Approach
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.[7]
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.[59]
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Empiric antibiotic therapy for suspected bacterial meningitis
Initial antibiotic choice is dependent on age:[46][53][60][61][62]
<1 month: cefotaxime or ceftriaxone PLUS ampicillin.
1 month to 50 years: cefotaxime or ceftriaxone or cefepime PLUS vancomycin.
>50 years or immunocompromised patients: ampicillin PLUS cefotaxime or ceftriaxone or cefepime PLUS vancomycin. Vancomycin plus meropenem is an alternative option for immunocompromised patients.
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 orS pneumoniae. However, the role of adjunctive corticosteroids in meningococcal meningitis remains controversial.[53][63][64]
For suspected bacterial meningitis, most experts recommend that immunocompetent patients >1 month of age receive dexamethasone for 2-4 days, with the first dose given prior to or concurrently with the first dose of antibiotics.
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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.[53]
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:[65]
Children age <1 month: cefotaxime or ceftriaxone or ceftazidime or an aminoglycoside PLUS ampicillin. Acyclovir is indicated in infants with an ill appearance, mucocutaneous vesicles, seizures, or cerebrospinal fluid pleocytosis.
Children age ≥1 month: cefotaxime or ceftriaxone or cefepime PLUS vancomycin.
Adults: vancomycin PLUS ceftriaxone or cefotaxime or cefepime or imipenem/cilastatin or meropenem PLUS/MINUS gentamicin or tobramycin or amikacin.
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.[50][66]
Patients with symptoms of compensated shock or respiratory distress should receive supplemental oxygen, and those with decompensated shock, hypoxia, severe respiratory distress, altered consciousness, or evidence of elevated intracranial pressure require intubation and mechanical ventilation.
Vasopressors (epinephrine, norepinephrine, milrinone, dopamine) should be administered to patients with hypotension or poor perfusion who do not respond promptly to fluid resuscitation. 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 an intravenous third-generation cephalosporin or other 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.[53][63]
The drug of choice for treatment of confirmed meningococcal infection is intravenous ceftriaxone, cefotaxime, or cefepime for 5-7 days. Alternative agents include penicillin G (for strains with a penicillin minimum inhibitory concentration of <0.1 microgram/mL), ampicillin, meropenem, or chloramphenicol. The choice of agent is based on individual patient circumstances, antibiotic susceptibilities, and local availability.
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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.[67] 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.[67] Chloramphenicol and fluoroquinolone resistance is increasingly reported in Africa and Asia, and amongst serotype Y strains in the US.[68]
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.[49]
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.[46][53]
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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