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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 (CAP):** Often used as empiric therapy. * **Bacterial meningitis:** Including *Neisseria meningitidis*, *Streptococcus pneumoniae*, and *Haemophilus influenzae*. * **Sepsis:** As part of empiric or targeted therapy. * **Disseminated gonococcal infection:** Including gonococcal meningitis and endocarditis. * **Pelvic inflammatory disease (PID):** Often in combination with other agents. * **Uncomplicated urinary tract infections (UTIs).** * **Prophylaxis** for surgical site infections. ## Adult Dosing * **General Infections:** 1 to 2 grams IV or IM every 24 hours. Higher doses (up to 4 grams daily) may be used for severe infections, divided every 12 hours. * **Meningitis:** 2 grams IV every 12 hours. * **Disseminated Gonococcal Infection:** 500 mg IM or IV once. For disseminated gonococcal infection with complications (e.g., meningitis, endocarditis), 1 gram IV every 24 hours for 10-14 days (meningitis) or at least 4 weeks (endocarditis). * **Surgical Prophylaxis:** 1 to 2 grams IV or IM 30-60 minutes before incision. Maximum daily dose: 4 grams. ## Pediatric Dosing Dosing varies significantly by indication and age. Consult specific pediatric guidelines or institutional protocols. * **General Infections (≤ 125 mg/kg/day, max 2g/day):** * **Neonates (0-14 days):** 25-50 mg/kg IV every 24 hours. * **Neonates (15-28 days):** 25-50 mg/kg IV every 24 hours, or potentially every 12 hours if weight-based dosing requires it. **Note:** Due to risk of kernicterus, ceftriaxone is generally contraindicated in hyperbilirubinemic neonates and should be avoided in premature neonates. * **Infants and Children (> 28 days):** 50-100 mg/kg/day IV or IM divided every 12-24 hours. * **Meningitis:** 100 mg/kg/day IV divided every 12 hours (max 4g/day). * **Disseminated Gonococcal Infection:** 125 mg IM or IV once. **Important Note:** Concurrent use with IV calcium-containing solutions is contraindicated in neonates due to risk of precipitate formation. ## Dose Adjustments * **Renal Impairment:** No dose adjustment is typically necessary as ceftriaxone is largely eliminated by non-renal mechanisms (biliary excretion). * **Hepatic Impairment:** No dose adjustment is typically necessary. ## Contraindications * Known hypersensitivity to ceftriaxone, other cephalosporins, or penicillins. * Neonates with hyperbilirubinemia, especially premature neonates. * Concurrent administration of IV calcium-containing solutions in neonates. ## Adverse Effects * **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia. * **Serious:** * *Clostridioides difficile*-associated diarrhea (CDAD). * Biliary pseudolithiasis (sludge formation) and cholecystitis, particularly in children. * Anaphylaxis. * Hemolytic anemia. * Seizures (rare). ## Key Drug Interactions * **Aminoglycosides:** Potential for additive nephrotoxicity, though data is mixed. Monitor renal function. * **Warfarin:** Ceftriaxone may decrease the effect of warfarin. Monitor INR closely and adjust warfarin dose as needed. * **Probenecid:** May increase ceftriaxone levels. * **Calcium-containing solutions:** As noted above, **contraindicated** in neonates. In adults, caution is advised, especially with IV administration. ## Monitoring * Signs and symptoms of infection. * Renal and hepatic function, particularly in patients with pre-existing impairment or receiving concurrent nephrotoxic agents. * Signs of hypersensitivity reactions. * For biliary pseudolithiasis: monitor for abdominal pain, jaundice, or signs of cholecystitis if symptoms arise. ## Clinical Pearls * Ceftriaxone's long half-life allows for once-daily dosing in many situations. * It readily crosses the blood-brain barrier, making it a preferred agent for bacterial meningitis. * Reconstituted solutions are stable for varying durations depending on the diluent and storage temperature; check manufacturer's recommendations. * IM administration can be painful; consider lidocaine as a diluent if appropriate and not contraindicated. *** *This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional guidelines before initiating therapy.*