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Fluoroquinolone-Resistant Meningococcal Disease Prompts Regional Change in Prophylaxis

Three cases in Minnesota and North Dakota are the first reported cases of ciprofloxacin-resistant meningococcal disease in North America.

Close contacts of an index case of meningococcal disease have a 500- to 800-fold higher risk for disease than the general population, and 1% to 3% of household contacts develop the disease if no prophylaxis is provided. Antibiotic prophylaxis can markedly decrease carriage rates and should be given to close contacts within the first 24 hours after the identification of an index case. Previously, CDC-recommended prophylaxis regimens included rifampin, ceftriaxone, and ciprofloxacin. However, three recent case reports of fluoroquinolone-resistant Neisseria meningitidis in North Dakota and Minnesota have led to a regional change in these recommendations.

The three cases involved a child who attended day care, an adult, and a college student. Meningococcal isolates from these patients were serogroup B, had indistinguishable pulsed-field gel electrophoreses patterns and multilocus sequence typing, and possessed the same gyr A sequence that confers fluoroquinolone resistance. To ensure adequate antibiotic prophylaxis for close contacts of infected patients, the CDC has issued the following interim recommendation: Fluoroquinolones should not be used for prophylaxis in close contacts in certain North Dakota and Minnesota counties. Rifampin, ceftriaxone, and azithromycin are acceptable alternatives, and ciprofloxacin can still be used for prophylaxis in adults in other regions.

Comment: The interim recommendations are limited to a small geographic area at this time, but the three cases serve as an important reminder of the importance of providing antibiotic prophylaxis to close contacts as soon as possible. One half of secondary cases occur within the first week of disease onset in the index case and 70% within 2 weeks. The prevention of secondary cases in close contacts is as critical as the care of an index case. The prophylaxis regimen should be based on local sensitivity patterns and availability of antibiotic agents. Clinicians should encourage laboratories to perform sensitivity testing on all Neisseria isolates and to report resistant strains to local health departments.

— Peggy Sue Weintrub, MD

Published in Journal Watch Pediatrics and Adolescent Medicine March 5, 2008

Citation(s):

Centers for Disease Control and Prevention (CDC). Emergence of fluoroquinolone-resistant Neisseria meningitidis — Minnesota and North Dakota, 2007–2008. MMWR Morb Mortal Wkly Rep 2008 Feb 22; 57:173.

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