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# Cefriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic with broad-spectrum activity against many Gram-positive and Gram-negative bacteria.
## Primary Indications
* Bacterial meningitis (including *Neisseria meningitidis*, *Haemophilus influenzae*, and *Streptococcus pneumoniae*)
* Pneumonia
* Skin and soft tissue infections
* Urinary tract infections
* Intra-abdominal infections
* Septicemia
* Gonorrhea (uncomplicated)
* Prophylaxis for surgical site infections
## Adult Dosing
* **General infections:** 1-2 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 as a single dose. For disseminated gonococcal infection, 1 gram IV/IM every 24 hours.
* **Surgical prophylaxis:** 1-2 grams IV within 60 minutes prior to incision.
Dosing frequency and duration are dependent on the site and severity of infection, as well as pathogen susceptibility.
## Pediatric Dosing
* **Neonates (0-14 days):** 25-50 mg/kg IV/IM every 24 hours. Avoid in hyperbilirubinemic neonates.
* **Neonates (15-28 days):** 50-100 mg/kg IV/IM every 24 hours.
* **Infants and Children (> 28 days to 12 years):**
* **General infections:** 50-100 mg/kg IV/IM every 24 hours.
* **Severe infections:** Up to 80-100 mg/kg/day IV, divided every 12 hours. Maximum daily dose is typically capped at 2 grams, but may be higher (up to 4 grams) for severe infections like meningitis, per institutional guidelines.
* **Meningitis:** 80-100 mg/kg/day IV, divided every 12 hours. Maximum daily dose typically capped at 4 grams.
* **Children > 12 years:** Dosing is generally the same as adults.
Specific pediatric dosing may vary based on indication and local protocols.
## Dose Adjustments
* **Renal impairment:** No dose adjustment is generally required for adults or children due to extensive hepatic and biliary excretion. However, caution is advised in severe renal impairment, and monitoring may be considered.
* **Hepatic impairment:** No dose adjustment is generally required.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* Neonates with hyperbilirubinemia, particularly premature neonates.
* Concurrent administration of IV calcium-containing solutions with ceftriaxone in neonates.
## Adverse Effects
Common: Diarrhea, rash, phlebitis at the injection site.
Less Common: Nausea, vomiting, abdominal pain, eosinophilia, leukopenia, thrombocytopenia, elevated liver enzymes, headache.
Rare: Anaphylaxis, *Clostridioides difficile*-associated diarrhea, biliary pseudolithiasis (especially in children), renal injury, Stevens-Johnson syndrome.
## Key Drug Interactions
* **Aminoglycosides:** Potential for increased nephrotoxicity.
* **Warfarin:** Ceftriaxone may decrease the effect of warfarin, requiring increased monitoring of INR.
* **Probenecid:** May increase and prolong ceftriaxone levels.
* **Calcium-containing solutions:** Do not mix or administer ceftriaxone simultaneously with IV calcium solutions, especially in neonates, due to risk of precipitation.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for diarrhea and signs of *C. difficile* infection.
* Monitor for signs of superinfection.
* Monitor renal and hepatic function, especially in patients with pre-existing impairment or receiving concurrent nephrotoxic agents.
* Monitor coagulation parameters if used with warfarin.
* Monitor for evidence of treatment failure or relapse.
## Clinical Pearls
* Ceftriaxone can be administered IV or IM. IM injection may be painful.
* It is a common choice for empirical treatment of many community-acquired and hospital-acquired infections.
* Due to its long half-life, it can often be dosed once daily.
* Ceftriaxone can cause biliary pseudolithiasis (sludge) and gallstones, particularly in pediatric patients. This is usually reversible upon discontinuation of the drug.
* Do not use in neonates with hyperbilirubinemia due to risk of bilirubin encephalopathy.
* Ensure adequate hydration to minimize the risk of crystalluria.
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*Disclaimer: This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and relevant clinical guidelines for complete and up-to-date details before making any clinical decisions.*
