Public Health Strategies for Antibiotic-resistant Neisseria meningitidis

Key points

  • CDC has detected penicillin- and ciprofloxacin-resistant serogroup Y meningococcal isolates in the United States.
  • Using these antibiotics for invasive meningococcal disease in areas with resistance can increase suffering and death.
  • Due to these concerns, CDC issued updated guidance related to treatment, prophylaxis, and surveillance.
How CDC is combating antibiotic resistance

The problem

Meningococcal disease is a rare but life-threatening illness requiring prompt antibiotic treatment for patients. Historically, resistance to the antibiotics used for meningococcal treatment and prophylaxis has been uncommon in the United States.

The number of cases caused by penicillin- and ciprofloxacin-resistant Neisseria meningitidis strains has increased in recent years. In some local areas, these cases account for over half of all reported meningococcal disease cases.



Healthcare providers should ascertain susceptibility of meningococcal isolates to penicillin before using penicillin or ampicillin for treatment.

Keep Reading: Clinical Guidance


CDC recommends antibiotic prophylaxis for close contacts of meningococcal disease patients. First-line choices for antibiotic prophylaxis include:

  • Ceftriaxone
  • Ciprofloxacin
  • Rifampin

However, antibiotic prophylaxis with ciprofloxacin in areas with ciprofloxacin resistance can result in prophylaxis failure. Antimicrobial susceptibility testing (AST) on meningococcal disease isolates can inform prophylaxis decisions.

Healthcare providers and public health staff should consider AST if their state has observed ciprofloxacin-resistance in the past 2 years.

Public health staff should update prophylaxis practices as needed based on detection of ciprofloxacin-resistance cases.


State and territorial health departments should

  • Submit all meningococcal isolates to CDC for AST and whole-genome sequencing.
  • Report any suspected meningococcal treatment and prophylaxis failures.
  • Complete a supplemental case report form for cases with resistant isolates.

Resistant isolates include those determined to be β-lactamase screen-positive, ciprofloxacin-resistant, or both.

Secure submission options

Submit supplemental case report forms to CDC via secure email ( or FTP site.

Implementation guidance for health departments

Health departments should use this guidance to make decisions about when and where to preferentially consider prophylaxis options other than ciprofloxacin. This guidance pertains to prophylaxis of close contacts of patients with invasive meningococcal disease in their jurisdictions.

When: Two threshold criteria

Discontinue ciprofloxacin use when both threshold criteria have been met in the catchment area during a rolling 12-month period:

  1. Two or more invasive meningococcal disease cases caused by ciprofloxacin-resistant strains have been reported
  2. Cases caused by ciprofloxacin-resistant strains account for at least 20% of all reported invasive meningococcal disease cases

Maintain updated prophylaxis guidance until 24 months have passed without any reported cases caused by ciprofloxacin-resistant strains in the catchment area.

Ciprofloxacin alternatives‎‎

Prescribe ceftriaxone, rifampin, or azithromycin instead of ciprofloxacin as prophylaxis when the threshold criteria have been reached.

Where: Catchment area determination

Implement updated prophylaxis guidance in all counties within the catchment area. The catchment area should be a single contiguous area that contains all counties reporting ciprofloxacin-resistant cases.

Jurisdictions should include surrounding counties, if warranted, based on population mixing patterns.

Strategies for special circumstances

Health departments have flexibility

Updated prophylaxis guidance can be implemented at a lower threshold. The guidance can also be extended across a broader area, like a metropolitan statistical or health department catchment area.

Other health department considerations in determining guidance implementation include:

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

Defining key terms

Close contacts

Close contacts include the following:

  • Household members and roommates
  • Childcare center contacts
  • Anyone directly exposed to an infected patient's oral secretions in the 7 days before symptom onset

Potential oral secretion exposures

Potential oral secretion exposures include the following:

  • Kissing
  • Mouth-to-mouth resuscitation
  • Endotracheal intubation or endotracheal tube management

These definitions are taken from the Manual for the Surveillance of Vaccine-Preventable Diseases, which provides information on recommended prophylaxis regimens.

Working together

Notify CDC about any local changes made to prophylaxis guidance. CDC is also available to consult if questions arise.

Contact the CDC Meningitis Team

Email questions and report prophylaxis changes to


Council of State and Territorial Epidemiologists (CSTE)
CSTE provides guidelines for determining residency for disease reporting.

Detection of ciprofloxacin-resistant, β-lactamase–producing Neisseria meningitidis serogroup Y isolates — United States, 2019–2020
This MMWR publication describes recent CDC findings of penicillin- and ciprofloxacin-resistant serogroup Y meningococcal isolates in the United States.

Antibiotic prophylaxis letter for close contacts
Health officials can use this letter to help ensure patients get appropriate antibiotic prophylaxis to prevent meningococcal disease.