NAPLEX Question of the Week: Time for a PEP Talk

This week's question evaluates an important area of meningitis management.
NAPLEX Question of the Week: Time for a PEP Talk
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WH is a 45-year-old female daycare attendant who was admitted to the ICU with concerns of meningitis after presenting to the ED with a headache, fever, and nuchal rigidity. A lumbar puncture was performed to obtain CSF cultures and gram-staining. Preliminary staining indicates infection with gram-negative diplococci bacteria, suggestive of Neisseria meningitidis. The patient’s empiric therapy was de-escalated to ceftriaxone 2g IV q12H pending sensitivities. After a couple days of treatment, the patient appears to be clinically improving with improving WBC and fever. However, a discussion arises about post-exposure prophylaxis given the patient’s occupation and shared household with immediate family.

Pertinent Labs on Admission to ICU:

  • Na: 140 mEq/L; K: 4.0 mEq/L: Cl: 96 mEq/L; Mg: 2.0 mg/dL; BUN: 15 mg/dL; SCr: 1.1 mg/dL; SBG: 110 mg/dL; AST 22 U/L; ALT 28 U/L
  • CSF Findings:
    • WBC: 2500 cells/mm3; Neutrophils: 85%; Protein: 480 mg/dL; Glucose: 40 mg/dL
    • Gram-stain: gram-negative diplococci
    • CSF Culture: Neisseria meningitidis
  • Vitals: BP: 165/84 mmHg; HR: 90; RR: 19; Temp: 101.4F
  • Weight: 100 kg; Height: 64 in

With confirmed infection of Neisseria meningitidis on culture, which of the following would be appropriate chemoprophylaxis options for close contacts of WH? (Select all that apply)

A. Rifampin 600 mg PO q12H for 2 days

B. Ceftriaxone 250 mg IM for 1 dose

C. Augmentin 875mg/125mg PO q12H for 2 days

D. Ciprofloxacin 500 mg PO for 1 dose

E. PCV23 0.5 mL IM x 1 dose

Rationale:

Explanation:

All close contacts to patient infected with Neisseria meningitidis should receive antimicrobial prophylaxis. Patients may be infectious for seven days prior to symptom onset and up to 24 hours after starting effective antibiotics. Prophylaxis serves to eradicate nasopharyngeal colonization of N. meningitidis and H. influenzae. It should ideally be initiated within 24 hours of identification of the index patient, with limited efficacy when started after 14 days. Rifampin, ciprofloxacin, and ceftriaxone have shown more than 90% efficacy as prophylactic agents. Augmentin does not have predictable activity and therefore is not a recommended agent by CDC (guidelines below). Additionally, vaccination as prophylaxis can be an effective adjunct to antimicrobials. However, meningococcal vaccines would be the vaccine of choice in this case and not pneumococcal vaccines.

Therefore the correct answers are A, B, and D. 

Brands/Generics covered: Augmentin (amoxicillin and clavulanate); Cipro (ciprofloxacin); Rocephin (ceftriaxone); Rifadin (rifampin)

NAPLEX Competencies Covered:

Area 1 (Obtain, Interpret, or Assess Data, Medical, or Patient Information) 1.6 Risk factors or maintenance of health and wellness

Area 2 (Identify Drug Characteristics), 2.1 Pharmacology, mechanism of action, or therapeutic class;

Area 3 (Develop or Manage Treatment Plans), 3.4 Therapeutic goals or outcomes and clinical endpoints, 3.5 Drug route of administration, dosage forms, or delivery systems, 3.11 Evidence-based practice

Reference: 

Meningococcal Disease with PEP Recommendations from CDC

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