Correspondence
Clinical Problem-Solving: Prevention of Meningococcal Infection
N Engl J Med 1994; 330:511-512February 17, 1994
- Article
To the Editor:
I wish to take issue with a comment in the Clinical Problem-Solving article that appeared in the September 2 issue.1 The case described was one of fulminating meningococcal septicemia. The discussant commented that the fellow travelers on the patient's flight back from Mexico “need immediate follow-up and prophylaxis if they had close contact with the patient.” In the United Kingdom we have to deal with a good deal of hysteria among the general public about meningococcal disease, and our recommendations would certainly not involve follow-up and prophylaxis in the event of contact as described here, unless the fellow travelers had to administer mouth-to-mouth resuscitation. The effort involved in tracing contacts from an international flight would be immense. Given the duration and nature of the contact, it cannot be justified.
1 ReferencesA.E. Murray, B.M.
Wirral Medical Microbiology, Bebington L63 4JY, United Kingdom1
Duffy TP . The sooner the better. N Engl J Med 1993;329:710-713
Full Text | Web of Science | Medline
To the Editor:
The case of fulminant meningococcemia was very educational. Nevertheless, I would like to make three remarks.
First, in a case of suspected bacterial meningitis, the identification of bacteria is of great importance. Unfortunately, many physicians are not very competent in the technique of Gram's staining. Methylene-blue staining of direct smears is very helpful. It takes only 30 seconds, and the configuration of bacteria is easily detected. It is a very useful technique in examinations of cerebrospinal fluid, pus, and other body fluids.
Second, regarding prevention, I would have appreciated a comment on any epidemiologic study of the contacts in this case, including follow-up on the travelers on the same flight from Mexico. In a very similar case involving a patient who came to Israel from Brazil (and fortunately recovered completely), we identified another youth who was on the same flight in whom meningitis developed two to three days later.
Finally, I think some recommendations about vaccinations for travelers abroad are indicated. It is important that practitioners know that there are vaccinations against meningococci, how to get them, and when to prescribe them, especially during travel to countries where the organism is endemic.
Dan Michaeli, M.D.
Kupat Holim Health Insurance Institution, Tel Aviv 62098, IsraelTo the Editor:
Dr. Duffy's claim that a considerable reduction in the case fatality rate can be achieved by the immediate antimicrobial treatment of patients with suspected meningococcemia is controversial. Divergent conclusions have been reached: both a benefit1 and an increase in mortality2 have been reported when antimicrobial treatment is initiated before hospital admission. Neither the efficacy nor the safety of immediate antimicrobial treatment in suspected meningococcal disease has been established3. In spite of this, prompt treatment seems warranted4.
The early initiation of intensive supportive measures, not merely immediate treatment with antibiotics, is most likely to correlate with a favorable outcome in meningococcemia. In addition to profiting from finding a physician carrying penicillin G, the patient in question might have benefited from undelayed admission to an intensive care unit.
4 ReferencesBruno Simini, M.D.
Ospedale Provinciale, Lucca, I-55100, Italy1
Cartwright K ,Strang J ,Gossain S ,Begg N . Early treatment of meningococcal disease. BMJ 1992;305:774-774
CrossRef | Web of Science | Medline2
Sorensen HT ,Moller-Petersen J ,Krarup HB ,Pedersen H ,Hansen H ,Hamburger H . Early treatment of meningococcal disease. BMJ 1992;305:774-774
CrossRef | Web of Science | Medline3
Peltola H . Early meningococcal disease: advising the public and the profession. Lancet 1993;342:509-510
CrossRef | Web of Science | Medline4
Begg N . Reducing mortality from meningococcal disease: give antibiotics before admission. BMJ 1992;305:133-134
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Duffy replies:
To the Editor: Dr. Simini's concluding statement summarizes the situation with meningococcal disease: the sooner antibiotic therapy and supportive care are initiated, the better. The counterintuitive findings of the Danish group1 -- that early antibiotic administration in meningococcal disease results in higher mortality -- may have a simple explanation: the antibiotics were not administered soon enough. The recommendation remains to treat promptly when there is any suspicion of meningococcal disease2.
Dr. Michaeli's experience highlights the appropriateness of seeking out close contacts of the patient, especially when prolonged international flights are involved. In this case, travelers on the same flight who were seated in the area immediately around the patient were contacted and advised of the situation; her friends, with whom she had shared a room while in Mexico, were treated with antibiotics. A tetravalent vaccine is available for administration in all except serotype B outbreaks, because protective antibody develops quickly after immunization. Still, contacts must be advised to seek prompt medical attention for any symptoms suggestive of meningococcal disease. The basis for such aggressive pursuit and treatment of close contacts (who live and sleep in the same household) is the risk, 500 to 1000 times higher, that such persons have of contracting the disease3.
3 ReferencesThomas P. Duffy, M.D.
Yale University School of Medicine, New Haven, CT 065101
Sorensen HT ,Moller-Petersen J ,Krarup HB ,Pedersen H ,Hansen H ,Hamburger H . Early treatment of meningococcal disease. BMJ 1992;305:774-774
CrossRef | Web of Science | Medline2
Peltola H . Early meningococcal disease: advising the public and the profession. Lancet 1993;342:509-510
CrossRef | Web of Science | Medline3
Boslego J, Tramont E. Neisseria meningitides. In: Gorback S, Bartlett J, Blacklow N, eds. Infectious diseases. Philadelphia: W.B. Saunders, 1992:1452-8.
