Suspected Meningococcal Disease -Chemoprophylaxis and antibiotic choice for contacts when appropriate

Suspected Meningococcal Disease -Chemoprophylaxis and antibiotic choice for contacts when appropriate - Management of Infection Guidance for Primary Care

Publication: 30/09/2010

Next review: 01/05/2023

Clinical Guideline

CURRENT

ID: 2566

Approved By:

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

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).

Suspected Meningococcal Disease - Chemoprophylaxis and antibiotic choice for contacts when appropriate - Management of Infection Guidance in Primary Care

The hospital will provide chemoprophylaxis for close contacts where possible. Antibiotic prophylaxis should be given as soon as possible (ideally within 24 hours) after the diagnosis of the index case.PHE Health Protection Team will contact the GP if a patient of theirs requires prophylaxis within 1 week. The contact will also be informed by the PHE Health Protection Team to collect the medication from the GP.

For confirmed serogroup A, C, W or Y infections, close contacts of any age should be offered the MenACWY conjugate vaccine, unless they are confirmed to have been immunised against the relevant meningococcal serogroup within the preceding 12 months’. The PHE Health Protection Team will contact the GP if this is the case.

Only prescribe following advice from your local health protection specialist/consultant: 0113 386 0300
Out of hours: contact on-call doctor: 0114 304 9843

Expert advice is available for managing clusters of meningitis. Please alert the appropriate organisation to any cluster situation.
Public Health England, Colindale (tel: 020 8200 4400)

Close contacts of patients should be given antibiotic prophylaxis to eliminate pharyngeal carriage. These include those living in the same household, those sharing a living space e.g. students in a hall of residence sharing a kitchen, or those with droplet/kissing contact.

Under normal circumstances prophylaxis is not required for members of healthcare staff looking after a patient with suspected or confirmed meningococcal infection. This is only likely to be needed for those involved in airway management without wearing a mask. Patients with meningococcal disease who have not received a dose of Ceftriaxone should receive one of the antibiotic regimes below to eliminate pharyngeal carriage.
Prophylaxis indicated
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 advice please contact PHE Health Protection Team):

Close contact is defined as 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, pupils in the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of residence (Evidence Grade B)

The definition of close contact does not include (Evidence Grade C):

staff and children attending same nursery or crèche
students/pupils in same school/class/tutor group
work or school colleagues
friends
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 (in the absence of intense exposure to nasopharyngeal secretions)

Preferred Option

Alternative Option

Ciprofloxacin
Recommended for use in all age groups and in pregnancy. Evidence grade B

All to be given as a single oral dose:

Adults/children aged 12 years +: 500 mg stat PO
Children aged 5–11 years: 250 mg stat PO
Children aged 1-4 years: 125 mg stat PO
Infants <1 year (prescribed off-label): 30mg/kg to a maximum 125mg stat PO

*Ciprofloxacin suspension contains 250mg/5ml
Caution

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.

The recent EU-wide restrictions and precautions on the use of systemic fluoroquinolone antibiotics (including Ciprofloxacin ), due to very rare reports of serious side-effects, do not apply to the single dose of Ciprofloxacin recommended for chemoprophylaxis of meningococcal disease. Ciprofloxacin , therefore, remains the recommended choice for meningococcal chemoprophylaxis because it has a number of advantages over Rifampicin . It is given as a single dose, does not interact with oral contraceptives, and is more readily available in community pharmacies; it is now licensed for this indication in adults. It is contraindicated in cases of known ciprofloxacin hypersensitivity.

Pregnancy
Either oral Ciprofloxacin , ceftriaxone injection or oral azithromycin can be used as chemoprophylaxis in pregnancy.
Evidence grade C

Ciprofloxacin PO (see above for doses)
Ciprofloxacin has the advantage of being easy to access in the community and in short duration usage appears to be safe in pregnancy.

Breastfeeding
For breastfeeding infants, a systematic review of antibiotic use in lactation considered Ciprofloxacin and Rifampicin as compatible with breastfeeding; other antibiotics were not studied

Rifampicin
Recommended for use in all age groups. Evidence grade B

All doses below to be given orally twice daily for 2 days:

Adults/children aged 12 years +: 600 mg twice daily PO for 2 days
Children aged 1–11 years: 10 mg/kg (maximum dose of 600mg) twice daily PO for 2 days
Infants <1 year: 5 mg/kg twice daily PO for 2 days

Suitable Rifampicin doses in children based on average weight for age are:
0–2 months 20 mg (1 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
Caution

Contraindicated in the presence of jaundice or known hypersensitivity to rifampicin
Interactions with other drugs, such as anticoagulants, phenytoin, and hormonal contraceptives should be considered.
Side effects should be explained including staining of urine and contact lenses. Written information for patients should be supplied with the prescription. This is the responsibility of the prescriber.

Pregnancy
Ceftriaxone IV or IM
Ceftriaxone can only be given by injection and can be painful. Potential side effects include diarrhoea, allergies, hepatic and blood disorders.
OR
Azithromycin PO Evidence grade B
A single dose of azithromycin may be offered for chemoprophylaxis for pregnant women.
Dosage: Azithromycin 500 mg PO stat

LTHT
PHE Managing Common Infections guidance
PHE guidance for public health management of meningococcal disease

General Principles for Treating Infections

This summary table is based on the best available evidence, but use professional judgement and involve patients in management decisions.

This summary table should not be used in isolation; it should be supported with patient information about safety netting, back-up antibiotics, self-care, infection severity and usual duration, clinical staff education, and audits. Materials are available on the RCGP TARGET website.
Prescribe an antibiotic only when there is likely to be clear clinical benefit, giving alternative, non-antibiotic self-care advice, where appropriate.
If person is systemically unwell with symptoms or signs of serious illness, or is at high risk of complications: give immediate antibiotic. Always consider possibility of sepsis, and refer to hospital if severe systemic infection
Use a lower threshold for antibiotics in immunocompromised, or in those with multiple morbidities; consider culture/specimens, and seek advice.
In severe infection, or immunocompromised, it is important to initiate antibiotics as soon as possible, particularly if sepsis is suspected. If patient is not at moderate to high risk for sepsis, give information about symptom monitoring, and how to access medical care if they are concerned.
Where an empirical therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 07825 906030, 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)
Limit prescribing over the telephone to exceptional cases.
Use simple, generic antibiotics if possible. Avoid broad spectrum antibiotics (for example coamoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase the risk of Clostridium difficile, MRSA and resistant UTIs.
Avoid widespread use of topical antibiotics, especially in those agents also available systemically (for example fusidic acid); in most cases, topical use should be limited.
Always check for antibiotic allergies. A dose and duration of treatment for adults is usually suggested, but may need modification for age, weight, renal function, or if immunocompromised. In severe or recurrent cases, consider a larger dose or longer course.
Avoid use of quinolones unless benefits outweigh the risk as new 2018 evidence indicates that they may be rarely associated with long lasting disabling neuro-muscular and skeletal side effects. *in the case of single dose for meningococcal chemoprophylaxis the benefit does outweigh the risk
Refer to the BNF for further dosing and interaction information (for example the interaction between macrolides and statins), and check for hypersensitivity.

Note
Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = expert opinion

Provenance

Record:	2566
Objective:
Clinical condition:	Suspected Meningococcal Disease
Target patient group:
Target professional group(s):	Primary Care Doctors
Adapted from:

Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design	Recommendation grade
Good recent systematic review and meta-analysis of studies	A+
One or more rigorous studies; randomised controlled trials	A-
One or more prospective studies	B+
One or more retrospective studies	B-
Non-analytic studies, eg case reports or case series	C
Formal combination of expert opinion	D

Document history

LHP version 2.0

Related information

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