Treatment of Neisseria meningitidis Urethritis
Treat Neisseria meningitidis urethritis with the same regimen as gonococcal urethritis: ceftriaxone 250-500 mg intramuscularly as a single dose, plus azithromycin 1 g orally as a single dose for presumptive chlamydial co-treatment. 1, 2
Clinical Context and Diagnostic Considerations
N. meningitidis urethritis is clinically and microscopically indistinguishable from gonococcal urethritis, presenting with purulent discharge and dysuria. 2, 3, 4 The key diagnostic challenge is that:
- Gram stain shows intracellular gram-negative diplococci identical to N. gonorrhoeae 2, 5
- Standard PCR testing for gonorrhea does NOT detect N. meningitidis 2
- Only conventional bacterial culture can definitively distinguish between these organisms 2
The epidemiologic clue is recent orogenital contact (fellatio), which transmits meningococcus from the oropharynx to the urethra. 2, 3, 4, 5 This differs from typical gonococcal urethritis transmission patterns. 6
Treatment Approach
Primary Treatment
Since N. meningitidis is sensitive to cephalosporins (specifically ceftriaxone), the standard gonococcal urethritis regimen is appropriate:
- Ceftriaxone 250-500 mg IM single dose 1, 2
- PLUS Azithromycin 1 g orally single dose (for presumptive chlamydial coverage, as PCR may show co-infection) 2
Alternative fluoroquinolone therapy (levofloxacin 300 mg daily for 7 days) has been reported as effective in case reports. 3
Why This Regimen Works
- Ceftriaxone is FDA-approved for uncomplicated gonorrhea caused by N. gonorrhoeae, including urethral infections 1
- N. meningitidis demonstrates similar antibiotic susceptibility patterns to N. gonorrhoeae 2, 4
- Single-dose therapy ensures compliance and provides directly observed treatment 7
Partner Management
All sexual partners within the preceding 60 days must be evaluated and treated. 7 This is critical because:
- Partners require treatment for potential urogenital N. meningitidis infection 7
- Oropharyngeal carriage in partners poses ongoing transmission risk 5
- Partners should receive the same ceftriaxone-based regimen 8, 9
Both patient and partners must abstain from sexual intercourse for 7 days after treatment initiation and until symptoms resolve. 7, 9
Special Consideration for Oropharyngeal Carriage
The emotional and clinical impact of misdiagnosis as gonorrhea is significant. 5 However, unlike meningococcal meningitis contacts, routine prophylaxis with rifampin is NOT indicated for sexual partners of urethritis cases, as this is not invasive meningococcal disease. 10 The focus should be on treating active urogenital infection with ceftriaxone-based regimens.
Follow-Up Recommendations
- Patients should return only if symptoms persist or recur after completing therapy 7, 8
- Symptoms alone without objective signs of urethritis (≥5 WBCs per oil immersion field on Gram stain) do not warrant re-treatment 7, 8
- Re-treatment with the initial regimen is indicated only if non-compliance or re-exposure to untreated partner occurred 8
Critical Pitfalls to Avoid
Do not rely solely on PCR testing – it will miss N. meningitidis while potentially showing false-positive or co-existent chlamydia 2
Do not assume gonorrhea based on Gram stain alone – obtain culture for definitive identification, especially when sexual history includes recent oral sex 2, 6
Do not use rifampin for treatment – rifampin is indicated only for asymptomatic nasopharyngeal carriers to prevent meningococcal disease, not for urethritis treatment 10
Do not fail to treat partners – untreated oropharyngeal carriage perpetuates transmission 5