The FDA has licensed Penbraya (Pfizer), a pentavalent polysaccharide conjugate meningococcal vaccine, for prevention of invasive meningococcal disease caused by Neisseria meningitidis serogroups A, B, C, W, or Y (MenABCWY) in persons 10-25 years old. Penbraya is the only meningococcal vaccine that contains all five of these serogroups. Two quadrivalent polysaccharide conjugate meningococcal vaccines containing serogroups A, C, W, and Y (MenACWY; Menveo, MenQuadfi) and two meningococcal serogroup B vaccines (MenB; Bexsero, Trumenba) are available in the US (see Table 2).

The FDA has licensed MenQuadfi (Sanofi Pasteur), a quadrivalent polysaccharide conjugate vaccine that uses tetanus toxoid as a protein carrier, for prevention of invasive meningococcal disease caused by Neisseria meningitidis serogroups A, C, W, and Y (MenACWY) in persons ≥2 years old.

The Advisory Committee on Immunization Practices (ACIP) has issued new recommendations for meningococcal vaccination. Booster vaccination against Neisseria meningitidis serogroup B (MenB) is now recommended in persons at increased risk for meningococcal disease (see Table 1). MenB booster doses were not recommended previously for any population.

Persons planning to travel outside the US should be up to date on routine vaccines and, depending on their destination, duration of travel, and planned activities, may also receive certain travel-specific vaccines. Tickborne encephalitis and dengue vaccines, which are not available in the US, are reviewed in a separate article available online. Detailed advice for travel to specific destinations is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel/destinations/list. Recommendations for administration of vaccines as part of routine adult immunization are discussed in a separate issue.

The 2017 adult immunization schedule approved by the CDC's Advisory Committee on Immunization Practices (ACIP) includes some new or revised recommendations.1 The complete schedule is available on the CDC's website (www.cdc.gov/vaccines/schedule). New recommendations for use of influenza vaccine during the 2016-2017 season were included in a previous issue of The Medical Letter.2 Updated recommendations for other vaccines are summarized below. Recommendations for routine use of vaccines in adults were reviewed in an earlier issue.3

1. DK Kim et al. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older – United States, 2017. MMWR Morb Mortal Wkly Rep 2017; 66:136.
2. Influenza vaccine for 2016-2017. Med Lett Drugs Ther 2016; 58:127.
3. Adult immunization. Treat Guidel Med Lett 2014; 12:39.
4. Gardasil 9 – a broader HPV vaccine. Med Lett Drugs Ther 2015; 57:47.
5. Trumenba: a serogroup B meningococcal vaccine. Med Lett Drugs Ther 2015; 57:5.
6. Bexsero – a second serogroup B meningococcal vaccine. Med Lett Drugs Ther 2015; 57:158.

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The FDA has approved Bexsero (Novartis/GSK), a vaccine that protects against invasive meningococcal disease caused by Neisseria meningitidis serogroup B. It is the second serogroup B meningococcal vaccine to be approved in the US; Trumenba was the first. Both vaccines are approved for use in persons 10-25 years old. Bexsero is approved in Europe, Canada, and Australia for use in children as young as 2 months old.

The FDA has approved Trumenba (Pfizer), a vaccine that protects against invasive meningococcal disease caused by Neisseria meningitidis serogroup B, for use in adolescents and young adults 10-25 years old.

Patients planning to travel to other countries should be up to date on routine immunizations and, depending on their destination, duration of travel, and planned activities, may also need to receive certain travel-specific vaccines. Common travel vaccines are listed in Table 2. More detailed advice for travelers is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel. Guidelines for routine adult immunization are discussed in a separate issue.

An outbreak (8 cases to date) of meningococcal disease at Princeton University caused by Neisseria meningitidis serogroup B has led the FDA and CDC to permit importation and investigational use (at Princeton University only) of a meningococcus B vaccine (4CMenB; Bexsero – Novartis) that has not been approved in the US. Bexsero has been approved for use in the European Union and in Australia.

THE VACCINE — Until recently, no serogroup B vaccine was widely available because the polysaccharide capsule of the B serogroup, unlike those of the other main meningococcal serogroups (A, C, Y, and W-135), is only weakly immunogenic. The 4CMenB vaccine contains 3 protein antigens identified in the N. meningitidis serogroup B genome and membrane components from a New Zealand outbreak strain. The vaccine has been tested in more than 8000 adults and children, has proved to be immunogenic, and appears to be safe.1 Its efficacy has not been established clinically, but laboratory testing, according to the CDC, has found that the vaccine should be protective against the strain causing the Princeton University outbreak. Bactericidal antibody levels develop about 2 weeks after one dose of the vaccine; a second dose is needed 1-6 months after the first to maintain protection.

CHEMOPROPHYLAXIS — Close contacts of patients with invasive meningococcal disease (e.g., same household, roommates, boyfriend or girlfriend) should receive antimicrobial chemoprophylaxis. Antimicrobial drugs can prevent secondary cases and eradicate the organism from the nasopharynx of healthy carriers. The susceptibility of serogroup B meningococci to antimicrobial agents is the same as that of other meningococcal serogroups. Regimens recommended by the CDC’s Advisory Committee on Immunization Practices are: oral rifampin 600 mg (10 mg/kg for children) q12h for 2 days; oral ciprofloxacin 500 mg once (not recommended for children); or a single IM injection of ceftriaxone 250 mg (125 mg for children).2

CONCLUSION — The new vaccine against serogroup B meningococcal disease, which is investigational in the US, appears to be immunogenic and safe. For immediate protection after close contact with an infected patient, antimicrobial prophylaxis is recommended.

1. NJ Carter. Multicomponent meningococcal serogroup B vaccine (4CMenB; Bexsero®): a review of its use in primary and booster vaccination. BioDrugs 2013; 27:263.

2. AC Cohn et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62(RR-2):1.

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Rates of meningococcal disease are highest in infancy, but until recently no meningococcal vaccine was approved for use in this age group. MenHibrix (GSK), a new conjugate vaccine that protects against Neisseria meningitidis serogroups C and Y and Haemophilus influenzae type b (Hib), has been approved by the FDA for use in infants ≥6 weeks old and Menveo, a meningococcal vaccine already approved for patients ≥2 years old that protects against serogroups A, C, Y, and W-135, is now approved for use in infants ≥2 months old.

SEROGROUPS — Five major serogroups of N. meningitidis, A, B, C, Y, and W-135, cause most of the reported cases of invasive meningococcal disease. Serogroup A is the leading cause of epidemic meningitis worldwide, especially in the meningitis belt of sub-Saharan Africa, but it is rare in the US. Serogroup B causes about 60% of all meningitis cases in infants and, together with serogroups C and Y, accounts for most of the endemic disease in the US. Serogroup W-135 has caused outbreaks worldwide, particularly among pilgrims to Mecca during the Hajj and their close contacts on arriving home. Serogroup B remains the only major serogroup for which no vaccine is available in the US. A meningococcal B vaccine (Bexsero – Novartis) is licensed in Europe and Australia for patients ≥2 months old.

IMMUNOLOGIC STUDIES — FDA approval of both MenHibrix and Menveo (for this age group) was based on immunologic studies in infants who received the vaccines at 2, 4, 6, and 12 months. Both vaccines produced protective antibody responses in almost all vaccinated infants. With MenHibrix, antibody levels against Hib were non-inferior to those with 2 standard monovalent Hib vaccines.1

RECOMMENDATIONS FOR USE — The CDC’s Advisory Committee on Immunization Practices (ACIP) does not recommend routine vaccination against meningococcal disease for infants. It does recommend use of either MenHibrix or Menveo for infants who are at increased risk of meningococcal disease because of persistent complement deficiencies, functional or anatomic asplenia, or exposure to a community outbreak of disease caused by one of the serogroups in the vaccine.2 Menveo is also recommended for infants traveling with their families to the Hajj or to the meningitis belt of sub-Saharan Africa. Both vaccines can be given on a 4-dose schedule at 2, 4, 6, and 12 months, but the first dose of MenHibrix can be administered as early as 6 weeks and the last dose as late as 18 months.

1. KA Bryant et al. Immunogenicity and safety of H. influenzae type b-N meningitidis C/Y conjugate vaccine in infants. Pediatrics 2011; 127:e1375.

2. AC Cohn et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2013; 62(RR-2):1.

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The text that follows reviews some common bacterial infections and their empiric treatment pending the results of culture and susceptibility testing. The recommendations made here are based on the results of susceptibility studies, clinical trials, and the opinions of Medical Letter reviewers. Tables 1 and 2 list the usual dosages of antibacterial drugs.

Vaccines recommended for routine use in US adults are reviewed here. Vaccines for travel have been reviewed separately.

Evidence of waning immunity by 5 years post-vaccination has led the US Advisory Committee on Immunization Practices (ACIP) to recommend, in addition to a primary dose of meningococcal conjugate vaccine at 11 or 12 years of age, a booster dose at age 16. Adolescents who receive a first dose of the vaccine at age 13-15 should receive a booster dose at 16-18 (before college). Those who receive their first dose at ≥16 years of age do not need a booster dose. Routine vaccination of healthy persons who are not at increased risk for exposure to Neisseria meningitidis is not recommended after age 21.1

1. CDC. Updated recommendations for use of meningococcal conjugate vaccines — Advisory Committee on Immunization Practices (ACIP), 2010. MMWR Morb Mortal Wkly Rep 2011; 60:72.

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The FDA has approved Menveo (Novartis), a new quadrivalent conjugated polysaccharide vaccine, for protection against disease caused by Neisseria meningitidis in people 11-55 years old.

The text below reviews some common bacterial infections and their treatment. The recommendations made here are based on the results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants.

Although immunization programs have produced high vaccination rates in US infants and children, similar successes have not been achieved in adults. Vaccines recommended for routine use in adults are reviewed here. Vaccines for travel are reviewed separately.

The CDC recently reported that fluoroquinoloneresistant strains of Neisseria meningitidis have been detected for the first time in the US in an area around the border of North Dakota and Minnesota (CDC. MMWR, Feb 22, 2008). These isolates were all serogroup B, for which meningococcal vaccines (Med Lett Drugs Ther 2005; 47:29) do not offer protection. Since many laboratories do not test N. meningitidis for antimicrobial susceptibility, it is possible that such resistance is more widespread.

A single oral dose of ciprofloxacin (Cipro, and others) 500 mg has been used for prophylaxis after close contact with infected patients. Oral rifampin (Rifadin, and others) 600 mg (10 mg/kg for children) q12h for 2 days, a single IM injection of ceftriaxone (Rocephin, and others) 250 mg (125 mg for children), or a single oral dose of azithromycin (Zithromax, and others) 500 mg (10 mg/kg for children) are reasonable alternatives.

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Information about empirical treatment of bacterial infections, emerging trends in antimicrobial resistance, new drugs and new data about older drugs continue to become available. Usual pathogens and empiric treatment for some common types of infections are summarized in the text and a table listing the drugs of choice and alternatives for each pathogen begins on page 40. The recommendations made here are based on the results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants.

New drugs for bacterial infections and new information about older drugs continue to become available. Empirical treatment of some common bacterial infections is discussed in this article. A table listing the drugs of choice and alternatives for each pathogen begins on page 18. These recommendations are based on results of susceptibility studies, clinical trials and the opinions of Medical Letter consultants. Local resistance patterns should be taken into account. Trade names are listed on page 24.

New drugs for treatment of bacterial infections and new information about older drugs continue to become available. Empirical treatment of some infections is discussed and a table listing the drugs of choice and alternatives for each pathogen are contained in this article. These recommendations are based on results of susceptibility studies, clinical trials and opinions of Medical Letter consultants. Local resistance patterns should be taken into account.

The US Public Health Service Advisory Committee on Immunization Practices has recently published new recommendations for prevention and control of meningococcal disease in college students.

Since The Medical Letter last reviewed the choice of drugs for treatment of bacterial infections, a few new drugs and some new information about older drugs have become available.