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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
* Bacterial meningitis
* Pneumonia
* Skin and soft tissue infections
* Urinary tract infections
* Sepsis
* Gonorrhea
* Perioperative prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 24 hours.
* **Severe Infections:** Up to 4 grams IV every 24 hours, typically divided into two doses (2 grams every 12 hours), though once-daily dosing is common and often effective for many severe infections.
* **Meningitis:** 2 grams IV every 12 hours.
* **Gonorrhea:** 250 mg IM as a single dose.
* **Perioperative Prophylaxis:** 1 to 2 grams IV 30-60 minutes before surgical incision.
## Pediatric Dosing
* **Neonates (0-14 days):** 25 to 50 mg/kg IV every 24 hours. Maximum 50 mg/kg/day.
* **Neonates (15-28 days) and Infants/Children:** 50 to 100 mg/kg IV or IM once daily. Maximum 2 grams/day.
* **Meningitis (Patients > 6 weeks):** 100 mg/kg/day IV, divided every 12 hours. Maximum 4 grams/day.
* **Note:** Dosing in neonates requires careful consideration due to immature hepatic and renal function. Higher doses may be used for specific severe infections, guided by clinical response and susceptibility.
## Dose Adjustments
No dose adjustment is generally required for renal impairment. However, in severe renal impairment (CrCl < 10 mL/min) not undergoing dialysis, the recommended maximum dose is 2 grams every 24 hours.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or any component of the formulation.
* Neonates (gestational age ≤ 41 weeks) receiving IV calcium-containing solutions or infusions. Concurrent administration of ceftriaxone and calcium-containing solutions in neonates can lead to fatal precipitation of ceftriaxone-calcium salt in the lungs and kidneys.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia.
* **Serious:** Anaphylaxis, Clostridioides difficile-associated diarrhea (CDAD), biliary pseudolithiasis (especially in children), hemolytic anemia, renal failure, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Calcium-containing solutions:** Contraindicated in neonates. In adults, caution is advised due to risk of precipitation. Separate administration by at least 48 hours if both are necessary.
* **Warfarin:** Ceftriaxone may decrease the effect of warfarin, potentially leading to increased INR. Monitor INR closely.
* **Aminoglycosides:** Increased risk of nephrotoxicity and ototoxicity, especially with prolonged or high-dose therapy.
* **Probenecid:** May increase and prolong ceftriaxone plasma concentrations.
## Monitoring
* Signs and symptoms of infection.
* Renal and hepatic function, especially in patients with pre-existing impairment or those receiving other nephrotoxic/hepatotoxic agents.
* Complete blood count (CBC) for potential hematologic changes.
* Signs of hypersensitivity reactions.
* Biliary sludge formation (consider ultrasound if symptoms develop).
## Clinical Pearls
* Ceftriaxone is often the preferred agent for empiric treatment of community-acquired pneumonia and meningitis due to its broad spectrum and favorable pharmacokinetic profile allowing for once-daily dosing.
* It is commonly used for disseminated gonococcal infections and Lyme disease.
* Due to its high protein binding, it is generally not recommended for empiric treatment of neutropenic fever in high-risk patients where rapid attainment of adequate tissue concentrations is critical.
* When reconstituting, use appropriate diluent (e.g., sterile water for injection, bacteriostatic water for injection, 0.9% sodium chloride) as per manufacturer guidelines. Intramuscular injection is often reconstituted with 1% lidocaine HCl.
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**Disclaimer:** This information is intended for healthcare professionals. Always verify current prescribing information and local institutional protocols before administering any medication.
