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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
* Meningitis (bacterial, including *Neisseria meningitidis*, *Haemophilus influenzae*, and *Streptococcus pneumoniae*)
* Uncomplicated gonorrhea
* Sepsis
* Skin and soft tissue infections
* Urinary tract infections
* Intra-abdominal infections
* Prophylaxis for surgical procedures
## Adult Dosing
* **General Infections:** 1-2 grams IV/IM every 24 hours. Doses up to 4 grams IV/IM daily have been used for severe infections, divided into two doses every 12 hours.
* **Meningitis:** 2 grams IV every 12 hours.
* **Uncomplicated Gonorrhea:** 500 mg IM once. For disseminated gonococcal infection, 1 gram IV/IM every 24 hours for 7 days.
* **Surgical Prophylaxis:** 1-2 grams IV/IM 30-60 minutes prior to incision.
## Pediatric Dosing
Dosing varies significantly by indication and weight. Consult pediatric infectious disease guidelines.
* **Meningitis (≥ 1 month):** 80-100 mg/kg IV per dose every 24 hours, or 50 mg/kg IV every 12 hours. Maximum dose: 4 grams/day.
* **Other Serious Infections (≥ 1 month):** 50-100 mg/kg IV/IM per day, divided every 12-24 hours. Maximum dose: 2 grams/day.
* **Neonates (< 1 month):** Dosing is more complex due to immature hepatic and renal function and risk of kernicterus. Generally, 25-50 mg/kg IV/IM every 24 hours. **AVOID in hyperbilirubinemic neonates.**
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is generally necessary in adults with renal impairment, as ceftriaxone is cleared by both renal and hepatic routes. In severe renal impairment (CrCl < 10 mL/min), maintaining the dose at 2 grams every 24 hours may be considered.
* **Hepatic Impairment:** No dose adjustment is generally necessary.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or other beta-lactam antibiotics.
* **Neonates (especially those receiving calcium-containing IV solutions or requiring transfusions with calcium-containing blood products):** Risk of ceftriaxone-calcium precipitates in the lungs and kidneys, potentially leading to fatal outcomes.
## Adverse Effects
* **Common:** Diarrhea, rash, phlebitis, eosinophilia, thrombocytosis.
* **Serious:** *Clostridioides difficile*-associated diarrhea, hypersensitivity reactions (including anaphylaxis), biliary sludging/cholelithiasis (especially in neonates and prolonged therapy), hemolytic anemia, neutropenia, renal/hepatic abnormalities.
## Key Drug Interactions
* **Aminoglycosides:** Potential for additive nephrotoxicity.
* **Probenecid:** May increase and prolong ceftriaxone levels.
* **Warfarin:** May alter the effect of warfarin; monitor INR.
* **Calcium-containing solutions (IV):** Fatal precipitates can form if mixed or administered concurrently via any route.
## Monitoring
* Signs and symptoms of infection.
* Renal and hepatic function.
* Signs of hypersensitivity.
* For neonates, monitor for signs of precipitation.
* Monitor INR if patient is on warfarin.
## Clinical Pearls
* Administer IV ceftriaxone slowly over 30 minutes to minimize phlebitis.
* Ceftriaxone is generally not recommended for routine empiric treatment of meningitis in neonates due to precipitation risk.
* The incidence of biliary sludging is higher with higher doses and longer durations of therapy. It is usually asymptomatic and resolves after discontinuation of the drug.
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*Always verify current prescribing information with the most up-to-date official product labeling and relevant clinical guidelines.*
