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Common questions about the management of meningococcal disease |
(Aust Prescr 1999;22:117-8)
The condition
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
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
Treatment
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
Further information
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.
References
1. Hall R. Communicable Disease Control Branch of the South Australian Department of Human Services. Personal communication 15 September 1998.
2. Writing Group for Therapeutic Guidelines: Antibiotic. Central nervous system infections. In: Therapeutic Guidelines: Antibiotic. 10th ed. Melbourne: Therapeutic Guidelines Limited;1988. p. 37-44.
3. Immunisation Working Party of the NHMRC Communicable Diseases Standing Committee. Vaccines for special purposes. In: The Australian Immunisation Handbook. 6th ed. Canberra: Australian Government Publishing Service, 1997:121-53.
4. National Health and Medical Research Council. Guidelines for the control of meningococcal disease in Australia. Canberra: Australian Government Publishing Service; 1996.
5. Australian Medicines Handbook Pty Ltd. Australian Medicines Handbook. 1st ed. Adelaide:Australian Medicines Handbook Pty Ltd.;1998.
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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
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State and Territory Public Health Contacts
State and Territory Public Health Contacts
* (current as at September 1999)
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ACT
ACT Department of Health and Community Care |
Phone 02 6205 2155 |
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NSW
Central Coast Public Health Unit Birralea Hospital |
Phone 02 4320 4545 |
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Central Sydney Public
Health Unit |
Phone 02 9515 3180 |
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Central Western Public
Health Unit |
Phone 02 6332 8505 |
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South Eastern Sydney Public
Health Unit |
Phone 02 9382 8333 |
| Hunter Public Health Unit | Phone 02 4924 6477 |
| Illawarra Public Health Unit | Phone 02 4226 4677 |
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Northern Districts Public
Health Unit |
Phone 02 6766 2288 |
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North Coast Public
Health Unit |
Phone 02 6621 7231 |
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Northern Sydney Public
Health Unit |
Phone 02 9477 9400 |
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Western NSW Public
Health Unit |
Phone 02 6881 2235 |
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Southern Eastern Public
Health Unit |
Phone 02 4827 3428 |
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South West Public
Health Unit (now Centre for Public Health) |
Phone 02 6021 4799 |
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South Western Sydney
Public Health Unit |
Phone 02 9828 5944 |
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Western Sector Public
Health Unit |
Phone 02 9840 3603 |
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NSW Health Department,
Aids & Infectious Diseases Branch |
Phone 02 9391 9192 |
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NT
Territory Health Services, Disease Control, Darwin |
Phone 08 8922 8044 |
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QLD
|
Phone 07 4631 9842
Mobile 0418 790 084 |
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Peninsula/Northern/Mackay
Zone (Tropical Public Health Unit) |
Phone 07 4050 3600
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Brisbane North/Sunshine
|
Phone 07 3250 8555
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Brisbane South/South
Coast Zone |
Phone 07 3214 5850
Mobile 0419 362 470 |
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Central/Central West/
|
Phone 07 4920 6989
Mobile 015 671 696 |
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Queensland Department
of Health |
Phone 07 3234 1152
Mobile 0412 072 168 |
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SA
SA Health Commission Communicable Disease Control Branch |
Phone 08 8226 7177 |
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TAS
Department of Health and Community Services |
Phone 03 6233 3775
03 6233 3768 1800 671 738 |
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VIC
Department of Human Services Victoria |
Phone 03 9637 4127
03 9637 4137 |
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After hours Medical
Officer on call |
Phone 03 9625 5000
Pager 46870 |
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WA
Health Department of WA (direct contact) |
Phone 08 9388 4999
08 9388 4816 |
