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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
* Lower respiratory tract infections
* Skin and skin structure infections
* Urinary tract infections
* Complicated intra-abdominal infections
* Bacterial meningitis (including in neonates >28 days)
* Bacterial endocarditis
* Disseminated gonococcal infections
* Prophylaxis for surgical site infections
## Adult Dosing
* **General Infections:** 1 to 2 grams IV/IM every 24 hours.
* **Severe or Life-Threatening Infections:** Up to 4 grams IV every 24 hours, typically administered as 2 grams every 12 hours.
* **Meningitis:** 2 grams IV every 12 hours.
* **Surgical Prophylaxis:** 2 grams IV/IM administered 30-60 minutes prior to incision.
* **Uncomplicated Gonococcal Infections:** 500 mg IM single dose (1 gram IM single dose for disseminated gonococcal infections).
Maximum daily dose in adults is 4 grams.
## Pediatric Dosing
Dosing varies significantly by indication and age/weight. Consult specific pediatric infectious disease guidelines.
* **Neonates (0-14 days):** Generally 25-50 mg/kg IV every 48 hours.
* **Neonates (15-28 days):** Generally 25-50 mg/kg IV every 24 hours.
* **Infants and Children (>28 days):**
* **General Infections:** 50-100 mg/kg/day IV/IM divided every 24 hours.
* **Meningitis:** 80-100 mg/kg/day IV divided every 12-24 hours.
* **Severe or Life-Threatening Infections:** Up to 150 mg/kg/day IV divided every 12-24 hours.
Maximum daily dose in pediatric patients is typically capped at 4 grams.
## Dose Adjustments
* **Renal Impairment:** No dose adjustment is generally required as ceftriaxone undergoes extensive hepatic metabolism. However, in severe renal impairment and hepatic dysfunction, caution and monitoring may be advised.
* **Hepatic Impairment:** No dose adjustment is generally required.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, penicillins, or other beta-lactam antibiotics.
* Use in **hyperbilirubinemic neonates** (especially premature neonates <41 weeks gestational age) due to the risk of bilirubin encephalopathy, particularly with IV administration. Do not mix or administer simultaneously with calcium-containing solutions in neonates.
## Adverse Effects
* **Common:** Diarrhea, nausea, vomiting, rash, eosinophilia, thrombocytosis, leukopenia.
* **Serious:** Anaphylaxis, Clostridioides difficile-associated diarrhea, biliary sludge or pseudolithiasis (especially in neonates and children), acute renal failure, hepatic dysfunction, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Calcium-containing solutions:** Avoid simultaneous administration (IV or sequential) in neonates due to risk of precipitation. In adults, concurrent administration via different IV sites is generally considered safe, but caution is advised.
* **Aminoglycosides:** Potential for additive nephrotoxicity.
* **Warfarin:** May decrease the effect of warfarin; increased INR monitoring is recommended.
* **Probenecid:** May increase and prolong ceftriaxone levels.
## Monitoring
* Signs and symptoms of infection.
* Renal and hepatic function tests, especially in patients with pre-existing impairment or those receiving prolonged therapy.
* Complete blood count.
* Monitor for hypersensitivity reactions.
* Monitor for diarrhea.
## Clinical Pearls
* Ceftriaxone's long half-life allows for once-daily dosing in most adult indications, simplifying therapy.
* Due to the risk of bilirubin displacement and precipitation, ceftriaxone is contraindicated in hyperbilirubinemic neonates.
* Biliary pseudolithiasis is a known phenomenon, particularly in children. If suspected, imaging may be warranted.
* For intramuscular administration, reconstitute according to manufacturer instructions. Lidocaine can be used as a diluent for IM injection to reduce pain, but this is not suitable for IV administration or in pediatric patients under 8 years of age or those with a history of neurological or seizure disorders.
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*Please verify current prescribing information and institutional protocols before use.*
