Meningococcemia and purpura fulminansMANAGEMENT

INFECTIOUS DISEASE PRESENTATIONS · 12 SECTIONS

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593 items

☷ Legend

01Approach to the Critical Patient/attcp54

Immediate priorities and time-critical antibiotics

›First-hour bundle

›Recognition triggers

›Fever with any non-blanching rash

›Fever with rapidly progressive petechiae or purpura

›Toxic appearance with limb pain, cold extremities, or abnormal skin colour

›Time-critical antibiotics

›Target antibiotics within 30 minutes of recognition

›Faster than the 1 hour benchmark used for bacterial meningitis without rash, given the hours-to-death trajectory of meningococcal septicaemia

›Do not delay antibiotics for lumbar puncture, CT, or any imaging

›Do not delay antibiotics to place an arterial or central line

›Give antibiotics before transfer if diagnosed in a pre-hospital or primary care setting

›Blood cultures before antibiotics when feasible without delay

›Do not delay antibiotics to obtain cultures

›Point-of-care glucose and lactate

›Infection control

›Droplet precautions on first suspicion

›Continue until 24 hours after effective antibiotics

›Mask, eye protection, and gown for any airway management

›Unprotected airway exposure creates a close contact requiring chemoprophylaxis for the clinician

Shock recognition and stabilization

›Airway and breathing

›Intubation indications

›GCS 8 or declining

›Refractory hypoxemia despite high-flow oxygen

›Ongoing seizure with airway compromise

›Supplemental oxygen targeting SpO2 94 percent or higher

›Hemodynamic stabilization

02History/hx50

Presentation patterns and early symptoms

›Core prodrome

›Fever

›Rapid onset over hours

›Headache and myalgia

›Nonspecific, often mistaken for viral illness early

›Nausea and vomiting

›Sore throat or coryza

›Common early mimic of upper respiratory infection

›Rash timeline

›Early rash may be blanching or maculopapular

›Morbilliform appearance easily mistaken for a viral exanthem

›A blanching rash does not exclude meningococcal disease

›Progression to non-blanching petechiae then purpura

›Can evolve within hours

›Rapidly extending purpura with skin discoloration

›Purpura fulminans concern

›Meningeal symptoms when present

›Neck stiffness

›Photophobia

›Altered mental status

›Meningitis overlap may or may not be present; meningococcemia can occur without meningitis

Rapid trajectory and pediatric red flags

›Features preceding the rash in children

›Limb pain

›Refusal to bear weight or walk

›Out of proportion to examination findings

›Cold hands and feet

03Physical Exam/exam45

Vital signs and shock physiology

›Hemodynamic assessment

›Hypotension or narrow pulse pressure

›SBP less than 90 mmHg or MAP less than 65 mmHg in adults

›Tachycardia disproportionate to fever

›Tachypnea

›Fever or hypothermia

›Hypothermia as a severity marker, particularly in infants

›Perfusion assessment

›Capillary refill greater than 3 seconds

›Cold shock pattern

›Cool, mottled extremities with narrow pulse pressure

›More common pattern in children with meningococcal septic shock

›Warm shock pattern

›Warm extremities with bounding pulses and wide pulse pressure

Skin and rash evolution

›Early rash

›Blanching maculopapular or morbilliform rash

›Does not exclude meningococcal disease

›Re-examine skin serially if suspicion remains

›Non-blanching petechiae

›Glass test unreliable early or with sparse lesions

›Purpura fulminans

›Rapidly extending retiform (star-shaped, non-blanching) purpura

›Central necrosis with surrounding erythematous or hemorrhagic border

›Hemorrhagic bullae

›Skin necrosis

›Full-thickness skin loss risk

04Differential Diagnosis/ddx41

Life-threatening alternatives and purpura fulminans mimics

›Other causes of DIC and purpura fulminans

›Severe sepsis from other organisms

›ICD-10 D65

›Congenital severe protein C or protein S deficiency (neonatal purpura fulminans)

›ICD-10 D68.5

›Presents in the first hours to days of life without infection

›Warfarin-induced skin necrosis

›Protein C depletion disproportionate to other factors early in warfarin therapy

›Toxin-mediated and vasculitic mimics

›Staphylococcal or streptococcal toxic shock syndrome

›ICD-10 A48.3

›Diffuse erythroderma with later desquamation, not typically retiform purpura

›Rocky Mountain spotted fever

›ICD-10 A77.0

›Rash classically starts on wrists and ankles, tick exposure history

›Henoch-Schonlein purpura (IgA vasculitis)

›ICD-10 D69.0

›Palpable purpura over buttocks and lower extremities, non-toxic appearance

›Disseminated gonococcal infection

›ICD-10 A54

›Pustular or vesiculopustular lesions with tenosynovitis

›Hematologic mimics

›Immune thrombocytopenic purpura

›ICD-10 D69.3

›Non-toxic appearance, isolated thrombocytopenia

›Thrombotic microangiopathy (TTP/HUS)

›ICD-10 M31.1

05Laboratory Tests/lt40

Core sepsis and DIC bundle

›Blood cultures

›Two sets before antibiotics when feasible without delay

›Do not delay antibiotics to obtain cultures

›Yield reduced after antibiotic exposure

›Complete blood count with differential

›Leukocytosis or leukopenia

›Leukopenia as a marker of severe overwhelming infection

›Thrombocytopenia

›Platelet count trend more informative than a single value; falling platelets track DIC progression

›Venous or arterial lactate

›Lactate 4 mmol/L or higher marks severe hypoperfusion

›Serial lactate every 2 to 4 hours to confirm clearance

›Comprehensive metabolic panel

›Creatinine and electrolytes

›Renal dose adjustment for antimicrobials

›Hyperkalemia and hyponatremia as adrenal hemorrhage clues

›Glucose

›Hypoglycemia in infants, adrenal insufficiency, or hepatic hypoperfusion

Coagulation and protein C pathway studies

›Coagulation panel

›PT/INR and aPTT prolongation

›Consumptive coagulopathy pattern in DIC

›Fibrinogen

›Consumption pattern; low fibrinogen tracks bleeding risk

›D-dimer markedly elevated

›Protein C, protein S, and antithrombin levels

›Severely reduced protein C activity drives microvascular thrombosis in purpura fulminans

06Diagnostic Tests/dt40

Scoring Systems

›Glasgow Meningococcal Septicaemia Prognostic Score

›Pediatric bedside prognostic score

›Incorporates hypotension, skin to core temperature gradient, GCS or deterioration, absence of meningism, extending purpura, and base deficit

›Higher score predicts higher mortality risk

›Limitation

›Prognostic tool, not a substitute for immediate resuscitation and antibiotics

›qSOFA

›Respiratory rate, systolic blood pressure, and mental status

›Screening tool for mortality risk outside the ICU; not sufficient alone for diagnosis

›Pediatric early warning score

›Age-adjusted vital sign and perfusion trend

›Trend over a single value more sensitive for early deterioration

MRI

›MRI brain

›Limited acute utility in hemodynamically unstable patients

›Contraindicated during active vasopressor titration outside an MRI-capable critical care environment

›Complication assessment when concomitant meningitis present

›Cerebritis, abscess, venous sinus thrombosis

›MRI or MR angiography of an ischemic limb

›Assessment of tissue viability and vascular occlusion extent

›Used to guide surgical planning, not to delay resuscitation

›CT head

›Pre-lumbar-puncture safety screening when concomitant meningitis suspected with altered mental status, focal deficit, papilledema, new seizure, or severe immunocompromise

›Do not delay antibiotics for CT

›CT abdomen

›Adrenal hemorrhage assessment when Waterhouse-Friderichsen syndrome suspected

07Disposition/dispo30

Level of care

›ICU or PICU admission criteria

›Any vasopressor requirement

›Purpura fulminans or evolving limb ischemia

›Respiratory failure or mechanical ventilation requirement

›GCS 12 or declining

›Ward admission

›Confirmed or suspected meningococcemia without shock, purpura fulminans, or airway compromise

›Close reassessment given the rapid trajectory of this disease

Transfer and surgical consultation

›Interfacility transfer triggers

›ICU-level care unrequired locally

›Early transfer before decompensation; antibiotics given before transfer, not delayed for it

›Limb ischemia requiring vascular or plastic surgery not locally available

›Surgical consultation timing

›Early vascular or plastic surgery involvement for evolving limb ischemia

›Serial reassessment for compartment syndrome

›Fasciotomy for confirmed compartment syndrome

›Amputation deferred until demarcation unless the limb threatens life through uncontrolled infection

Public health and prophylaxis logistics

›Notification

›Immediate public health authority notification on clinical suspicion

›Do not wait for culture confirmation

›Close contact identification

›Household members

›Kissing or intimate contacts

›Those sharing eating or drinking utensils

›Childcare or nursery contacts within the 7 days before symptom onset

08Treatment/t184

Time-critical empiric and targeted antibiotics

›Pre-hospital or first-dose antibiotic

›Benzylpenicillin

›Adult and child 10 years or older: 1200 mg IM or IV single dose

›Child 1 to 9 years: 600 mg IM or IV single dose

›Child under 1 year: 300 mg IM or IV single dose

›Give before transfer when meningococcal disease is suspected; do not delay for confirmatory testing

›Penicillin allergy alternative

›Ceftriaxone IM or IV single dose per weight-based pediatric or standard adult dosing where available pre-hospital

›Hospital empiric therapy, adult (covers meningococcus and pneumococcus until organism known)

›Ceftriaxone

›2 g IV every 12 hours

›Vancomycin

›15 to 20 mg/kg IV every 8 to 12 hours

›Trough target 15 to 20 mg/L

›Do not withhold either agent pending lumbar puncture or CT

›Hospital empiric therapy, pediatric (over 1 month)

›Ceftriaxone

›50 mg/kg IV every 12 hours

›Maximum 2 g per dose

›Vancomycin

›15 mg/kg IV every 6 hours

›Trough target 15 to 20 mg/L

›Add when pneumococcus cannot be excluded

›Neonatal antibiotics (0 to 28 days)

›Age 0 to 7 days

›Ampicillin

›50 mg/kg IV every 8 hours

›Verify against current neonatal guideline before use

›Plus gentamicin

›4 mg/kg IV every 24 hours

›Verify against current neonatal guideline before use

›Or plus cefotaxime where gentamicin is unavailable

›50 mg/kg IV every 12 hours

›Verify against current neonatal guideline before use

›Age 8 to 28 days

›Ampicillin

›50 mg/kg IV every 6 hours

›Plus cefotaxime

›50 mg/kg IV every 8 hours

›Or plus gentamicin

›4 mg/kg IV every 24 hours

›Ampicillin monotherapy is not adequate at neonatal age

›Gram-negative organisms causing neonatal sepsis and purpura fulminans are not covered by ampicillin alone; an aminoglycoside or third-generation cephalosporin must be added

›Avoid ceftriaxone in neonates when possible

›Bilirubin displacement and calcium-ceftriaxone precipitation risk

›Targeted therapy once meningococcus confirmed

›Penicillin G

›4 million units (2.4 g) IV every 4 hours

›Total approximately 24 million units per day in adults

›Or continue ceftriaxone 2 g IV every 12 hours if susceptibility or allergy favors it

›Duration 7 days

›Discontinue vancomycin once meningococcus confirmed and pneumococcus excluded

Fluid resuscitation and shock management

›Adult fluid strategy

›Crystalloid 30 mL/kg within 3 hours for hypotension or lactate 4 mmol/L or higher

›Balanced crystalloid preferred

›Reassess for fluid responsiveness after each 500 to 1000 mL bolus rather than giving a fixed total

›Avoid colloids as initial resuscitation fluid

›Hydroxyethyl starch associated with increased mortality and acute kidney injury; contraindicated

›Pediatric fluid strategy

›Initial bolus 10 to 20 mL/kg IV or IO over 5 to 10 minutes

›Verify against current pediatric guideline before use

›Repeat with reassessment for fluid overload, hepatomegaly, and worsening respiratory status between boluses

›Up to 40 to 60 mL/kg in the first hour if shock persists and no fluid overload signs develop

›Fluid overload caution specific to purpura fulminans

›Endothelial and capillary leak increases risk of pulmonary edema and worsening limb and tissue edema with aggressive fluid loading

›Dynamic reassessment (passive leg raise, serial lung ultrasound) preferred over a fixed volume target beyond the initial bolus

Vasopressor and inotrope strategy

›Norepinephrine (first-line adult vasopressor, warm shock or unclear pattern)

›0.01 to 0.1 mcg/kg/min IV infusion

›Titrate every 5 to 15 minutes to MAP 65 mmHg or higher

›Up to 1 to 2 mcg/kg/min in refractory shock

›Can be started via peripheral IV without delaying for central access

›Peripheral vasoconstriction from vasopressor therapy can worsen limb ischemia already present from purpura fulminans

›Reassess distal perfusion each time the dose is escalated

›Discuss target MAP versus limb perfusion trade-off with surgery if severe limb ischemia is present

›Epinephrine (preferred first agent for pediatric cold shock or myocardial dysfunction)

›0.05 to 0.3 mcg/kg/min IV infusion

›Verify against current pediatric guideline before use

›Titrate every 5 to 15 minutes to perfusion and MAP targets

›Tachyarrhythmia and lactate elevation via beta-2 stimulation may confound lactate trending

›Vasopressin (add-on, adult)

›Fixed dose 0.03 units/min IV infusion, not titrated

›Add when norepinephrine reaches 0.25 to 0.5 mcg/kg/min

›Dobutamine (myocardial dysfunction with adequate MAP)

›2.5 to 20 mcg/kg/min IV infusion

›Titrate to cardiac output or perfusion markers

›Do not use without a background vasopressor if MAP is not yet at target; dobutamine alone can worsen hypotension through vasodilation

›Monitoring during titration

›Reassess MAP and perfusion every 5 to 15 minutes during active titration

›Distal limb perfusion check with every vasopressor dose change

Corticosteroids

›Adjunctive dexamethasone for concomitant meningitis

›Benefit for adjunctive dexamethasone in bacterial meningitis is best established for pneumococcal meningitis in adults

›Evidence for benefit specific to confirmed meningococcal meningitis is not established

›Discontinue if meningococcus is confirmed and no benefit is expected

›Stress-dose hydrocortisone for vasopressor-refractory shock or suspected adrenal hemorrhage

›Hydrocortisone 200 mg/day IV (50 mg every 6 hours or continuous infusion) in adults

›Do not delay for a resulted cortisol level if the patient is hemodynamically unstable and Waterhouse-Friderichsen syndrome is suspected

›Evidence stated honestly

›Mortality and shock-reversal evidence for stress-dose hydrocortisone is extrapolated from general septic shock trials (APROCCHSS, ADRENAL), not from meningococcemia-specific randomized trials

›APROCCHSS showed a 90-day mortality benefit with combined hydrocortisone and fludrocortisone; ADRENAL showed faster shock reversal without a clear mortality difference

›Taper when vasopressors are weaned

›Abrupt discontinuation after more than 3 days may cause rebound vasodilation

Disseminated intravascular coagulation and purpura fulminans management

›Supportive coagulation management

›Fresh frozen plasma for active bleeding or before an invasive procedure, guided by INR and fibrinogen

›Cryoprecipitate if fibrinogen falls below 1.5 g/L

›Platelet transfusion for active bleeding or before a procedure with severe thrombocytopenia

›Not routinely given for a low count alone without bleeding or a planned procedure

›Protein C replacement

›Protein C concentrate may be considered in severe purpura fulminans with confirmed severe protein C deficiency

›Evidence is limited to case series and small studies, not large randomized trials; use guided by hematology

›Recombinant activated protein C (drotrecogin alfa) is not used

›Withdrawn from the market in 2011 after the PROWESS-SHOCK trial showed no mortality benefit and increased bleeding risk

›Anticoagulation

›Therapeutic heparin for purpura fulminans is not routinely recommended

›Proposed to interrupt microvascular thrombosis but lacks strong supporting evidence and carries substantial bleeding risk in a consumptive coagulopathy

›Reserve for hematology-guided protocols in select cases

›Fibrinolysis

›Systemic thrombolysis for limb ischemia is generally avoided

›Consumptive coagulopathy and thrombocytopenia raise catastrophic hemorrhage risk; discuss with hematology and vascular surgery before considering

Limb ischemia and surgical management

›Serial limb assessment

›Distal pulses, capillary refill, and skin colour every 1 to 2 hours during active resuscitation

›Compartment pressure assessment if clinical concern for compartment syndrome

›Surgical intervention

›Fasciotomy for confirmed compartment syndrome

›Amputation deferred until tissue demarcation

›Early amputation before demarcation reserved for uncontrolled life-threatening infection

›Hyperbaric oxygen

›Sometimes used adjunctively in severe limb ischemia; evidence is limited and it should not delay surgical or antimicrobial priorities

Supportive care, iatrogenic-harm mitigation, and troubleshooting

›Airway management cautions

›Etomidate for rapid sequence induction

›Adrenal suppression from a single dose is a specific concern when Waterhouse-Friderichsen syndrome (adrenal hemorrhage) is already present or suspected; this combination can precipitate fatal adrenal crisis

›Ketamine 1 to 2 mg/kg IV preferred for hemodynamic stability during induction in shock

›Verify against current pediatric guideline before use in children

›Sedation

›Propofol can cause vasodilation and worsen hypotension; use cautiously with reduced doses in active shock

›Fluid loading caution

›Reassess for pulmonary edema and worsening limb edema after each bolus rather than giving a fixed total volume

›Oxygen

›Titrate to SpO2 94 to 98 percent once stabilized; avoid sustained hyperoxia

›Vasopressors and mechanical circulatory support

›Vasopressor-induced peripheral vasoconstriction can worsen or precipitate limb necrosis in purpura fulminans

›Balance MAP target against limb perfusion with surgery input

›Intra-aortic balloon pump is not indicated in the distributive shock physiology of meningococcemia

›Afterload-augmenting mechanical support can worsen a low-SVR shock state; reserve mechanical circulatory support decisions for a documented cardiogenic component

›Extracorporeal membrane oxygenation may be considered for refractory pediatric septic shock with severe myocardial dysfunction unresponsive to fluid, vasopressor, and inotrope therapy

›Anticoagulation and fibrinolysis

›Both carry elevated bleeding risk in the setting of consumptive coagulopathy; use only under hematology guidance as above

›Analgesia

›Limb pain from ischemia and evolving purpura fulminans is often severe

›Morphine 0.05 to 0.1 mg/kg IV every 2 to 4 hours titrated to effect

›Adult starting dose 2 to 4 mg IV every 2 to 4 hours titrated to effect

›Avoid NSAIDs

›Bleeding risk in consumptive coagulopathy and renal risk in shock or acute kidney injury

›Acetaminophen for fever and pain

›15 mg/kg PO, PR, or IV every 6 hours in children, maximum 1000 mg per dose

›650 to 1000 mg PO or IV every 6 hours in adults, maximum 4000 mg per day

›Seizure management

›Lorazepam 0.1 mg/kg IV, maximum 4 mg per dose

›Verify against current pediatric guideline before use

›Levetiracetam 60 mg/kg IV, maximum 4500 mg, as second-line agent

›Verify against current pediatric guideline before use

›Hypoglycemia

›Dextrose 10 percent, 2 to 4 mL/kg IV, for confirmed hypoglycemia in a lethargic or poorly feeding infant

›Verify against current pediatric guideline before use

›Raised intracranial pressure if concomitant bacterial meningitis

›Hypertonic saline 3 percent, 2 mL/kg IV bolus

›Verify against current pediatric guideline before use

›Mannitol 0.5 to 1 g/kg IV bolus, avoid in hypotension

›Verify against current pediatric guideline before use

›Arrhythmia and electrolyte monitoring

›Continuous ECG monitoring when hyperkalemia is present from acute kidney injury or adrenal crisis

›Peaked T waves, widened QRS, or loss of P waves as findings requiring urgent hyperkalemia treatment

›Continuous ECG monitoring with massive transfusion

›Citrate-related hypocalcemia can prolong the QT interval and cause hypotension

›Pediatric defibrillation if pulseless ventricular arrhythmia develops

›2 J/kg first shock, 4 J/kg subsequent shocks

›Verify against current pediatric guideline before use

›Shock not responding to fluid and vasopressor therapy

›Consider undiagnosed or undertreated adrenal insufficiency

›Empiric hydrocortisone if not already given

›Consider myocardial dysfunction

›Bedside echocardiography and inotrope addition

›Consider ongoing uncontrolled hemorrhage or DIC-related bleeding

›Repeat coagulation panel and transfusion support

›Escalate to ECMO evaluation in refractory pediatric cases

09Special Populations/sp25

Pregnancy

›Presentation and risk

›Physiologic tachycardia and lower baseline blood pressure in pregnancy can mask early shock

›Fetal monitoring when viable gestation

›Treatment modification

›Penicillin and ceftriaxone are safe throughout pregnancy

›Ceftriaxone preferred over ciprofloxacin or rifampin for chemoprophylaxis in a pregnant close contact

›250 mg IM single dose

›Left lateral positioning during resuscitation to relieve aorto-caval compression

›Obstetric consultation for any pregnant patient with suspected meningococcemia or shock

Geriatric

›Atypical presentation

›Confusion or delirium as the presenting feature rather than classic rash and meningism

›Blunted fever response

›Treatment modification

›Renal dosing for vancomycin and other renally cleared agents

›Higher MAP target (70 to 80 mmHg) may be needed in patients with chronic hypertension

›Goals-of-care discussion given higher case fatality with frailty and comorbidity

Pediatrics

›Age-stratified presentation

›Infants and young children carry the highest incidence and the highest risk of rapid deterioration

›Nonspecific irritability, poor feeding, and lethargy may precede classic findings

›Weight-based dosing

›Use actual weight; apply adult maximum doses where stated

›Every pediatric resuscitation dose in this document (fluid boluses, epinephrine infusion, dextrose, anticonvulsants, hyperosmolar therapy, RSI induction agent, defibrillation energy) carries a verify-before-use flag given documented unreliability of model and even corpus-original pediatric dosing recall

›Shock pattern

›Cold shock more common in children with meningococcal septic shock than in adult septic shock generally

›Epinephrine favored as the first vasopressor in this pattern

10Background/b29

Epidemiology

›Incidence and burden

›Endemic incidence roughly 0.5 to 1 per 100,000 population per year in many high-income countries, with substantial decline following conjugate vaccination programs

›Peak incidence in infants under 1 year and a second peak in adolescents and young adults 15 to 24 years

›Outcomes

›Case fatality for meningococcemia and septic shock is higher than for meningococcal meningitis alone, roughly 10 to 15 percent overall and substantially higher, up to about 40 percent, with purpura fulminans and refractory shock

›Roughly 10 to 20 percent of survivors have permanent sequelae

›Limb loss, skin scarring, and hearing loss among the most common

›Serogroup distribution

›Serogroups B, C, W, and Y account for most disease in high-income countries, with regional and temporal variation

Pathophysiology

›Bacteremic invasion

›Nasopharyngeal colonization followed by bloodstream invasion in susceptible hosts

›Endotoxin-driven inflammatory cascade

›Lipooligosaccharide release triggers massive cytokine release

›Endothelial injury and increased vascular permeability

›Coagulation cascade activation

›Disseminated intravascular coagulation with consumption of protein C, protein S, and antithrombin

›Microvascular thrombosis drives the retiform purpura and skin necrosis of purpura fulminans

›Concurrent bleeding tendency from factor and platelet consumption despite ongoing microthrombosis

›Adrenal hemorrhage mechanism

›Bacteremic seeding and DIC-related hemorrhage into the adrenal glands

›Waterhouse-Friderichsen syndrome with acute adrenal insufficiency compounding shock

Therapeutic Considerations

›Antibiotic timing principle

›Every hour of antibiotic delay in this disease is associated with rising mortality; do not wait for LP, imaging, or confirmatory testing

›Steroid rationale stated honestly

›Dexamethasone benefit is established for pneumococcal meningitis, not meningococcal disease specifically

11Patient Discharge Instructions/pdi34

copy discharge instructions

›Discharge context

›Meningococcemia and purpura fulminans require inpatient, usually ICU, treatment

›Discharge instructions apply after inpatient treatment completion

›Follow-up plan

›Infectious diseases follow-up within 1 to 2 weeks

›Plastic surgery or wound care follow-up for any skin necrosis or evolving limb changes

›Audiology follow-up if concomitant meningitis occurred

›Medications at discharge

›Acetaminophen for fever or pain

›Adult 650 to 1000 mg PO every 6 hours, maximum 4000 mg per day

›Child 15 mg/kg PO every 6 hours, maximum 1000 mg per dose

›Return immediately for

›Fever 38.0 C or higher

›New or spreading rash, especially non-blanching spots

›Worsening limb pain, colour change, or numbness

›Confusion, excessive sleepiness, or a new severe headache

›Decreased urine output for more than 6 to 8 hours

›Any new weakness, speech difficulty, or seizure

Household and close contact instructions

›Chemoprophylaxis for close contacts

›Ciprofloxacin

›Adult and child 1 month or older: 500 mg PO single dose

›Weight-based alternative in younger children 20 mg/kg PO, maximum 500 mg, single dose

›Rifampin

›Adult: 600 mg PO every 12 hours for 2 days (4 doses)

›Child over 1 month: 10 mg/kg PO, maximum 600 mg, every 12 hours for 2 days

›Infant under 1 month: 5 mg/kg PO every 12 hours for 2 days

12References/r21

Guidelines and evidence sources

›Core guidelines

›NICE guideline on meningitis (bacterial) and meningococcal disease: recognition, diagnosis, and management

›Pre-hospital benzylpenicillin dosing by age and time-critical antibiotic principle

›CDC and Advisory Committee on Immunization Practices guidance on meningococcal disease chemoprophylaxis

›Ciprofloxacin, rifampin, and ceftriaxone regimens and close contact definitions

›UK Green Book chapter on meningococcal disease

›Chemoprophylaxis dosing and close contact criteria

›IDSA practice guideline for bacterial meningitis

›Empiric and targeted antimicrobial regimens

›Surviving Sepsis Campaign guidelines

›Fluid, vasopressor, and time-to-antibiotic principles applied to septic shock

›Landmark trials

›PROWESS-SHOCK trial

›Drotrecogin alfa (activated protein C) showed no mortality benefit, leading to market withdrawal

›APROCCHSS trial

›Combined hydrocortisone and fludrocortisone reduced 90-day mortality in septic shock

›ADRENAL trial

›Hydrocortisone accelerated shock reversal without a clear mortality difference

›Prognostic score reference

›Original description of the Glasgow Meningococcal Septicaemia Prognostic Score

›Bedside variables for mortality risk stratification in pediatric meningococcal sepsis

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.