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

Publication: 30/09/2010  --
Last review: 01/02/2016  
Next review: 01/02/2019  
Clinical Guideline
CURRENT 
ID: 2566 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2016  

 

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).

Guidance for the management of meningococcal disease in Primary care

Chemoprophylaxis and antibiotic choice for contacts when appropriate

See also Pre-admission management of suspected bacterial meningitis

Recommendation: Chemoprophylaxis

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 electronic Medicines Compendium information on Ciprofloxacin 
Recommended for use in all age groups and in pregnancy. Avoid in patients with Ciprofloxacin electronic Medicines Compendium information on 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

Dosage orally:

  • Adults and children over 12 years 500 mg stat
  • Children aged 5–12 years 250 mg stat
  • Children 1 month–4years 125 mg stat

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.

Second line - Rifampicin electronic Medicines Compendium information on Rifampicin
Recommended for use in all age groups. Avoid if patient has jaundice or known hypersensitivity to Rifampicin electronic Medicines Compendium information on Rifampicin.

Evidence grade B

Dosage orally:
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 electronic Medicines Compendium information on Rifampicin syrup contains 100 mg/5 ml

Caution

  • 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.
Pregnancy

Either Ciprofloxacin electronic Medicines Compendium information on CiprofloxacinCeftriaxone electronic Medicines Compendium information on Ceftriaxone or Azithromycin electronic Medicines Compendium information on Azithromycin can be used as chemoprophylaxis in pregnancy.

Evidence grade C

First line –Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin
Whilst Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin is contraindicated in its SPC for use in pregnancy, short duration treatment for other indications appears to be safe. 2,3,4
Dosage orally.

  • Adults and children over 12 years 500 mg stat

Second line Azithromycin electronic Medicines Compendium information on Azithromycin
A single dose Azithromycin electronic Medicines Compendium information on Azithromycin can be advised for chemoprophylaxis for pregnant women.

Evidence grade B

Dosage orally

Breast feeding

 A systematic review of antibiotic use in lactation considered Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and Rifampicin electronic Medicines Compendium information on 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.

Background Information

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.

Risk reduction

  • Rifampicin electronic Medicines Compendium information on Rifampicin and Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin were shown to be more effective in eliminating carriage than placebo in six and two RCTs respectively.6
  • Rifampicin electronic Medicines Compendium information on Rifampicin continued to be effective compared to placebo for up to four weeks of follow-up in two studies.
  • Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin and Rifampicin electronic Medicines Compendium information on Rifampicin showed non-significant differences in effectiveness in two RCTs.
  • Azithromycin electronic Medicines Compendium information on Azithromycin were as effective as Rifampicin electronic Medicines Compendium information on Rifampicin.7,8,9
  • The approximate number needed to treat to prevent a case was estimated to be about 200 individuals.
  • Ciprofloxacin electronic Medicines Compendium information on 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 electronic Medicines Compendium information on Benzyl penicillin suppresses meningococcal growth in the throat it does not reliably eradicate carriage. Around 5% of cases treated with Benzyl penicillin electronic Medicines Compendium information on 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.

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 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
  • 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.

Evidence grade D

Timing
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

Provenance

Record: 2566
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Suspected Meningococcal Disease

Target patient group:
Target professional group(s): Primary Care Doctors
Adapted from:

Evidence base

References

  1. Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Antibiotics for preventing meningococcal infections. Cochrane Database Syst Rev. 2006 Oct;(4):CD004785.

Pregnancy safety

  1. Connell W, Miller A. Treating inflammatory bowel disease during pregnancy: risks and safety of drug therapy. Drug Saf. 1999 Oct;21(4):311–23.
  2. Ferrero S, Ragni N. Inflammatory bowel disease: management issues during pregnancy. Arch Gynecol Obstet. 2004 Sep;270(2):79–85.
  3. Matteo Cassina, Luca Fabris, Maria Teresa Gervasi, Alessia Memmo, Gian Mario Tiboni, Elena Di Gianantonio & Maurizio Clementi Therapy of inflammatory bowel diseases in pregnancy and lactation Expert Opin Drug Saf. 2009 Nov;8(6):695-707. http://informahealthcare.com/action/doSearch?action=runSearch&type=advanced&result=true&prevSearch= %2Bauthorsfield%3A(Okolicsanyi%2C+Lajos)

Breast feeding

  1. Nahum GG, Uhl K, Kennedy DL. Antibiotic use in pregnancy and lactation: what is and is not known about teratogenic and toxic risks. Obstet Gynecol. 2006;107(5):1120–38.

Risk reduction

  1. Fraser A, Gafter-Gvili A, Paul M, Leibovici L. Antibiotics for preventing meningococcal infections.Cochrane Database Syst Rev. 2006 Oct;(4):CD004785.
  2. 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.
  3. Podgore J K, Girgis N, E L-Refai; M, Abdel- Moneim A. A double-blind randomized trial of
  4. cefixime compared to rifampin in the eradication of meningococcal pharyngeal carriage in a closed population. J of Trop Med. 1993:2(5):41–5.
  5. British National Formulary 60. BMJ Publishing Group, London September 2010.
  6. 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.
  7. Drew TM, Altman R, Black K, Goldfield M. Minocycline for prophylaxis of infection with Neisseria meningitidis: high rate of side effects in recipients. J Infect Dis. 1976 Feb;133(2):194–8.
  8. Burkhardt JE, Walterspiel JN, Schaad UB. Quinolone arthropathy in animals versus children. Clin Infect Dis.1997 Nov;25(5):1196–204.
  9. Drossou-Agakidou V, Roilides E, Papakyriakidou-Koliouska P, Agakidis C, Nikolaides N,
  10. 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.
  11. 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.
  12. Barroso D. Neisseria meningitidis nasopharynx colonization of diseased patients on presentation and on discharge. Tropical Doctor 1999; 29: 108-9.
  13. 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.
  14. 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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