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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
* **Serious bacterial infections:** Including pneumonia, meningitis, sepsis, intra-abdominal infections, and bone and joint infections.
* **Community-acquired pneumonia (CAP):** Often a first-line agent.
* **Bacterial meningitis:** Especially in children and adults.
* **Disseminated gonococcal infections.**
* **Lyme disease:** Particularly neuroborreliosis and Lyme arthritis.
* **Surgical prophylaxis.**
## Adult Dosing
* **General infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 12 to 24 hours.
* **Severe infections:** Up to 4 grams IV daily, divided every 12 hours.
* **Meningitis:** 2 grams IV every 12 hours. Duration varies based on pathogen.
* **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 to 60 minutes prior to incision.
Dosing frequency and duration should be guided by the severity of infection, pathogen susceptibility, and clinical response. Local protocols may dictate specific dosing for certain indications.
## Pediatric Dosing
* **Neonates (0-14 days):** 25 to 50 mg/kg IV or IM every 24 hours. Avoid in hyperbilirubinemic neonates.
* **Neonates (15-28 days):** 50 mg/kg IV or IM every 24 hours.
* **Children (>28 days to 12 years):** 50 to 100 mg/kg IV or IM daily, not to exceed 2 grams daily.
* **Children (>12 years):** Dosing as per adult guidelines.
* **Meningitis (pediatric):** 100 mg/kg IV daily, not to exceed 4 grams daily, divided every 12 to 24 hours.
Dosing in pediatric patients should be guided by weight and clinical indication.
## Dose Adjustments
No dose adjustment is necessary for renal impairment. Ceftriaxone is primarily eliminated by hepatic metabolism and biliary excretion. In severe hepatic impairment, caution may be warranted, but dose reduction is typically not required.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates with hyperbilirubinemia or those receiving calcium-containing IV solutions.
## Adverse Effects
Common adverse effects include diarrhea, nausea, vomiting, rash, phlebitis at the injection site, eosinophilia, and thrombocytosis. Less common but serious adverse effects include severe allergic reactions, Clostridioides difficile-associated diarrhea, biliary sludging (especially in neonates), and hematologic abnormalities.
## Key Drug Interactions
* **Calcium-containing solutions:** Coadministration can lead to precipitation of ceftriaxone-calcium in the lungs and kidneys, particularly in neonates. Do not mix or administer ceftriaxone and calcium-containing solutions simultaneously via any route, including Y-sites.
* **Aminoglycosides:** Potential for additive nephrotoxicity or ototoxicity, although this is debated.
* **Warfarin:** Ceftriaxone may reduce the effect of warfarin; monitor INR.
* **Probenecid:** May increase ceftriaxone levels.
## Monitoring
* Monitor for signs and symptoms of allergic reaction.
* Assess for gastrointestinal side effects, including diarrhea.
* Monitor renal and hepatic function, especially with prolonged therapy or in patients with pre-existing impairment.
* Consider CBC and liver function tests periodically.
* Monitor for signs of superinfection.
## Clinical Pearls
* Ceftriaxone has a long half-life, allowing for once or twice daily dosing, which can improve adherence.
* It is well-suited for outpatient parenteral antibiotic therapy (OPAT) due to its dosing interval and availability for IM administration.
* Biliary sludging is a common, usually transient, finding, particularly in children. It is typically asymptomatic and resolves after discontinuation of the drug.
* When reconstituting, follow manufacturer instructions for diluent and volume. Reconstituted solutions should be used promptly or stored as recommended due to potential degradation.
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*Please verify current prescribing information and institutional protocols for the most up-to-date dosing and safety recommendations.*
