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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.
## Primary Indications
* Bacterial meningitis (including *Neisseria meningitidis*, *Streptococcus pneumoniae*, *Haemophilus influenzae*)
* Pneumonia
* Skin and soft tissue infections
* Urinary tract infections
* Bone and joint infections
* Sepsis
* Gonorrhea (uncomplicated)
* Surgical prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 24 hours.
* **Severe Infections:** May increase to 4 grams IV every 24 hours, divided into two doses (2 grams every 12 hours).
* **Meningitis:** 2 grams IV every 12 hours.
* **Uncomplicated Gonorrhea:** 250 mg IM as a single dose.
* **Surgical Prophylaxis:** 1 to 2 grams IV 30-60 minutes before surgical incision.
* **Maximum Dose:** 4 grams per day.
## Pediatric Dosing
Dosing varies significantly based on indication, age, and weight. Consult specific pediatric infectious disease guidelines or protocols.
* **General Infections (3 months to 12 years):** 50-100 mg/kg/day IV or IM divided every 12-24 hours.
* **Severe Infections (3 months to 12 years):** Up to 80-100 mg/kg/day IV divided every 8-12 hours.
* **Meningitis (1 month and older):** 100 mg/kg/day IV divided every 12-24 hours.
* **Neonates (birth to 28 days):** Dosing and frequency are critical due to risk of kernicterus. Typically 25-50 mg/kg/day IV or IM divided every 24-48 hours. **Ceftriaxone is contraindicated in neonates >41 weeks gestation or premature neonates with hyperbilirubinemia.**
* **Maximum Dose:** 4 grams per day.
## Dose Adjustments
No dose adjustment is typically required for renal or hepatic impairment due to its unique elimination pathway. However, caution is advised in severe hepatic and renal dysfunction.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates (gestation ≤41 weeks) receiving IV calcium-containing solutions or infusions.
* Neonates with hyperbilirubinemia.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, injection site reactions (pain, phlebitis).
* **Serious:** *Clostridioides difficile*-associated diarrhea, anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis, biliary sludge or pseudolithiasis, hematologic abnormalities (eosinophilia, leukopenia, thrombocytopenia).
## Key Drug Interactions
* **Calcium-containing solutions/infusions (IV):** Ceftriaxone can precipitate with calcium, especially in neonates. Avoid concurrent administration, even via separate lines, in neonates. In adults, careful Y-site compatibility and flushing procedures are necessary.
* **Aminoglycosides:** Potential for increased nephrotoxicity, though not consistently demonstrated with ceftriaxone.
* **Warfarin:** Ceftriaxone may decrease the effect of warfarin; monitor INR.
* **Probenecid:** May increase and prolong ceftriaxone levels.
## Monitoring
* Monitor for signs and symptoms of allergic reaction.
* Monitor for diarrhea, especially if severe or persistent.
* Monitor renal and liver function, and complete blood count periodically, especially with prolonged therapy or in patients with pre-existing abnormalities.
* Monitor for signs of secondary infections.
## Clinical Pearls
* Ceftriaxone is often administered once daily due to its long half-life.
* Reconstitute with appropriate diluent (e.g., sterile water for injection, bacteriostatic water for injection, normal saline). Do not use lidocaine for IV administration in neonates.
* Intramuscular administration can be painful; consider adding lidocaine (for adults only and not for IV).
* Ceftriaxone is a common cause of biliary sludge/pseudolithiasis, which is typically transient and asymptomatic.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the official prescribing information and current clinical guidelines for complete details and to verify dosing and safety information before prescribing or administering any medication.
