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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
* Bacterial meningitis
* Pneumonia (community-acquired and hospital-acquired)
* Skin and soft tissue infections
* Urinary tract infections
* Sepsis
* Gonorrhea
* Pelvic inflammatory disease
* Intra-abdominal infections
* Surgical prophylaxis
## Adult Dosing
* **General Infections:** 1-2 grams intravenously (IV) or intramuscularly (IM) every 24 hours.
* **Severe Infections:** Doses up to 4 grams IV daily, divided into two doses (2 grams every 12 hours).
* **Meningitis:** 2 grams IV every 12 hours.
* **Surgical Prophylaxis:** 1-2 grams IV or IM given 30-60 minutes prior to incision.
* **Gonorrhea:** 250 mg IM as a single dose.
## Pediatric Dosing
* **Neonates (0-14 days):** 25-50 mg/kg IV or IM every 24 hours. Do not exceed 50 mg/kg/day.
* **Neonates (15-28 days) and Children < 12 years:** 50-100 mg/kg IV or IM every 24 hours. Divide into two doses (25-50 mg/kg every 12 hours) for moderate to severe infections. Maximum daily dose is 4 grams.
* **Children ≥ 12 years:** Dosing as per adults.
* **Bacterial Meningitis (Pediatric):** 100 mg/kg IV daily, divided into two doses (50 mg/kg every 12 hours). Maximum daily dose is 4 grams.
* **Note:** Ceftriaxone is contraindicated in neonates ≤ 28 days if receiving concurrent IV calcium-containing solutions or infusions.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is typically necessary due to significant biliary excretion. However, caution and close monitoring are advised in severe renal impairment.
* **Hepatic Impairment:** No dose adjustment is typically necessary due to significant renal excretion. However, caution and close monitoring are advised in severe hepatic impairment.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates (≤ 28 days) receiving intravenous calcium-containing solutions or infusions.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, phlebitis at injection site.
* **Serious:** *Clostridioides difficile*-associated diarrhea, hypersensitivity reactions (including anaphylaxis), Stevens-Johnson syndrome, toxic epidermal necrolysis, hepatic dysfunction, biliary sludging, hematologic abnormalities (eosinophilia, leukopenia, hemolytic anemia), seizures (rare).
## Key Drug Interactions
* **Aminoglycosides:** Potential for increased nephrotoxicity, particularly in patients with renal impairment.
* **Warfarin:** Ceftriaxone may decrease the effect of warfarin, leading to increased INR. Monitor INR closely.
* **Probenecid:** May increase ceftriaxone levels.
* **Calcium-containing solutions/infusions:** Contraindicated in neonates. Avoid concurrent administration in all patients, especially in young infants, due to risk of precipitates. If concurrent administration is necessary, administer separately and flush lines.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for signs and symptoms of *C. difficile* infection.
* Assess renal and hepatic function periodically, especially in patients with pre-existing impairment or those receiving prolonged therapy.
* Monitor CBC for hematologic abnormalities.
* Observe injection sites for signs of phlebitis.
* Monitor for biliary sludging, particularly in neonates and children.
## Clinical Pearls
* Ceftriaxone can be administered IM without lidocaine in children if lidocaine is unavailable, but it may be painful.
* Biliary sludging can occur and is usually asymptomatic, resolving after discontinuation. However, it can mimic cholecystitis.
* Due to its long half-life, ceftriaxone is often dosed once daily for many indications, improving patient adherence.
* For moderate to severe infections, splitting the daily dose every 12 hours may be preferred.
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*This information is intended for healthcare professionals. Always consult the current prescribing information and relevant clinical guidelines before making any treatment decisions.*
