Common questions about the management of meningococcal disease

1. Which organism(s) are associated with the current cases of meningococcal disease?

Neisseria meningitidis (often referred to as meningococcus) has been implicated in all cases of meningococcal disease. These cases have been caused by various serotypes.¹ The common causes of bacterial meningitis are N. meningitidis, Streptococcus pneumoniae, Listeria monocytogenes and Haemophilus influenzae type b (Hib).² Since the use of routine immunisation against Hib, and immunisation of at-risk populations against S. pneumoniae, N. meningitidis is now the most common cause of bacterial meningitis in Australia.³

2. What are the typical presentations of meningococcal disease?

The typical presentations are:

• meningitis
• sepsis with rash
• sepsis without rash
• bacteraemia without sepsis (uncommon)

Any of the first three presentations are common, and sepsis without rash in particular is difficult to diagnose clinically.

Key manifestations of meningococcal infection include:

• abrupt onset
• very rapid progression
• haemorrhagic rash, which may be petechial only

The rash of meningococcal disease

Picture provided by Dr David Mitchell, I.C.P.M.R.,
Westmead Hospital and the Board of Education,
The Royal College of Pathologists of Australasia

3. How long are 'close contacts' at risk of developing meningococcal disease?

The greatest risk is in the first week following the onset of disease in the index case.⁴ It is important that all `close contacts' are identified immediately and prophylactic treatment commenced.

4. Is there a vaccine available in Australia for meningococcal disease?

There are two vaccines available: Mencevax ACWY and Menomune. Both are non-PBS items. Routine vaccination is not recommended as these vaccines have several limitations, including lack of effect against serogroup B, which is the most frequently occurring strain in Australia.⁴

5. Which drugs for initial treatment of meningococcal disease are available as Emergency Drug (Doctor's bag) Supplies?

The following are recommended and available:

• benzylpenicillin injection 3 g (with sterilised water for injections 10 mL), one ampoule (BenPen)
• benzylpenicillin injection 600 mg (with sterilised water for injections 2 mL), 10 ampoules (BenPen)

The recommended dose for empirical therapy prior to hospitalisation is 60 mg/kg (for all ages) up to 3 g intravenously or intramuscularly.²

If the patient has had an anaphylactic or immediate urticarial reaction to penicillin, do not give a penicillin or a cephalosporin antibiotic, but arrange for immediate transfer to hospital.¹

Collection of a blood sample for culture should be attempted prior to the administration of antibiotics; however, this should not delay treatment.⁴

6. Why is the preferred route for the initial benzylpenicillin dose intravenous rather than intramuscular?

Intramuscular administration of benzylpenicillin is not the preferred route in this setting, as supervening shock and hypotension may lead to failure of absorption of the injected antibiotic from the injection site.⁴ However, if intravenous access is unavailable, it is preferable to give benzylpenicillin intramuscularly rather than delay treatment.

7. Why is rifampicin used instead of penicillin for prophylaxis?

Penicillin does not reliably eliminate nasopharyngeal carriage of meningococci. Hence rifampicin or, alternatively, ceftriaxone or ciprofloxacin is used for prophylaxis in contacts to prevent further infection.⁴

8. How are rifampicin capsules/syrup, ceftriaxone or ciprofloxacin for prophylaxis in 'close contacts' obtained?

The state or regional health authority* will co-ordinate the management of `close contacts'. The `close contacts' will be advised to go to the nearest Emergency Department and the relevant health authority will arrange for medication to be supplied to the individual.¹

It is important that the contact knows about the adverse effects and potential drug interactions that may occur with rifampicin.

9. How long does the rifampicin/oral contraceptive interaction last?

Rifampicin decreases the effectiveness of both combined and progestogen-only oral contraceptives and the effect may persist after rifampicin is stopped. Non-hormonal contraception is recommended to be used during rifampicin treatment and for at least four weeks afterwards.⁵

10. Is there current information available on the Internet?

Websites available include:

• NHMRC site
  http://www.health.gov.au/nhmrc
• U.K. Public Health Laboratory Service
  http://www.phls.co.uk/advice/mening.htm
• Centers for Disease Control and Prevention (U.S.A.)
  http://www.cdc.gov/ncidod/dbmd/diseaseinfo/meningococcal_t.htm

Reprinted with permission from Drug & Therapeutics Information Service (DATIS), Pharmacy Department, Repatriation General Hospital, Daw Park, South Australia 5041.

State and Territory Public Health Contacts
* (current as at September 1999)