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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:** Moderate to severe.
* **Hospital-acquired pneumonia:**
* **Bacterial meningitis:**
* **Sepsis:**
* **Skin and soft tissue infections:**
* **Urinary tract infections:** Complicated and uncomplicated.
* **Intra-abdominal infections:**
* **Pelvic inflammatory disease:**
* **Gonococcal infections:** Uncomplicated anogenital, rectal, and pharyngeal gonorrhea.
* **Lyme disease:** Early and late disseminated stages.
* **Surgical prophylaxis:**
## Adult Dosing
* **General infections:** 1 to 2 grams intravenously (IV) or intramuscularly (IM) every 12 or 24 hours.
* **Severe infections:** Up to 4 grams IV every 24 hours.
* **Meningitis:** 2 grams IV every 12 hours.
* **Uncomplicated gonorrhea:** 500 mg IM single dose. (For disseminated gonococcal infection, dosing may be higher and for longer duration, consult specific guidelines).
* **Surgical prophylaxis:** 1 to 2 grams IV 30-60 minutes prior to incision.
Dosing frequency and duration depend on the infection site, severity, and pathogen.
## Pediatric Dosing
* **Neonates (0-14 days):** 25-50 mg/kg IV every 24 hours. Maximum 50 mg/kg/day. Do not exceed adult single dose.
* **Neonates (15-28 days):** 25-50 mg/kg IV every 24 hours, or every 12 hours for severe infections.
* **Children (> 15 days to 12 years):**
* **General infections:** 50-100 mg/kg/day IV or IM divided every 12 or 24 hours.
* **Severe infections:** Up to 150 mg/kg/day IV divided every 8-12 hours. Maximum 4 grams/day.
* **Meningitis:** 100 mg/kg/day IV divided every 12 hours. Maximum 4 grams/day.
* **Uncomplicated gonorrhea:** 125 mg IM single dose.
Higher doses may be required for specific indications (e.g., meningitis) or in patients with impaired elimination. Consult pediatric infectious disease guidelines for specific indications.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is generally needed in adults due to high biliary excretion. However, in severe renal impairment with concurrent hepatic dysfunction, caution and monitoring may be warranted.
* **Hepatic Impairment:** No dose adjustment is generally needed due to significant renal excretion.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or any component of the formulation.
* Concurrent use with intravenous calcium-containing solutions in neonates due to the risk of precipitation in the lungs and kidneys.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia.
* **Serious:**
* **Anaphylaxis:**
* **Clostridioides difficile-associated diarrhea (CDAD):**
* **Biliary sludging/pseudolithiasis:** Especially in neonates and prolonged therapy.
* **Hemolytic anemia:**
* **Seizures:** (rare, typically with high doses).
## Key Drug Interactions
* **Aminoglycosides:** Increased risk of nephrotoxicity when used concurrently.
* **Warfarin:** Ceftriaxone may alter INR. Monitor INR closely.
* **Probenecid:** May increase and prolong ceftriaxone plasma concentrations.
* **Calcium-containing solutions:** Contraindicated in neonates (see Contraindications). In adults, separate administration by at least 48 hours or flush lines meticulously.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for signs and symptoms of CDAD.
* Monitor CBC, renal, and liver function tests periodically, especially with prolonged therapy or in patients with impaired organ function.
* Monitor for biliary sludge formation, especially in neonates and those on prolonged treatment.
## Clinical Pearls
* Ceftriaxone has a long half-life, allowing for once or twice-daily dosing in many cases.
* It is a preferred agent for empiric treatment of meningitis, pneumonia, and sepsis in many settings.
* Due to potential for biliary sludging, prolonged use in neonates should be carefully considered and alternatives may be preferred if possible.
* Always reconstitute and dilute according to manufacturer instructions.
* IM injections may cause pain; consider lidocaine for reconstitution if available and appropriate.
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**Disclaimer:** This information is intended for healthcare professionals. Always consult the most current prescribing information, institutional protocols, and patient-specific factors before making clinical decisions.
