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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 via intravenous or intramuscular routes.
## Primary Indications
* Bacterial meningitis
* Pneumonia
* Skin and soft tissue infections
* Urinary tract infections
* Sepsis
* Gonorrhea
* Pelvic inflammatory disease
* Osseous and joint infections
* Perioperative prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams (g) intravenously (IV) or intramuscularly (IM) every 12 to 24 hours.
* **Serious/Meningitis:** Up to 4 grams IV every 24 hours, often divided as 2 grams every 12 hours.
* **Uncomplicated Gonorrhea:** Single dose of 250 mg IM.
* **Perioperative Prophylaxis:** 1 to 2 g IV 30-60 minutes prior to surgical incision.
Dosing frequency and duration depend on the type and severity of infection. Consult institutional guidelines for specific indications.
## Pediatric Dosing
* **Neonates (0-14 days):** 25 to 50 mg/kg/day IV or IM once daily. Do not exceed 50 mg/kg/day.
* **Neonates (15-28 days):** 25 to 50 mg/kg/day IV or IM once daily, or divided as 12.5 to 25 mg/kg every 12 hours.
* **Children (>28 days):**
* **General Infections:** 50 to 100 mg/kg/day IV or IM once daily or divided as 25 to 50 mg/kg every 12 hours.
* **Serious Infections/Meningitis:** Up to 100 mg/kg/day (maximum 4 g/day) IV or IM divided every 12 to 24 hours.
Dosing is weight-based and may need adjustment for premature infants or those with impaired renal or hepatic function.
## Dose Adjustments
No dose adjustment is typically required for mild to moderate renal impairment. In severe renal impairment (CrCl <10 mL/min), the daily dose may be halved, but dosing interval can remain the same. In patients with hepatic impairment and renal impairment, ceftriaxone doses should not exceed 2 g daily.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates (birth weight <41 weeks postmenstrual age) receiving IV calcium-containing solutions or infusions. This is due to the risk of precipitation of ceftriaxone-calcium.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia.
* **Serious:** *Clostridioides difficile*-associated diarrhea, anaphylaxis, biliary sludging/pseudolithiasis (especially in neonates and with prolonged therapy), cholelithiasis, hemolytic anemia.
## Key Drug Interactions
* **Calcium-containing solutions/products:** Avoid concurrent administration via IV. If unavoidable, administer ceftriaxone first, flush line, then administer calcium product, or vice versa, with adequate flushing between administrations. This is particularly critical in neonates.
* **Aminoglycosides:** Increased risk of nephrotoxicity when used together, especially at higher doses. Monitor renal function.
* **Warfarin:** Ceftriaxone may decrease the effectiveness of warfarin; monitor INR.
* **Probenecid:** May increase ceftriaxone levels.
## Monitoring
* Renal and hepatic function.
* Signs and symptoms of infection resolution.
* Electrolytes, complete blood count, and coagulation parameters, particularly with prolonged therapy or in vulnerable populations.
* Monitor for signs of hypersensitivity reactions.
* For neonates, monitor for signs of biliary precipitation.
## Clinical Pearls
* Ceftriaxone is highly protein-bound and has a long half-life, allowing for once or twice-daily dosing.
* It is a common choice for empiric treatment of community-acquired pneumonia, meningitis, and febrile neutropenia.
* Due to its efficacy and dosing convenience, it is often used for outpatient parenteral antibiotic therapy (OPAT).
* Reconstituted solutions for IM injection should be prepared with lidocaine HCl 1% to reduce injection pain.
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*Please verify current prescribing information and institutional protocols before initiating therapy.*
