Ciprofloxacin-Resistant Meningococcal Strains Found in Minnesota and North Dakota
Wayne Staggs, MS
ISDH Invasive Disease Epidemiologist
A February 22, 2008, MMWR report describes the first incidence of ciprofloxacin-resistant meningococcal disease in North America. Three cases, one in 2007 and two in 2008, were identified in Minnesota and North Dakota. You may link to the MMWR report at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5707a2.htm.
This report briefly summarizes the situation and provides recommendations for Indiana health care providers and laboratories.
Invasive meningococcal disease causes substantial morbidity and mortality with approximately 10 percent of cases being fatal. Nasopharyngeal carriage of Neisseria meningitidis is a precursor to disease, but most carriers do not develop disease. Household and other high risk contacts of persons with meningococcal disease have a higher risk for carriage of N. meningitidis and development of invasive disease and, therefore, should receive antibiotic chemoprophylaxis to eliminate carriage of N. meningitidis as soon as possible after exposure. Ciprofloxacin has been one of the recommended antimicrobial agents for use in chemoprophylaxis of adults.
Recommendations from the MMWR report include:
- Ciprofloxacin should not be used for chemoprophylaxis in areas where resistant strains have been identified. Currently, the only areas affected by this restriction include 34 specific counties in Minnesota and North Dakota. (These counties are listed in the MMWR Report.) Azithromycin is now included as an alternative antibiotic for chemoprophylaxis in the 34 restricted Minnesota and North Dakota counties; however, its use in Indiana is not warranted at this time.
- Ciprofloxacin may continue to be used for chemoprophylaxis of adults outside the specific counties in Minnesota and North Dakota. (See Table 1 for information on recommended chemoprophylaxis regimens for high risk contacts in Indiana.)
To date, ciprofloxacin-resistant strains of meningococcal disease have not been identified in Indiana.
- In decisions regarding chemoprophylaxis of close contacts, all antibiotics should be used cautiously due to possible resistance resulting from widespread use. (See box for listing of high and low risk contacts of invasive meningococcal disease.)
Indiana State Department of Health Actions and Recommendations
The Indiana State Department of Health (ISDH) will monitor for ciprofloxacin-resistant organisms and chemoprophylaxis failure. To assist the ISDH in monitoring the situation, the following actions should be taken by health care providers and laboratories:
- As currently required by the Indiana Communicable Disease Reporting Rule (410 IAC 1-2.3), all invasive Neisseria meningitidis isolates should be submitted to the ISDH Laboratory:
Indiana State Department of Health Laboratories
Bacteriology Laboratory
550 West 16th Street, Suite B
Indianapolis, Indiana 46202
-
Any laboratory routinely testing meningococcal isolates for resistance to ciprofloxacin should report ciprofloxacin-resistant organisms to the Indiana State Department of Health (Wayne Staggs at 317.234.2804)
Disease Risk for Contacts of Individuals with Invasive Meningococcal Disease*
High Risk (chemoprophylaxis recommended):
- Any household contact, especially young children
- Child-care or nursery-school contact during 7 days before onset of illness
- Direct exposure to patient’s oral secretions through activities such as kissing, sharing toothbrushes, eating utensils, or drinking containers
- Mouth-to-mouth resuscitation, unprotected contact during endotracheal intubation during 7 days before onset of illness
- Frequent sleeping or eating at same dwelling as patient during 7 days before onset of illness
- Passengers seated directly next to index case during airline flight lasting more than 8 hours
Low Risk (chemoprophylaxis not recommended):
- Casual contact: no history of direct exposure to index patient’s oral secretions (e.g., school or work)
- Indirect contact: only contact is with high risk contact, no direct contact with index patient
- Health care professionals without direct exposure to patient’s oral secretions
In outbreak or cluster:
- Chemoprophylaxis for people other than people at high risk should be administered only after consultation with public health authorities
Table 1. Recommended Chemoprophylaxis Regimens for High-Risk Contacts*
|
Age |
Dose |
Duration |
Efficacy (%) |
Cautions |
|
Rifampin1 | ||||
|
<1 month |
5mg/kg, orally, |
2 Days |
90-95% |
|
|
≥1 month |
10 mg/kg (max. |
2 Days |
90-95% |
Can interfere with efficacy of oral contraceptives and some seizure prevention and anticoagulant medications; may stain soft contact lenses |
|
Ceftriaxone | ||||
|
<15 years |
125 mg, intramuscularly |
Single Dose |
90-95% |
To decrease pain at injection site, dilute with 1% lidocaine |
|
≥15 years |
250 mg, intramuscularly |
Single Dose |
90-95% | |
|
Ciprofloxacin1 | ||||
|
≥18 years |
500 mg. orally |
Single Dose |
90-95% |
Not recommended for persons <18 years of age |
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