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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 has a long half-life, allowing for once-daily dosing.
## Primary Indications
* Bacterial meningitis (including *Neisseria meningitidis*, *Haemophilus influenzae*, *Streptococcus pneumoniae*)
* Pneumonia (community-acquired and hospital-acquired)
* Skin and soft tissue infections
* Urinary tract infections
* Sepsis
* Gonorrhea (uncomplicated)
* Pelvic inflammatory disease
* Surgical prophylaxis
## Adult Dosing
* **General Infections:** 1 to 2 grams intravenously or intramuscularly every 24 hours.
* **Severe Infections:** Up to 4 grams intravenously every 24 hours, often divided every 12 hours.
* **Meningitis:** 2 grams intravenously every 12 hours.
* **Surgical Prophylaxis:** 1 to 2 grams intravenously 30-60 minutes before incision.
* **Uncomplicated Gonorrhea:** 500 mg intramuscularly as a single dose. For disseminated gonococcal infection, consult specific guidelines, often 1 gram IV/IM every 24 hours.
## Pediatric Dosing
Dosing in neonates and pediatric patients requires careful consideration of weight and age. Consult specific pediatric guidelines or institutional protocols. General pediatric dosing is as follows:
* **Neonates (≤ 7 days):** 25-50 mg/kg intravenously or intramuscularly every 24 hours. Do not exceed 50 mg/kg/day.
* **Neonates (> 7 days) and Children:** 50-100 mg/kg intravenously or intramuscularly every 24 hours.
* **Severe Infections/Meningitis:** Up to 100 mg/kg intravenously every 12-24 hours. Do not exceed 4 grams per day.
## Dose Adjustments
No dose adjustment is typically required for renal impairment, as ceftriaxone is primarily eliminated by hepatic metabolism. However, in severe hepatic impairment, doses may need to be adjusted based on clinical response and antibiotic levels, though this is uncommon.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates (birth to 28 days) receiving intravenous calcium-containing solutions or infusions due to risk of precipitation in the lungs and kidneys.
## Adverse Effects
* **Common:** Diarrhea, rash, eosinophilia, thrombocytosis, leukopenia, elevated liver enzymes (AST/ALT), injection site reactions.
* **Serious:** *Clostridioides difficile*-associated diarrhea, hemolytic anemia, biliary sludging (especially in neonates), anaphylaxis, seizures (rare).
## Key Drug Interactions
* **Aminoglycosides:** Potential for increased nephrotoxicity when used together, especially in patients with renal dysfunction.
* **Probenecid:** May increase and prolong ceftriaxone serum levels.
* **Warfarin:** Ceftriaxone may potentiate the effect of warfarin. Monitor INR closely.
* **Calcium-containing solutions:** Contraindicated for IV coadministration, especially in neonates, due to risk of fatal precipitate formation.
## Monitoring
* Signs and symptoms of infection.
* Renal and hepatic function (baseline and periodically if indicated).
* Complete blood count (CBC) if prolonged therapy.
* INR if patient is on warfarin.
* Bilirubin and liver function in neonates.
## Clinical Pearls
* Ceftriaxone is not recommended for empiric treatment of *Listeria monocytogenes* meningitis due to insufficient CNS penetration.
* Intramuscular administration is often less painful when reconstituted with 1% lidocaine hydrochloride (without epinephrine).
* Ensure adequate hydration in patients receiving high doses to minimize risk of crystalluria.
* Dosing for specific indications like endocarditis or osteomyelitis may vary and require consultation with infectious disease specialists or adherence to established institutional protocols.
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*Please verify current prescribing information and institutional guidelines before administration.*
