Threshold for Changing Meningococcal Disease Prophylaxis Antibiotics in Areas with Ciprofloxacin Resistance

Antibiotic prophylaxis with ciprofloxacin in areas with ciprofloxacin resistance can result in prophylaxis failure. This guidance is intended to help health departments decide when, where, and for how long they should discontinue use of ciprofloxacin for prophylaxis of close contacts1 of patients with invasive meningococcal disease in their jurisdictions.

Antibiotic prophylaxis is recommended for close contacts

Meningococcal disease is a life-threatening illness requiring prompt antibiotic treatment for patients and antibiotic prophylaxis for their close contacts. First-line choices for antibiotic prophylaxis include:

  • Rifampin
  • Ciprofloxacin
  • Ceftriaxone

Azithromycin may also be used in areas with ciprofloxacin-resistant strains.

Antibiotic resistance is increasing

Historically, resistance to the antibiotics used for meningococcal treatment and prophylaxis has been rare in the United States. However, the number of cases caused by ciprofloxacin-resistant strains has been increasing. In some local areas, these cases account for over half of all reported meningococcal disease cases.

Recommendations for discontinuing use of ciprofloxacin
  • Discontinue use of ciprofloxacin for prophylaxis of close contacts when both of the following threshold criteria have been met in the catchment area2 during a rolling 12-month period:
    • Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have been reported, and
    • Cases caused by ciprofloxacin-resistant strains make up at least 20% of all reported invasive meningococcal disease cases.
  • Prescribe rifampin, ceftriaxone, or azithromycin instead of ciprofloxacin as prophylaxis when the threshold criteria have been reached.3
  • Implement updated prophylaxis guidance in all counties within the catchment area.
  • Maintain updated prophylaxis guidance until a full 24 months have passed without any invasive meningococcal disease cases caused by ciprofloxacin-resistant strains having been reported in the catchment area.

Health departments have flexibility in guidance implementation

Updated prophylaxis guidance can be implemented at a lower threshold or extended across a broader area.4 Health departments should consider the following when determining how to implement the guidance:

  • Local epidemiology
  • Feasibility (e.g., logistical simplicity of having a particular geographic area follow uniform guidance)
  • Epidemiologic linkages among patients
  • Travel history, including travel to/from school for college and other students5
  • Patterns in population movement, including movement across jurisdictional borders

Contact CDC

Notify CDC about any local changes made to prophylaxis guidance. CDC is also available to consult if questions arise. For questions or reporting prophylaxis changes, please contact the CDC meningitis team at