Meningococcal Disease Janet Groth, MS, CFNP eningococcal disease is a very serious infection caused by the bacterium Neisseria meningitidis. Meningococcus is now the second most common Mcause of bacterial meningitis among children and the third leading cause among adults. Despite advances in antibiotics, the overall mortality in the USA is 13%. Meningococcus has a particular affinity for the infection follows a fulminant course, known as bloodstream and the lining around the brain, called Waterhouse-Friedrichsen Syndrome. This rapidly the meninges. The severity of infection ranges from progressive disease, marked by hemorrhages into the a transient fever with bacteremia to severe life- skin, joints, and internal organs, can lead to septic threatening illness. Infrequently, meningococcal shock and death even when appropriate antibiotics infection causes pneumonia or conjunctivitis. are started immediately. The clinical syndrome of meningococcal A positive outcome of meningococcal disease infection is similar to other types of meningitis. depends on prompt diagnosis, early referral, and Symptoms may first appear as a respiratory tract rapid treatment with antibiotics. illness, often followed by the abrupt onset of fever, headache, stiff neck, and vomiting. Changes in Prevalence and Distribution mental status may ensue, including confusion, Endemic disease is most common in children drowsiness, stupor, and even coma. Infants may under the age of 5, particularly within the 6-12 have fever with irritability, poor feeding, vomiting, month age group. Outbreaks are common among or a high-pitched cry. school age children and young adults in group Waterhouse- Friedrichsen A specific feature in the presentation of settings, such as day care centers, military camps, Syndrome. meningococcal disease is the appearance of tiny and colleges. Freshman college students living in This rapidly hemorrhages, called petechiae. These are usually dormitories are at particular risk. This infection progressive form found on the trunk and lower extremities. Petechiae appears to be seasonal, with the majority of cases of meningococcal are present in 75% of patients with meningococcal occurring in winter and early spring. disease is marked by hemorrhages into the infection. skin and joints. Septic Meningococcal infection is associated with high Transmission shock and death rates of morbidity and mortality. Even with optimal Neisseria meningitidis spreads when carriers can result, even medical care and appropriate treatment, almost one cough or sneeze infected secretions into the air that with appropriate antibiotics. in ten patients die from this disease, while as many as others inhale. The disease also spreads through Photo courtesy 20% are left with hearing loss, neurological impair- infected nose and throat secretions that come into of the ment, or loss of a limb. In rare cases, meningococcal contact with the mucous membranes of others. Meningitis Trust The Health Care of Homeless Persons - Part I - Meningococcal Disease 89 The onset of disease usually occurs within 10 days tory tract fluids to destroy the organism at the site (commonly 3-4 days), although longer intervals are of colonization in the nasopharynx. To eradicate the possible. organism completely, patients treated with these Meningococcus inhabits the upper respiratory antibiotics should also be treated with an antibiotic tract of a significant proportion of individuals that is known to clear the nasopharynx of organ- without causing illness. It is not known why some isms, namely ciprofloxacin, ceftriaxone, or rifampin. who carry invasive strains of the bacteria become ill Ciprofloxacin (Cipro™) 500 mg in a single oral while others do not. Some speculate that a concur- dose can be given to adults but is not recommended rent viral infection or exposure to passive or active for children under age 18 unless there is no alterna- cigarette smoke may diminish a person’s resistance tive therapy. It is not recommended for pregnant or to Neisseria meningitidis that has colonized a lactating women. person’s upper respiratory tract, thus allowing illness Ceftriaxone (Rocephin™) in a one-time dose to develop in someone who has been carrying the at 125 mg for children less than age 15 and 250 mg organism. Persons with certain immune deficiencies for those ages 15 and above is an alternative course and persons without a spleen may be at increased of therapy. risk for infection. Rifampin (Rimactane™, Rifadin™) is a drug that has long been used to eradicate meningococcal Diagnosis colonization. Dosing is 5 mg/kg every 12 hours for Anyone suspected of meningococcal disease 2 days in infants less than 1 month old, 10 mg/kg should have blood cultures and a lumbar puncture of body weight with a maximum of 600 mg every without delay. The organism may also be cultured 12 hours for two days in all persons older than one from synovial, pleural, or pericardial fluid. month. For infants, the liquid form of rifampin is easier to administer. If liquid rifampin is unavail- Treatment able, the contents of the capsules can be mixed with Meningococcal Disease applesauce. Rifampin cannot be given to pregnant Persons suspected of having meningococcal women or those with active liver disease. disease require intravenous antibiotic therapy and Urine, stool, sweat, tears, and semen may turn close supervision in a hospital setting. The disease orange-red when taking rifampin. Soft contact calls for strict respiratory isolation for at least 24 lenses can be permanently stained, so glasses should hours after the beginning of antibiotic therapy. A be worn while taking the medication. Rifampin third generation cephalosporin such as ceftriaxone may also diminish the effects of methadone and the (Rocephin™) in high doses is usually used initially effectiveness of birth control pills. Patients should to treat the infection. High doses of penicillin G or use a barrier form of contraception (condoms, chloramphenicol for 1 to 2 weeks have also success- diaphragm) for the duration of the entire birth fully treated this infection. control pill cycle in which rifampin therapy occurs. Colonization Antibiotics other than ceftriaxone usually used Prevention and Control to treat meningococcal infection do not reliably All persons who have been in close contact with reach high enough concentrations in upper respira- a person with meningococcal disease should receive antibiotic prophylaxis with ciprofloxacin, rifampin, or ceftriaxone. The risk of developing disease from Rash from such contact varies with the duration and closeness Meningococcus. A characteristic of exposure. In general, persons with less than 20 feature is the hours of contact in the week prior to illness are likely appearance of tiny to be at less risk than those with a longer duration hemorrhages on the of contact. However, persons with direct mucous skin, called petechiae. When glass is membrane exposure to secretions from an infected pressed against the person’s nose or throat are at higher risk. Such types skin, the petechiae of exposure include: do not blanche or • mouth-to-mouth resuscitation; lose their color. • kissing; Photo courtesy of the Meningitis Trust • mouthing toys; • sharing food, glasses, bottles, or cigarettes. 90 The Health Care of Homeless Persons - Part I - Meningococcal Disease The Health Care of Homeless Persons - Part I - Meningococcal Disease 91 Identified close contacts should be evaluated for linings covering the brain). This illness can be life rifampin, ciprofloxacin, or ceftriaxone prophylaxis threatening and occurs most commonly in infants within 24 hours of exposure. Refer to the treatment and young adults. section above for dosages. If antibiotics cannot be Initial symptoms can be similar to an upper initiated within 10 days of exposure, the efficacy is respiratory tract illness, followed by the abrupt diminished. onset of fever, headaches, stiff neck, vomiting, and Due to the emergence of resistant strains of occasionally a change in behavior. Infants may have Neisseria meningitidis and possible non-adherence a fever, appear irritable, have a high-pitched cry, and with recommended antibiotic prophylaxis, care- feed poorly. Petechiae, or tiny hemorrhages into the givers should monitor all close contacts for at least skin, may appear on the trunk or legs in both adults 2 weeks following the diagnosis of the initial case. and children. We recommend that smaller shelters, where families The spread of meningococcal disease occurs or adults live for weeks or months, hold any new when infected individuals cough or sneeze into admissions until all identified persons at risk within air that is then inhaled by others. Direct exposure the shelter have received prophylaxis with ciproflox- to an infected person’s saliva will also spread this acin, rifampin, or ceftriaxone. If compliance with infection. therapy cannot be assured, then admissions should Those suspected of having meningococcal further be held until 2 weeks following the diagnosis disease must be evaluated as soon as possible in an of the last case of meningococcal disease. Any close acute care setting. Respiratory isolation, antibiotic contact who develops a febrile illness should go to therapy, and close monitoring are required. an acute care facility immediately for evaluation. Persons likely to be at greatest risk from expo- Staff or caregivers should notify the facility ahead of sure include those who have spent 20 or more hours time to ensure that precautions are taken to lessen