasone, and the decision to stop or continue can be made on an individual basis 2

Outpatient Transition Criteria

Outpatient IV therapy should be considered only in patients who meet ALL of the following criteria: 1

• Clinically well and afebrile
• Reliable IV access established
• Completion of at least 5 days of inpatient therapy and monitoring
• 24-hour access to medical advice and care from the outpatient parenteral antibiotic therapy (OPAT) team

Common Pitfalls to Avoid

• Do not delay antibiotics for lumbar puncture or imaging - the mortality benefit of immediate treatment far outweighs diagnostic considerations 1
• Do not use rifampin alone for treatment of active meningococcal infection - rapid emergence of resistant organisms makes it unsuitable for treatment, only for prophylaxis 5
• Do not assume beta-lactams other than ceftriaxone will eradicate nasopharyngeal carriage - supplemental prophylaxis is required 1, 5
• Do not shorten treatment duration based on early clinical improvement alone - complete the full 5-day course at minimum 3, 1