Suspected Meningococcal Disease -Chemoprophylaxis and antibiotic choice for contacts when appropriate - Management of Infection Guidance for Primary Care
|Last review: 01/02/2016|
|Next review: 01/02/2019|
|Copyright© Leeds Teaching Hospitals NHS Trust 2016|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (MHRA advice November 2018).
Guidance for the management of meningococcal disease in Primary care
Chemoprophylaxis and antibiotic choice for contacts when appropriate
Close contacts that need prophylaxis within 24 hours will be issued with the medication from the hospital. A HPA or CCG public health doctor will contact the GP if a patient of theirs requires prophylaxis within 1 week. The contact will also be informed by the HPA or PCT public health doctor to collect the medication from the GP.
First line - Ciprofloxacin
Recommended for use in all age groups and in pregnancy. Avoid in patients with Ciprofloxacin hypersensitivity. The use of single dose ciprofloxacin is recommended by a Cochrane review1. Please note that this is an unlicensed indication.
Evidence grade B
- Adults and children over 12 years 500 mg stat
- Children aged 5–12 years 250 mg stat
- Children 1 month–4years 125 mg stat
- advise patient of possible anaphylactic reaction and give information sheet
- Interact with other drugs – see BNF or product SPC; however, a single dose is unlikely to have a significant effect.
- Epilepsy – unpredictable effect but may be preferable to rifampicin if the patient is on treatment with phenytoin.
Evidence grade B
All to be given twice daily for 2 days:
- Adults and children over 12 years of age 600 mg
- Children aged 1–12 years 10 mg/kg
- Infants (under 12 months of age) 5 mg/kg
Suitable doses in children based on average weight for age are:
0–2 months 20 mg (l ml*)
3–11 months 40 mg (2 ml*)
1–2 years 100 mg (5 ml*)
3–4 years 150 mg (7.5 ml*)
5–6 years 200 mg (10 ml*)
7–12 years 300 mg (as capsule/or syrup)
* Rifampicin syrup contains 100 mg/5 ml
- Interactions with other drugs, such as anticoagulants, phenytoin, and hormonal contraceptives.
- Advice patients of expected side effects such as staining of urine and contact lenses.
Evidence grade C
- Adults and children over 12 years 500 mg stat
Evidence grade B
- Azithromycin 500 mg stat
A systematic review of antibiotic use in lactation considered Ciprofloxacin and Rifampicin as compatible with breastfeeding; other antibiotics were not studied.5 Safety of antibiotic regimen for the nursing infant is poorly studied, and a drug that is safe for use during pregnancy may not be safe for the infant.
Aim of chemoprophylaxis
Chemoprophylaxis aims to reduce the risk of invasive disease by eradicating carriage in the group of close contacts at highest risk. It may act in two ways:
- by eradicating carriage from established carriers who pose a risk of infection to others
- by eradicating carriage in those who have newly acquired the invasive strain and who may themselves be at risk.
The short- and medium-term reduction in risk among household contacts who are given antibiotics suggest that both mechanisms may operate.
- Rifampicin and Ciprofloxacin were shown to be more effective in eliminating carriage than placebo in six and two RCTs respectively.6
- Rifampicin continued to be effective compared to placebo for up to four weeks of follow-up in two studies.
- Ciprofloxacin and Rifampicin showed non-significant differences in effectiveness in two RCTs.
- Azithromycin were as effective as Rifampicin .7,8,9
- The approximate number needed to treat to prevent a case was estimated to be about 200 individuals.
- Ciprofloxacin was not previously recommended in children due to induced arthropathy in juvenile animals, but abundant evidence of lack of joint damage has been found in young children given ciprofloxacin. In one RCT on carriage eradication, ciprofloxacin when compared to rifampicin did not lead to a higher rate of side effects.10 Multiple controlled prospective and retrospective studies, using higher doses of ciprofloxacin, showed that the rate of adverse events of ciprofloxacin in children was similar to that seen using other antibiotics, and that long-term cartilage damage was not seen in humans.11,12. In all studies, the risk of arthropathy due to ciprofloxacin was very low; arthralgias was transient and most were coincidental. A controlled study of 116 neonates receiving ciprofloxacin also showed similar clinical growth compared to 100 controls, even at one year of follow-up.13 The risk of tendon disorders in a large retrospective study involving 4,531 children given ciprofloxacin was similarly low compared to children given azithromycin (0.8%).14 In all studies, side effects resolved after cessation of therapy.
- Although Benzyl penicillin suppresses meningococcal growth in the throat it does not reliably eradicate carriage. Around 5% of cases treated with Benzyl penicillin still carry the invasive strain after completing treatment and before discharge from hospital. 15,16,17
- Convalescent cases may then pose a risk to household contacts unless given a course of antibiotic treatment to eradicate carriage.
Chemoprophylaxis should be offered to close contacts of cases, irrespective of vaccination status, that require public health action (see case definitions) in the following categories (For further information and advise please contact Public Health or refer to full HPA guidance, link below):
- Those who have had prolonged close contact with the case in a household type setting during the seven days before onset of illness. Examples of such contacts would be those living and/or sleeping in the same household (including extended household), pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence. Evidence grade C
- Those who have had transient close contact with a case only if they have been directly exposed to large particle droplets/secretions from the respiratory tract of a case around the time of admission to hospital (see section 8 of Full HPA guidance).Evidence grade D.
Prophylaxis NOT indicated (unless already identified as close contacts) for
- Staff and children attending same nursery or crèche
- Students/pupils in same school/class/tutor group
- Work or school colleagues
- Residents of nursing/residential homes
- Kissing on cheek or mouth (intimate kissing would normally bring the contact into the close prolonged contact category)
- Food or drink sharing or similar low level of salivary contact
- Attending the same social function
- Travelling in next seat on same plane, train, bus, or car.
Evidence grade D
Antibiotic prophylaxis should be given as soon as possible (ideally within 24 hours) after the diagnosis of the index case. Evidence grade C
Information taken from the Health Protection agency - Guidance for public health management of meningococcal disease in the UK, Version 01.4-2011, http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947389261
Suspected Meningococcal Disease
|Target patient group:|
|Target professional group(s):||Primary Care Doctors
- Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Antibiotics for preventing meningococcal infections. Cochrane Database Syst Rev. 2006 Oct;(4):CD004785.
- Connell W, Miller A. Treating inflammatory bowel disease during pregnancy: risks and safety of drug therapy. Drug Saf. 1999 Oct;21(4):311–23.
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- Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Antibiotics for preventing meningococcal infections.Cochrane Database Syst Rev. 2006 Oct;(4):CD004785.
- Schwartz B, Al-Ruwais A, A’Ashi J, Broome CV, Al-Tobaiqi A, Fontaine RE, et al. Comparative efficacy of ceftriaxone and rifampicin in eradicating pharyngeal carriage of group A Neisseria meningitidis. Lancet 1988; 1239-42.
- Podgore J K, Girgis N, E L-Refai; M, Abdel- Moneim A. A double-blind randomized trial of
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- British National Formulary 60. BMJ Publishing Group, London September 2010.
- 70 Cuevas LE, Kazembe P, Mughogho GK, Tillotson GS, Hart CA. Eradication of nasopharyngeal carriage of Neisseria meningitidis in children and adults in rural Africa: a comparison of ciprofloxacin and rifampicin. J Infect Dis. 1995 Mar;171(3):728–31.
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- Burkhardt JE, Walterspiel JN, Schaad UB. Quinolone arthropathy in animals versus children. Clin Infect Dis.1997 Nov;25(5):1196–204.
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- Sarafidis K, et al. Use of ciprofloxacin in neonatal sepsis: lack of adverse effects up to one year. Pediatr Infect Dis J. 2004 Apr;23(4):346–9.
- Yee CL, Duffy C, Gerbino PG, Stryker S, Noel GJ. Tendon or joint disorders in children after treatment with fluoroquinolones or azithromycin. Pediatr Infect Dis J. 2002 Jun;21(6):525–9.
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- Alvez F, Aguilera A, Garcia-Zabarte A. Effect of chemoprophylaxis on the meningococcal carrier state after systemic infection. Pediatr Infect Dis J 1991; 10(9): 700.
- Abramson JS, Spika JS. Persistence of Neisseria meningitidis in the upper respiratory tract afterintravenous antibiotic therapy for systemic meningococcal disease. J Infect Dis 1985; 151(2): 370-1.
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