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# Ceftriaxone
## Overview
Third-generation cephalosporin with broad-spectrum bactericidal activity. Long half-life permits once-daily dosing for most indications. Available as sodium salt for IM/IV use.
## Primary Indications
- Community-acquired pneumonia
- Meningitis (esp. pneumococcal, meningococcal)
- Gonorrhea (uncomplicated)
- Lyme disease (early disseminated, neurologic)
- Intra-abdominal infections (with metronidazole)
- Septicemia
- Acute bacterial otitis media, sinusitis
## Adult Dosing
- **Usual**: 1–2 g IV/IM once daily.
- **Serious infections (e.g., meningitis)**: 2 g IV every 12 hours.
- **Uncomplicated gonorrhea**: 500 mg IM single dose (250 mg IM per some older guidelines; check local protocol).
- **Maximum daily dose**: 4 g.
## Pediatric Dosing
- **Neonates (≥28 days)**: 50–80 mg/kg IV/IM once daily. **Contraindicated with IV calcium in neonates ≤28 days**.
- **Infants/children**: 50–100 mg/kg IV/IM once daily; maximum 2 g/day.
- **Meningitis**: 100 mg/kg IV once daily (or divided every 12–24 h); maximum 4 g/day.
- **Acute otitis media**: 50 mg/kg IM single dose (max 1 g).
## Dose Adjustments
- **Renal impairment**: No adjustment for CrCl ≥10 mL/min. For CrCl <10 mL/min, maximum 2 g/day.
- **Hepatic impairment**: No specific adjustment; monitor for biliary sludging.
- **Combined renal/hepatic**: Consider reducing dose; use clinical judgment.
## Contraindications
- Hypersensitivity to ceftriaxone or any cephalosporin.
- Severe immediate-type penicillin allergy (e.g., anaphylaxis) – use caution, cross-reactivity low but documented.
- Neonates (≤28 days) receiving intravenous calcium-containing solutions (risk of precipitates in lungs/kidneys).
- Do not mix with calcium-containing IV solutions (including TPN) in any age, but especially contraindicated in neonates.
## Adverse Effects
- **Common**: diarrhea, eosinophilia, elevated liver enzymes, injection site reactions.
- **Serious**: hypersensitivity reactions, C. difficile colitis, biliary pseudolithiasis (sludge/gallstones – reversible), hemolytic anemia (rare), thrombocytopenia, nephrolithiasis (with high doses or prolonged use).
## Key Drug Interactions
- **Ethanol**: disulfiram-like reaction (cephalosporins with NMTT side chain – ceftriaxone lacks it but rare case reports; still advise avoiding alcohol).
- **Calcium-containing IV fluids**: do not administer simultaneously via same line; risk of precipitation. Separate administration by at least 48 hours in neonates.
- **Oral anticoagulants (warfarin)**: may prolong PT/INR; monitor.
- **Live bacterial vaccines (e.g., typhoid)**: may reduce efficacy.
- **Probenecid**: reduces ceftriaxone renal clearance; not usually required.
## Monitoring
- Baseline CBC, renal/hepatic function.
- Signs of hypersensitivity, anaphylaxis.
- Periodic CBC with prolonged therapy (pancytopenia, hemolysis).
- Monitor INR if on warfarin.
- Observe for diarrhea (C. difficile).
## Clinical Pearls
- **IM injection**: reconstitute with lidocaine 1% to reduce pain; do not use lidocaine for IV administration.
- **Biliary sludging**: more common in children, critically ill, or those on high doses; usually reversible after discontinuation.
- **Do not use in hyperbilirubinemic neonates**: ceftriaxone displaces bilirubin from albumin, risk of kernicterus.
- **Ceftriaxone is not active against MRSA, Listeria, or atypical pathogens** (e.g., Legionella, Mycoplasma).
- For meningitis, combine with vancomycin until sensitivities return.
- After reconstitution, store at room temperature for up to 24 hours or refrigerate up to 10 days (check manufacturer).
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*This information is for educational purposes only. Always consult current prescribing information, local protocols, and verify dosing with a reliable drug reference before administration.*
