Meningitis Chemoprophylaxis

There are a lot of rewarding parts of our jobs… getting to play pat-a-cake with a toddler is certainly one of them… but I was recently reminded of a potential downside: placing yourself in harm’s way. Do not construe that our job has similar inherent physical hazards that firefighters face during the course of what they call “work,” but we do routinely encounter potential hazards. For instance, that LP you just performed had purulent fluid drain into the tubes… the nurse and family immediately become concerned for themselves… should you too. What “bystanders” need therapy too? Here’s what I have deduced regarding Meningitis Chemoprophylaxis:

1st of all, try to abate the hysteria!

1. The risk of hysteria is far greater than the risk of an epidemic meningitis occurring.
2. Outbreaks do occur, but is usually limited to only a few cases.
3. No one needs chemoprophylaxis immediately after the patient has had the LP… you can wait for preliminary culture results (~24hours).

• Bacterial Meningitis is not especially contagious (except, perhaps in sub-Saharan Africa – the “meningitis belt”).

“Close Contacts” are who deserve consideration for chemoprophylaxis.

1. People who live in the same house as the patient
2. Intimate contacts – boy/girlfriends, anyone who shares saliva with the patient.
3. Daycare classmates should be considered in this group, as they like to inadvertently share saliva (that is scientific… well, kind of).
4. Hospital providers who have been exposed to patient’s secretions (ex, mouth-mouth ventilation {serious, use a bag to ventilate with}).
5. Classmates are not generally at risk (unless sharing saliva during biology class)
6. Hospital personnel who are involved in routine patient care do not have greater risk.

• ** YOUR HOSPITAL EMPLOYEE HEALTH DEPARTMENT MAY HAVE DIFFERENT OPINIONS ON THIS… IT IS LIKELY BEST TO SIMPLY FOLLOW THEIR GUIDELINES**

Meningococcal Meningitis

1. Most commonly agreed upon reason to give chemoprophylaxis to close contacts.
2. The attack rate for household contacts has been noted to be as high as 500 times the rate of the general population (yet, still leads small absolute numbers).
3. Chemoprophylaxis options:
   1.  Rifampin orally x 2 days (drug of choice in kids per RedBook)
   2. Ceftriaxone single IM dose
   3. Ciprofloxacin single oral dose (most popular option in adults, consider local resistance patterns)
   4. Azithromycin single oral dose

Haemophilus influenzae type b Meningitis

1. Fortunately, rarely encountered today… but it is not eradicated.
2. The attack rate in day-care contacts is 25 times greater than general public.
3. The attack rate in siblings can be as high as 550 fold, and particularly worse in those <7 yrs.
4. Chemoprophylaxis recommended for:
   1. Everyone in the house that contains a child younger than 12 months who has not received primary Hib vaccine series.
   2. Everyone in the house that contains an immunocompromised child regardless of vaccine status.
   3. Everyone in the house that contains a child <4 yrs of age who is unimmunized or incompletely immunized.
   4. Nursery school and child care contacts if there have been 2 or more Hib cases within 2 months.
5. Chemoprophylaxis: Rifampin orally x 4 days.

Pneumococcal Meningitis

1. Quick and simple – chemoprophylaxis is not generally recommended in these cases.
2. The possible exception may be close contacts that are at special risk for invasive pneumococcal infections like the patient with asplenia (functional or anatomic; ex, Sickle Cell Disease).

There is still some debate about the utility of chemoprophylaxis and what constitutes “close contacts,” but in the end, everyone should be given explicit anticipatory guidance regarding signs and symptoms of meningoencephalitis… even those who have been given chemoprophylaxis… unfortunately, nothing is perfect.
Peltola H. Prophylaxis of Bacterial Meningitis. Infectious Disease Clinics of North America. 1999, September; Vol 13 (3): pp. 686-710.

American Academy of Pediatrics Red Book.

Souter J. Meningitis: Vaccines and Prophylaxis. SA Pharmaceutical Journal. 2010, September: pp. 44-47.