Avoid delay
- Treatment should not be delayed pending investigations.
- Specimens for collection:
- Blood: for culture, glucose and EDTA blood for meningococcal & pneumococcal PCR
- CSF: for microscopy and culture, glucose estimation and PCR
- Throat swab for culture: labelled ‘? N. meningitidis’
- Once pathogen is identified, treatment should be tailored to the narrowest spectrum agent that is sensitive. Seek microbiology advice
Meningitis prophylaxis
Bacterial meningitis is a notifiable disease. Inform Public Health: +353 21 4927601. They will advise on chemoprophylaxis of contacts.
Outside of normal working hours advice on chemoprophylaxis for contacts of meningococcal disease can be obtained from the emergency Public Health Advisory Service (ambulance control).
Meningococcal Infection
Chemoprophylaxis is indicated only for those who had close prolonged cantact with the case in the preceding seven days:
- shared living/sleeping accommodation with case
- were mouth kissing contacts
- were nursery/crèche contacts
- were boarding school dormitory contacts
Casual contacts, e.g. school classmates, playmates and neighbours are generally not considered to need chemoprophylaxis. Seek advice from Public Health or microbiology if unsure.
- Unless the index case has received ceftriaxone in hospital, chemoprophylaxis should also be given to the patient prior to discharge. When the disease has been treated with cefotaxime it may be prudent to give chemoprophylaxis until studies are available on its effectiveness in eradicating carriage
- Chemoprophylaxis is recommended only for healthcare workers whose mouth ort nose is directly exposed to large particle droplets/secretions from the respiratory tract of a probable or confirmed case of meningococcal mdisease during the actue illness until the case has completed 24 hours of antibiotics. Thsi type of contact will only occur among staff who are working close to teh face of a case without wearing a mask or other mechanical protection. In practice this implies a clear perception of pacial contact with droplets/secretions and is unlikely to occur unless using suction during airway management, inserting an airway, intubating or is the patient coughs in your face. General medical or nursing care of cases is not an indication for prophylaxis
Haemophilus influenzae type b (Hib) infection
Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.
| Adults and children >12 years | Ciprofloxacin 500mg po single dose |
|---|---|
| Female adults on the oral contraceptive pill | Ciprofloxacin 500mg po single dose |
| Pregnant women | Ciprofloxacin 500mg po single dose Alternative: Ceftriaxone 250mg im stat |
| Children: 5-12 years | Ciprofloxacin 250mg po single dose |
| Children < 5years | Ciprofloxacin single dose 30mg/kg po (max 125mg) |
| Children and adults | Rifampicin 20mg/kg once daily for 4 days up to max of 600mg/day |
|---|---|
| Infants under 1 year of age | Rifampicin 10mg/kg once daily for 4 days |
| Pregnant women | Not indicated |
Notes on rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after rifampicin treatment. If on other drugs, check BNF / consult pharmacy regarding drug interactions with rifampicin.
CUH Emergency Department
Meningitis prophylaxis drugs are kept in a box in the DDA press in the clean utility room. These are supplied by public health but include rifampicin liquid & capsules. These may be supplied to family contacts, staff etc out of hours as indicated above.
Vaccination
If Haemophilus influenzae type b, pneumococcal meningitis or Neisseria meningitidis Groups C, A, Y and W135, vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
References:
- British National Formulary 61 March 2011
- Immunisation Guidelines for Ireland 2008 Edition (Online update August 2010), National Immunisation Advisory Committee, Royal College of Physicians of Ireland
- Guidance for public health management of meningococcal disease in the UK 2011. Health protection agency (accessed via www.hpa.org.uk)
- Cochrane Database Syst Rev. 2006 Oct;(4):CD004785. Antibiotics for preventing meningococcal infections
** Moxifloxacin is contraindicated in clinically relevant heart failure with ↓ ventricular ejection fraction, in bradycardia, QT prolongation or history of symptomatic arrhythmias.
Moxifloxacin should not be used concurrently with other drugs that prolong the QT interval, e.g. amiodarone, sotalol, neuroleptics e.g. haloperidol, chlorpromazine.
Seek advice from pharmacy. It is also contraindicated in patients with impaired liver function (Child Pugh C).
Prophylaxis drugs - CUH
Meningitis prophylaxis drugs (plus info) are kept in a box in the DDA press in the clean utility room. These are supplied by public health but it includes rifampicin liquid & capsules. These may be supplied to family contacts, staff etc out of hours.