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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
* Lower respiratory tract infections (e.g., pneumonia)
* Skin and soft tissue infections
* Urinary tract infections, including pyelonephritis
* Bacterial meningitis (adjunct or primary therapy depending on pathogen)
* Sepsis
* Bone and joint infections
* Gonorrhea (disseminated and uncomplicated)
* Pelvic inflammatory disease
* Perioperative prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 24 hours.
* **Severe Infections/Meningitis:** Up to 4 grams IV every 24 hours, usually as 2 grams every 12 hours.
* **Uncomplicated Gonorrhea:** 500 mg IM as a single dose.
* **Disseminated Gonococcal Infection:** 1 gram IV or IM every 24 hours for 7 days.
* **Surgical Prophylaxis:** 1 to 2 grams IV within 60 minutes prior to incision.
Maximum daily dose generally should not exceed 4 grams.
## Pediatric Dosing
Dosing is weight-based and varies by indication. Consult specific pediatric guidelines.
* **Serious Infections (including meningitis):** 80 to 100 mg/kg/day IV or IM divided every 12 to 24 hours. Maximum daily dose is 4 grams.
* **Uncomplicated Gonorrhea:** 125 mg IM as a single dose.
* **Neonates (0-14 days):** 25 to 50 mg/kg/day IV or IM divided every 24 hours.
* **Neonates (15-28 days) and Infants < 40 kg:** 50 to 75 mg/kg/day IV or IM divided every 24 hours.
**Note:** Higher doses in neonates may be associated with bilirubin displacement and kernicterus; avoid use in hyperbilirubinemic neonates.
## Dose Adjustments
No dose adjustment is generally required in mild to moderate hepatic or renal impairment. In severe renal impairment (CrCl < 10 mL/min) not undergoing dialysis, the daily dose should not exceed 2 grams.
## Contraindications
* Known hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Use in neonates (especially premature and those with hyperbilirubinemia) with IV calcium-containing solutions due to risk of precipitation.
## Adverse Effects
Common: Diarrhea, nausea, vomiting, rash, phlebitis at injection site, eosinophilia, thrombocytosis, leukopenia.
Serious: *Clostridioides difficile*-associated diarrhea, biliary sludge/cholelithiasis, hemolytic anemia (rare), anaphylaxis, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Aminoglycosides:** Potential for increased nephrotoxicity, although synergy can occur in some serious infections. Monitor renal function.
* **Oral anticoagulants (e.g., warfarin):** May enhance the effect of oral anticoagulants. Monitor INR.
* **Probenecid:** Can increase and prolong ceftriaxone levels.
* **Calcium-containing solutions:** Do not mix or administer concurrently with IV calcium-containing solutions in any patient, especially neonates, due to risk of fatal precipitation in lungs and kidneys. Separate administration by at least 48 hours.
## Monitoring
* Assess for signs and symptoms of infection.
* Monitor for allergic reactions.
* Monitor renal and hepatic function, particularly with prolonged therapy or in patients with pre-existing impairment.
* Monitor for diarrhea, especially *C. difficile*.
* Monitor INR if patient is on oral anticoagulants.
## Clinical Pearls
* Ceftriaxone's long half-life allows for once-daily dosing in most adult indications.
* The 2-gram IV dose in adults is often reconstituted with lidocaine for IM administration to reduce pain; ensure compatibility and patient has no allergy to lidocaine.
* Biliary sludging is a common, usually asymptomatic, finding. If symptomatic, management may involve discontinuation of ceftriaxone or temporary discontinuation.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and institutional protocols before administering any medication. Dosing and recommendations may vary.*
