How should meningococcal disease caused by Neisseria meningitidis be managed, including first‑line antibiotics, alternatives for β‑lactam allergy, contact chemoprophylaxis, isolation precautions, and vaccination?

Management of Meningococcal Disease (Neisseria meningitidis)

First-Line Antibiotic Treatment

For suspected or confirmed meningococcal disease, immediately initiate ceftriaxone 2g IV every 12-24 hours or cefotaxime 2g IV every 6 hours as first-line therapy. 1

• Ceftriaxone is preferred over cefotaxime because it reliably eradicates nasopharyngeal carriage of N. meningitidis, eliminating the need for additional chemoprophylaxis before hospital discharge 1
• Benzylpenicillin 2.4g IV every 4 hours may be used as an alternative if the organism is confirmed susceptible, though most centers continue cephalosporins 1
• Treatment duration is 5-7 days for uncomplicated meningococcal disease, assuming satisfactory clinical progress 1
• Antibiotics can be safely discontinued by day 5 if the patient has clinically recovered 1

Critical Caveat on Penicillin Resistance

Recent surveillance data shows emerging penicillin-resistant N. meningitidis isolates (containing blaROB-1 β-lactamase) in the United States, particularly among Hispanic populations 2, 3. Do not switch from ceftriaxone/cefotaxime to penicillin or ampicillin without confirmed susceptibility testing 2.

Alternatives for β-Lactam Allergy

For patients with true β-lactam allergy, chloramphenicol remains an acceptable alternative, though this is based on older evidence and antimicrobial resistance patterns must be monitored 4. The guidelines do not provide robust alternatives for severe β-lactam allergy in the modern era, representing a significant gap 1. Consultation with infectious disease specialists is essential for managing these cases, as third-generation cephalosporins remain the gold standard 1, 4.

Eradication of Nasopharyngeal Carriage

If the patient received antibiotics other than ceftriaxone (including cefotaxime or penicillin), administer a single dose of ciprofloxacin 500mg orally before hospital discharge to eradicate nasopharyngeal carriage 1. This prevents transmission to close contacts 1.

• If ciprofloxacin is contraindicated (pregnancy, resistance concerns), use rifampin 600mg orally twice daily for 2 days 1
• Ceftriaxone-treated patients do not require additional chemoprophylaxis 1

Contact Chemoprophylaxis

Administer chemoprophylaxis to close contacts within 24 hours of index case identification 1. Close contacts include:

• Household members 1
• Daycare center contacts 1
• Anyone directly exposed to the patient's oral secretions (kissing, mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management) 1, 5

Recommended Prophylaxis Regimens (All Equally Effective)

First-line options (90-95% effective at eradicating nasopharyngeal carriage) 1, 6:

• Ciprofloxacin 500mg orally as a single dose (preferred for ease of administration) 1, 5
• Ceftriaxone 250mg IM as a single dose (preferred in pregnancy) 1, 5
• Rifampin 600mg orally twice daily for 2 days 1, 6

Emerging Resistance Concerns

In areas with documented ciprofloxacin resistance, preferentially use rifampin, ceftriaxone, or azithromycin instead of ciprofloxacin when both criteria are met in a 12-month period: (1) ≥2 invasive cases caused by ciprofloxacin-resistant strains, and (2) ≥20% of all cases are ciprofloxacin-resistant 7. Ciprofloxacin-resistant N. meningitidis has increased since 2019, particularly in serogroup Y isolates 7, 2, 3.

Avoid rifampin as first-line during outbreaks due to potential emergence of resistant isolates 6, 5.

Who Does NOT Need Prophylaxis

• Healthcare workers without direct exposure to respiratory secretions 5, 8
• Casual contacts (classmates, coworkers without close contact) 1
• Prophylaxis administered >14 days after index case onset has limited or no value 1

Isolation Precautions

Place all patients with suspected meningococcal disease in droplet precautions immediately 5, 8:

• Single room placement (negative pressure not required) 5, 8
• Surgical mask for all individuals in close contact with the patient 5, 8
• Eye protection, gown, and gloves for healthcare workers 8
• Standard infection prevention precautions 5

Discontinue isolation after 24 hours of effective antibiotic therapy (ceftriaxone or single dose ciprofloxacin) 5, 8. This is based on evidence showing significant reduction in nasopharyngeal carriage after this period 5.

Aerosol-Generating Procedures

Upgrade to N95 respirator (or PAPR) during aerosol-generating procedures: endotracheal intubation, bag-mask ventilation, chest compressions, positive-pressure ventilation 5, 8. Standard surgical masks are insufficient during these high-risk procedures 8.

Vaccination

Administer meningococcal conjugate vaccine to high-risk populations 1:

• Individuals with asplenia, complement deficiencies, or on complement inhibitors (e.g., eculizumab) 5, 9
• College students living in dormitories 1
• Military recruits 1
• Travelers to endemic areas 1

Vaccinate recovered patients before discharge to prevent recurrence, as natural infection does not always confer immunity 1. Conjugate vaccines (covering serogroups A, C, W, Y) are preferred over polysaccharide vaccines due to longer duration of immunity and immunologic memory 1.

Serogroup B Considerations

Serogroup B vaccines are available but not covered by the older guidelines reviewed here 1. Current practice includes serogroup B vaccination for high-risk individuals and outbreak settings.

Common Pitfalls to Avoid

• Do not delay antibiotics to perform lumbar puncture in patients with severe sepsis, hypotension, or altered mental status 5
• Do not use vancomycin alone for suspected meningococcal disease; it has poor CSF penetration 1
• Do not perform oropharyngeal cultures to determine need for chemoprophylaxis; this unnecessarily delays treatment 1
• Do not give prophylaxis to healthcare workers unless they had direct exposure to respiratory secretions 5, 8
• Do not use ciprofloxacin in pregnancy; use ceftriaxone instead 5, 9