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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 has a long half-life, allowing for once-daily dosing.
## Primary Indications
* Bacterial meningitis (including *Neisseria meningitidis*, *Haemophilus influenzae*, *Streptococcus pneumoniae*)
* Community-acquired pneumonia
* Pneumonia acquired in healthcare settings
* Complicated urinary tract infections and pyelonephritis
* Skin and soft tissue infections
* Bone and joint infections
* Sepsis
* Gonorrhea
* Prophylaxis for surgical site infections
## Adult Dosing
* **General Infections:** 1-2 grams IV/IM every 24 hours.
* **Severe Infections:** Up to 4 grams IV every 24 hours (administered as 2 grams every 12 hours).
* **Uncomplicated Gonorrhea:** 500 mg IM single dose. For disseminated gonococcal infection, 1 gram IV/IM every 24 hours for 7 days.
* **Meningitis:** 2 grams IV every 12 hours.
## Pediatric Dosing
* **Neonates (0-14 days):** 25-50 mg/kg IV every 24 hours. Do not exceed 50 mg/kg/day. Avoid concurrent use with IV calcium-containing solutions.
* **Neonates (15-28 days):** 50 mg/kg IV every 24 hours.
* **Children (>28 days to 12 years, <50 kg):**
* **Uncomplicated infections:** 50-75 mg/kg IV/IM every 24 hours.
* **Severe infections, meningitis, or *H. influenzae* meningitis:** 80-100 mg/kg/day IV divided every 12 hours. Do not exceed 2 grams/day.
* **Children (>12 years or >50 kg):** Use adult dosing.
Dosing for pediatric meningitis may vary based on specific pathogens and local protocols.
## Dose Adjustments
No dose adjustment is generally needed for renal impairment. However, in patients with both hepatic and severe renal impairment, the adult maximum dose should not exceed 2 grams daily.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Concurrent administration of IV calcium-containing solutions in neonates (<28 days old), including those receiving parenteral nutrition.
## Adverse Effects
Common: Diarrhea, nausea, vomiting, rash, phlebitis (with IV administration), eosinophilia, thrombocytosis, leukopenia.
Less Common: Jaundice, hepatic enzyme elevations, renal toxicity (rare), hemolytic anemia (rare), biliary sludge/cholelithiasis (especially in neonates and with prolonged therapy).
## Key Drug Interactions
* **Aminoglycosides:** Potential for increased nephrotoxicity and ototoxicity, especially in severe renal impairment.
* **Oral Contraceptives:** Ceftriaxone may reduce the efficacy of oral contraceptives. Advise alternative contraception.
* **Probenecid:** May increase and prolong ceftriaxone serum levels.
* **Warfarin:** Ceftriaxone may potentiate the effect of warfarin, increasing INR.
* **Calcium-containing solutions:** Contraindicated in neonates due to risk of precipitation in lungs and kidneys.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for signs of superinfection (e.g., *Clostridioides difficile*-associated diarrhea).
* Monitor renal and hepatic function periodically, especially in patients with pre-existing impairment or on prolonged therapy.
* Monitor coagulation parameters if co-administered with warfarin.
## Clinical Pearls
* Ceftriaxone can be administered IM without lidocaine in adults, but lidocaine is often used to reduce pain. If lidocaine is used, ensure it is not contraindicated in the patient.
* When reconstituting, use appropriate diluents as per manufacturer instructions.
* Discard any unused reconstituted solution after the recommended stability period.
* Consider potential for cross-reactivity in patients with penicillin allergy, though the risk is lower with third-generation cephalosporins compared to first-generation.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols before making any clinical decisions.
