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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic with broad-spectrum activity against many Gram-positive and Gram-negative bacteria. It is administered intravenously or intramuscularly.
## Primary Indications
* Community-acquired pneumonia
* Bacterial meningitis
* Skin and soft tissue infections
* Urinary tract infections, including pyelonephritis
* Sepsis
* Gonorrhea and other sexually transmitted infections
* Prophylaxis for surgical site infections
## Adult Dosing
* **General infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 24 hours.
* **Meningitis:** 2 grams IV every 12 hours.
* **Uncomplicated gonorrhea:** 500 mg IM as a single dose. For disseminated gonococcal infection, 1 gram IV or IM every 24 hours for 7 days.
* **Surgical prophylaxis:** 1 to 2 grams IV 30-60 minutes before incision.
* **Maximum dose:** 4 grams per day.
Specific dosing for complex infections, such as complicated meningitis or endocarditis, may require higher doses and is often guided by institutional protocols or infectious disease consultation.
## Pediatric Dosing
Dosing varies significantly by indication and patient weight. Consult pediatric infectious disease guidelines for precise dosing. General guidelines include:
* **< 7 days of age:** 25-50 mg/kg IV every 24 hours.
* **> 7 days of age (premature infants):** 25-50 mg/kg IV every 24 hours.
* **> 7 days of age (full-term infants):** 50-100 mg/kg IV every 24 hours, divided into 2 doses (every 12 hours).
* **Children > 1 month:**
* **Meningitis:** 80-100 mg/kg/day IV, divided every 12 hours.
* **Other infections:** 50-100 mg/kg/day IV or IM, divided every 12-24 hours.
* **Maximum dose for neonates:** 50 mg/kg/day.
* **Maximum dose for children and adolescents:** Generally 2 grams per day, though higher doses (up to 4 grams/day) may be used for severe infections under specialist guidance.
**Note:** Ceftriaxone is contraindicated in neonates ≤ 28 days of age receiving concurrent IV calcium-containing solutions, regardless of age or duration of administration, due to the risk of fatal precipitate formation in the lungs and kidneys.
## Dose Adjustments
No dose adjustment is typically required for renal or hepatic impairment. However, close monitoring for adverse effects is recommended in patients with severe impairment.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates (≤ 28 days of age) receiving calcium-containing solutions IV.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia.
* **Serious:** Anaphylaxis, Clostridioides difficile-associated diarrhea, biliary sludge or pseudolithiasis (especially in neonates), renal and hepatic toxicity, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Calcium-containing solutions:** Contraindicated in neonates (see pediatric dosing). In adults, co-administration via the same IV line is generally avoided, but sequential administration with flushing of the line is usually acceptable.
* **Aminoglycosides:** Potential for increased nephrotoxicity when used together, especially in severe infections.
* **Warfarin:** Ceftriaxone may alter INR. Monitor INR closely.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Assess for diarrhea, particularly if severe or persistent, to rule out C. difficile infection.
* Monitor renal and hepatic function, especially in patients with pre-existing impairment or those receiving prolonged therapy.
* Monitor complete blood count (CBC) and platelet count.
* For patients receiving warfarin, monitor INR.
## Clinical Pearls
* Ceftriaxone's long half-life allows for once-daily dosing in most indications, improving patient adherence.
* It penetrates the cerebrospinal fluid (CSF) well, making it a cornerstone for treating bacterial meningitis.
* Biliary precipitation is a known phenomenon, particularly with higher doses and prolonged therapy, and can mimic cholecystitis. This is usually reversible upon discontinuation.
* IM administration may be painful; consider lidocaine as a diluent for IM injections if local protocol allows.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional guidelines before administering any medication.*
