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Meningococcal meningitis prophylaxis ciprofloxacin

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Key Points

  1. IV ceftriaxone / cefotaxime should be given as soon as meningococcal disease is suspected. If unavailable, give penicillin.
  2. If IV access cannot be obtained within 15 minutes, administer IM or IO ceftriaxone/cefotaxime, or penicillin.
  3. No investigation should delay antibiotic administration. Collect blood culture prior to antibiotics if possible. 

Background

Acute meningococcal disease (caused by the bacterium Neisseria meningitidis) is a potentially devastating cause of severe sepsis.

The most recognisable presentations of acute meningococcal disease are sepsis with a progressive non-blanching petechial/purpuric rash, and meningitis  with or without sepsis and rash. Rarer presentations include septic arthritis, pneumonia, pharyngitis and occult bacteraemia. 

Assessment

  • Rapid onset of symptoms (usually)
  • Signs of sepsis: see sepsis guideline
  • Fever
  • Leg pain
  • Altered conscious state (late sign >12 hours)
  • Neck stiffness, headache, photophobia, bulging fontanelle (late sign >12 hours)
  • Rash: petechiae / purpura – a non-blanching rash meningococcal meningitis prophylaxis ciprofloxacin (late sign >12 hours).

Note: a blanching rash does not exclude meningococcal disease (can initially be macular, maculopapular) 

Examples of rash: Click here to see full size


Management

Investigations:

Investigations should not delay antibiotic administration.

  • Blood (or marrow) culture should be obtained prior to antibiotic administration if possible.
  • Meningococcal PCR (separate EDTA tube, minimum volume 0.2mL)
  • CSF: For Gram stain (Gram negative diplococci), culture, and meningococcal PCR if suspected meningitis and no purpuric rash or other contraindication to lumbar puncture. DO NOT delay antibiotics to obtain CSF.  

Treatment:

  • General approach as per Sepsis guideline
  • Administer ceftriaxone (50mg/kg, max 2g) or cefotaxime (50mg/kg, max 2g). If no IV/IO access, give IM (repeat dose once IV access available). If ceftriaxone and cefotaxime are unavailable, administer benzylpenicillin (60mg/kg, max 2.4g).  

Ward management / other treatment considerations:

Duration of antibiotics is generally 5-7 days.  

Isolation

Meningococcal disease is spread person-to-person by respiratory droplets.

Patients should be isolated and droplet precautions continued for 24 hours after administration of appropriate antibiotics.  

Notification

All cases of presumed or confirmed meningococcal disease should be urgently notified to the Department of Human Services by telephone 1300 651 160 (fax 1300 651 170) (after hours pager 03 9625 5000, pager number 46870)

Link to DHS notifications (including form)  

Chemoprophylaxis

Prophylaxis should be given to contacts as soon as possible

  • Close household, intimate, and childcare contacts within 7 days prior to disease onset
  • Healthcare workers exposed to respiratory secretions (e.g. intubation without personal protective equipment, discuss with hospital Infection Control)

Additional vaccinations for close contacts may be considered. This will be directed by the responsible public health service.  

Recommended prophylaxis:

Age Drug Dose and schedule
Infants <1 month rifampicin Rifampicin 5mg/kg 12-hourly for 4 doses  
Children > 1 month

rifampicin

OR

ciprofloxacin

Rifampicin 10mg/kg (max 600mg) 12-hourly for 4 doses

 

Ciprofloxacin 125mg single dose ( <5yo) or 250mg single dose (5-12yo)

 
Adults ciprofloxacin 500mg oral single dose  
Pregnant or contraindication to rifampicin (e.g. severe liver or renal disease) ceftriaxone 125mg ( <12 yo) or 250mg (>12yo) IM single dose  


Inform patients/carers that rifampicin causes orange/red discolouration of tears and urine and negates the effect of the oral contraceptive pill. 

Consider consultation with local paediatric team when:

All cases of suspected meningococcal disease in children. 

Consider transfer when:

All cases of acute meningococcal disease should be managed in a facility with the capacity to provide paediatric intensive care. If these facilities are unavailable, the patient should be stabilised and transferred as appropriate.

For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650. 

Parent information sheet:

Can be found at RCH Kids Health Info here

Information specific to RCH

All patients should be admitted under General Medicine.

If severe sepsis, shock, or meningitis, consider consulting the Paediatric Intensive Care Unit (x52327).

If prophylaxis is required after hours, a limited supply of rifampicin is available in the Emergency Department (after-hours cupboard) and in the PICU/Rosella medication room (cupboard below bench).

Last revised June 2017



Source: http://www.rch.org.au/clinicalguide/guideline_index/Acute_Meningococcal_Disease/


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