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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
* Pneumonia (community-acquired and hospital-acquired)
* Bacterial meningitis
* Sepsis
* Skin and soft tissue infections
* Urinary tract infections
* Gonorrhea and Pelvic Inflammatory Disease
* Lyme disease (early and late disseminated)
* Surgical prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams intravenously or intramuscularly every 12 or 24 hours.
* **Severe Infections:** Up to 4 grams intravenously every 24 hours.
* **Meningitis:** 2 grams intravenously every 12 hours.
* **Uncomplicated Gonorrhea:** 250 mg intramuscularly as a single dose.
* **Surgical Prophylaxis:** 1 to 2 grams intravenously 30-60 minutes before incision.
Dosing depends on the severity of infection and the specific pathogen. Local antibiograms and treatment guidelines should be consulted.
## Pediatric Dosing
* **Neonates (< 28 days):** Dosing varies significantly by gestational and postnatal age. Typically:
* < 7 days: 25-50 mg/kg intravenously or intramuscularly every 48 hours.
* 7-14 days: 25-50 mg/kg intravenously or intramuscularly every 24 hours.
* > 14 days: 50-100 mg/kg intravenously or intramuscularly every 24 hours.
* Maximum daily dose generally 50 mg/kg in neonates.
* **Note:** Ceftriaxone is generally contraindicated in hyperbilirubinemic neonates due to potential for bilirubin displacement from albumin.
* **Children (> 15 days):**
* **General Infections:** 50 to 100 mg/kg intravenously or intramuscularly every 12 to 24 hours.
* **Severe Infections:** Up to 150 mg/kg intravenously per day, divided every 12 hours, not to exceed 4 grams daily.
* **Meningitis:** 100 mg/kg intravenously every 12 hours.
Dosing in children should be based on weight and adjusted for severity of illness and renal/hepatic function. Local pediatric infectious disease guidelines are essential.
## Dose Adjustments
No dose adjustment is typically required for mild to moderate renal or hepatic impairment. However, in severe renal impairment (CrCl < 10 mL/min) *without* concomitant hepatic impairment, the daily dose should not exceed 2 grams. In severe hepatic impairment *without* renal impairment, no adjustment is needed. If both are severely impaired, dosing should be guided by clinical response and drug levels if available.
## Contraindications
* Known hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or other beta-lactam antibiotics.
* Neonates with hyperbilirubinemia, particularly premature infants, due to the risk of kernicterus.
## Adverse Effects
* **Common:** Diarrhea, rash, phlebitis at injection site, eosinophilia, thrombocytosis.
* **Serious:** Anaphylaxis, C. difficile-associated diarrhea, cholelithiasis (biliary sludge formation), pancreatitis, Stevens-Johnson syndrome, aplastic anemia, renal failure.
## Key Drug Interactions
* **Aminoglycosides:** Potential for additive nephrotoxicity, especially when used for severe infections. Monitor renal function.
* **Probenecid:** May increase and prolong ceftriaxone plasma concentrations.
* **Oral anticoagulants (e.g., warfarin):** Ceftriaxone may potentiate the effect of oral anticoagulants. Monitor INR.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for gastrointestinal side effects, including C. difficile infection.
* Monitor renal and hepatic function, especially in patients with pre-existing impairment or those receiving concurrent nephrotoxic agents.
* Monitor INR if co-administered with warfarin.
* Monitor for signs of biliary sludge or cholelithiasis with prolonged use or in pediatric patients.
## Clinical Pearls
* Ceftriaxone can be reconstituted with lidocaine for IM injection to reduce pain; however, lidocaine is contraindicated in neonates.
* Due to its long half-life, ceftriaxone is often dosed every 24 hours for many indications.
* Biliary sludging can occur, especially in children, and may be asymptomatic or mimic cholecystitis. It is usually reversible after discontinuation of the drug.
* If used in neonates, avoid concurrent administration with calcium-containing solutions or products, even through separate IV lines or sites, due to risk of precipitation.
**Disclaimer:** This information is intended for healthcare professionals. Always consult the official prescribing information and local guidelines for the most current and comprehensive drug details.
