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 make decisions about when and where recommended antibiotic prophylaxis options other than ciprofloxacin should be preferentially considered. This pertains to prophylaxis of close contacts1 of patients with invasive meningococcal disease in their jurisdictions.

Read the MMWR publication: Selection of antibiotics for prophylaxis of close contacts of patients with meningococcal disease in areas with ciprofloxacin resistance.

Antibiotic prophylaxis is recommended for close contacts

Meningococcal disease is a rare but 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 uncommon in the United States. However, the number of cases caused by ciprofloxacin-resistant strains has increased. In some local areas, these cases account for over half of all reported meningococcal disease cases.

Implementation guidance for health departments for favoring antibiotics other than ciprofloxacin for invasive meningococcal disease prophylaxis
  • 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:
    • ≥2 invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have been reported, and
    • Cases caused by ciprofloxacin-resistant strains account for ≥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 Other health department considerations in determining guidance implementation include:

  • 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