Meningococcal disease

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Key Recommendations

All patients with presumed meningococcal infections should be isolated in private rooms and droplet precautions taken. Antibiotics should be administered as soon as possible. This may reduce the yield of lumbar puncture, but administration of antibiotics should not be delayed if diagnostic evaluation cannot be completed promptly.

Meningococcal disease is a notifiable disease in many countries, including the US; cases should be reported immediately to local and national health departments.[19]

Because meningococcal infections are not readily differentiated from serious infections caused by other bacterial pathogens, empiric antibiotic therapy should include broad-spectrum agents that encompass coverage of Streptococcus pneumoniae and Staphylococcus aureus.[54][64] [ ]

Empiric antibiotic therapy for suspected bacterial meningitis

Initial antibiotic choice is dependent on age:[54][67][68]

Age ≤1 month and immunocompetent: ampicillin plus cefotaxime. If a cephalosporin cannot be administered (e.g., patients with an allergy), an alternative regimen is ampicillin (to cover Listeria monocytogenes) plus an aminoglycoside (e.g., gentamicin). Specialist advice should be sought for newborns.
Age >1 month to <50 years and immunocompetent: ceftriaxone or cefotaxime plus vancomycin. If a cephalosporin cannot be administered (e.g., patients with an allergy), a carbapenem (e.g., meropenem) plus vancomycin can be considered.
Age ≥50 years or immunocompromised (any age): ampicillin plus ceftriaxone or cefotaxime plus vancomycin. If ampicillin cannot be administered (e.g., patients with an allergy), trimethoprim/sulfamethoxazole could be considered as an alternative in place of ampicillin for some patient groups to ensure cover for L monocytogenes. Specialist advice should be sought for immunocompromised newborns.

Adjunctive corticosteroid therapy for suspected bacterial meningitis

Some studies have shown that high-dose corticosteroids reduce the likelihood of neurologic sequelae, particularly in meningitis secondary to Haemophilus influenzae or S pneumoniae. However, the role of adjunctive corticosteroids in meningococcal meningitis remains controversial.[54][69][70]
For suspected bacterial meningitis, most experts recommend that patients age >6 weeks receive dexamethasone for 2-4 days, with the first dose given prior to or concurrently with the first dose of antibiotics.[48][68][71][72] [ ] [ ]
Corticosteroids should be discontinued if the diagnosis of bacterial meningitis is disproved. Most experts advise discontinuing corticosteroids for bacterial meningitis if the causative organism is proven to be Neisseria meningitidis, although some advise that adjunctive treatment should continue irrespective of the pathogen.[54]

Empiric antibiotic therapy for suspected meningococcal bacteremia

The choice of empiric therapy for patients with suspected meningococcal bacteremia should be based on local susceptibility patterns, but in general includes:[73]

Children age <1 month: cefotaxime or ceftriaxone or ceftazidime or an aminoglycoside (e.g., gentamicin) plus ampicillin. Acyclovir is indicated in infants with clinical features of herpes simplex virus (HSV) infection, including an ill appearance, mucocutaneous vesicles, seizures, or cerebrospinal fluid pleocytosis.
Children age ≥1 month: ceftriaxone or cefotaxime or cefepime plus vancomycin.
Adults: vancomycin plus ceftriaxone or cefotaxime or cefepime or imipenem/cilastatin or meropenem with or without an aminoglycoside (e.g., gentamicin).

The management of suspected bacteremia is becoming increasingly complex and should be based on local microbiology, risk factors (e.g., immunocompromised state, focal infection), and the severity of illness.

Supportive therapy

The major goal of supportive therapy is to restore and maintain normal respiratory, cardiac, and neurologic function.

Meningococcal infections may progress rapidly, and clinical deterioration may continue despite the prompt institution of antibiotic therapy. Initial assessment should follow the principles of pediatric and adult advanced life support, with evaluation of the patient's airway, breathing, and circulatory status, and the establishment of secure large-caliber intravenous catheters for administration of fluids.[51][74]

Patients with shock (pulse rate may be persistently elevated, the skin mottled, the extremities cool due to increased systemic vascular resistance, the capillary refilling prolonged, and the urinary output decreased) or respiratory distress should receive appropriate respiratory support. This might include supplemental oxygen, or intubation and mechanical ventilation for those with severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure.[74][75]

Adequate oxygenation, prevention of hypoglycemia and hyponatremia, anticonvulsant therapy if needed for early control of seizures, and measures to decrease intracranial pressure and to prevent fluctuating cerebral blood flow are important in managing patients with bacterial meningitis and meningococcal disease.[48][74][75][76]

Vasopressors should be administered to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation.[74][75] If necessary, consult a specialist for guidance on suitable vasopressor/inotrope regimens.

Fluids should be administered cautiously in patients with evidence of elevated intracranial pressure, myocardial dysfunction, or acute respiratory distress syndrome (ARDS).

Treatment for confirmed meningitis

Once the diagnosis of a meningococcal infection is confirmed (generally within 12-48 hours of hospitalization), the patient's antibiotic therapy is changed, if necessary, to suitable definitive therapy. Most experts advise discontinuing corticosteroids for bacterial meningitis if the causative organism is proven to be N meningitidis, although some advise that adjunctive treatment should be continued irrespective of the pathogen, to a total of 2-4 days' treatment.[54][69]

The treatment for confirmed N meningitidis (duration of therapy 7 days) is based on susceptibilities:[54][67][77]

Penicillin-susceptible (minimum inhibitory concentration [MIC] <0.1 micrograms/mL): ampicillin or penicillin-G. Alternatives include a third-generation cephalosporin (e.g., ceftriaxone).
Penicillin-intermediate (MIC 0.1 to 1.0 micrograms/mL): ceftriaxone or cefotaxime. Alternatives include a fluoroquinolone or meropenem.

Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[78]

Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.

The choice of agent is based on individual patient circumstances, antibiotic susceptibilities, and local availability. [ ]

Patients not treated with third-generation cephalosporins should receive therapy with rifampin, ceftriaxone, or ciprofloxacin to eradicate nasopharyngeal colonization prior to hospital discharge.

Resistant strains

In a national population-based survey of antimicrobial susceptibility of US meningococcal isolates, 25% of strains were penicillin or ampicillin intermediate.[79] Less than 1% were resistant to penicillin and ampicillin, ciprofloxacin, or levofloxacin, and all strains were susceptible to cefotaxime, ceftriaxone, meropenem, rifampin, minocycline, and azithromycin.[79] Chloramphenicol and fluoroquinolone resistance is increasingly reported in Africa and Asia, and among serotype Y strains in the US.[80]

Treatment of infections caused by these resistant strains should be based on results of antibiotic susceptibility testing. Resistant isolates reported to date have remained susceptible to cefotaxime and ceftriaxone.

Treatment for confirmed meningococcal bacteremia

Once the diagnosis of meningococcal bacteremia without meningitis is confirmed, the patient's antibiotic therapy should be changed to an intravenous third-generation cephalosporin or other definitive therapy. Treatment is usually for a duration of 5-7 days depending on the patient's age, severity of infection, and response to initial therapy.[50]

Most meningococcal isolates in the US are susceptible to penicillin, and this may be used for fully susceptible strains. Alternative agents include ampicillin, meropenem, or chloramphenicol. The choice of agent is based on individual patient circumstances, antibiotic susceptibilities, and local availability. If the patient is receiving dexamethasone for suspected meningitis, this should be discontinued.[47][54]

Patients not treated with third-generation cephalosporins should receive therapy with rifampin, ceftriaxone, or ciprofloxacin to eradicate nasopharyngeal colonization prior to hospital discharge.

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