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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 via intravenous (IV) or intramuscular (IM) routes.
## Primary Indications
* **Bacterial infections:** Including pneumonia, meningitis, gonorrhea, pelvic inflammatory disease, skin and soft tissue infections, bone and joint infections, intra-abdominal infections, and urinary tract infections.
* **Prophylaxis:** Surgical prophylaxis.
## Adult Dosing
* **General infections:** 1 to 2 grams (g) every 12 to 24 hours.
* **Severe infections:** Up to 4 grams (g) per day in divided doses every 12 hours.
* **Meningitis:** 2 grams (g) every 12 hours.
* **Uncomplicated gonorrhea:** A single dose of 250 milligrams (mg) IM. Higher doses may be recommended for disseminated gonococcal infections.
* **Surgical prophylaxis:** 1 to 2 grams (g) administered 30 to 60 minutes before surgery.
* **Maximum dose:** 4 grams (g) per day.
## Pediatric Dosing
* **Neonates (0-14 days):** 25 to 50 mg/kg/day IV every 24 hours. Maximum: 50 mg/kg/day.
* **Neonates (15-28 days):** 50 to 75 mg/kg/day IV every 12 to 24 hours. Maximum: 75 mg/kg/day.
* **Infants and Children (>28 days):**
* **General infections:** 50 to 100 mg/kg/day IV or IM in divided doses every 12 to 24 hours.
* **Severe infections:** Up to 100 to 150 mg/kg/day IV in divided doses every 12 to 24 hours.
* **Meningitis:** 100 mg/kg/day IV in divided doses every 12 hours (maximum 4 g/day).
* **Maximum dose for children:** 4 grams (g) per day.
*Note: Dosing for neonates is limited to IV administration. Concurrent administration with calcium-containing solutions is contraindicated in neonates.*
## Dose Adjustments
* **Renal impairment:** No dose adjustment is generally needed as ceftriaxone is largely eliminated by non-renal routes (biliary excretion). However, in severe renal impairment (creatinine clearance < 10 mL/min), the dose should not exceed 2 grams (g) daily.
* **Hepatic impairment:** No dose adjustment is usually required. Use with caution in severe hepatic impairment.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or any component of the formulation.
* Neonates (term and preterm) receiving IV calcium-containing solutions or infusions due to the risk of precipitation of ceftriaxone-calcium.
## Adverse Effects
* **Common:** Diarrhea, rash, injection site reactions (pain, phlebitis), eosinophilia, thrombocytosis.
* **Serious:** *Clostridioides difficile*-associated diarrhea, Stevens-Johnson syndrome, anaphylaxis, biliary sludge/lithiasis, hemolytic anemia, neutropenia, hepatic dysfunction, renal dysfunction, neurological effects (rare).
## Key Drug Interactions
* **Calcium-containing solutions/products:** Contraindicated in neonates and should be avoided in adults due to risk of precipitation. If coadministration is necessary, separate administration times (e.g., flush IV line with saline between infusions) and monitor closely.
* **Aminoglycosides:** Potential for additive nephrotoxicity or ototoxicity, though synergistic effects against certain organisms may occur.
* **Warfarin:** May decrease the effectiveness of warfarin; monitor INR.
* **Probenecid:** May increase ceftriaxone levels.
* **Oral contraceptives:** Ceftriaxone may reduce the efficacy of oral contraceptives.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for diarrhea and signs of *C. difficile* infection.
* Monitor liver and renal function tests, especially in patients with pre-existing impairment or during prolonged therapy.
* Monitor CBC with differential and platelet count.
* Monitor for signs of biliary sludge or gallstones with prolonged therapy, especially in pediatric patients.
## Clinical Pearls
* Ceftriaxone can be reconstituted with lidocaine for IM injection to reduce pain. Do NOT administer IV with lidocaine.
* When reconstituting for IV use, use sterile water for injection or 0.9% sodium chloride.
* Ceftriaxone is often used in empiric therapy for serious community-acquired infections due to its broad spectrum and convenient dosing.
* The extended half-life allows for once or twice-daily dosing, improving patient compliance.
* Its poor penetration into cerebrospinal fluid (CSF) in the absence of inflammation limits its use as monotherapy for bacterial meningitis, but it is a cornerstone agent once inflammation is present.
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**Disclaimer:** This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and institutional protocols before administering any medication.
