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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic with broad-spectrum activity against Gram-positive and Gram-negative bacteria. It has a long half-life, allowing for once-daily dosing. It is excreted via both hepatic and renal routes.
## Primary Indications
* Community-acquired pneumonia
* Meningitis (often in combination with vancomycin)
* Gonococcal infections
* Complicated intra-abdominal infections
* Pyelonephritis and complicated urinary tract infections
* Skin and soft tissue infections
* Surgical prophylaxis
## Adult Dosing
* **General infections:** 1–2 g IV/IM every 24 hours.
* **Meningitis:** 2 g IV every 12 hours.
* **Uncomplicated Gonorrhea:** 500 mg IM (1 g if weight ≥150 kg) as a single dose.
* **Maximum dose:** Typically 2 g per dose; up to 4 g/day may be used in severe infections (e.g., meningitis).
## Pediatric Dosing
* **General infections:** 50–75 mg/kg/day IV/IM divided every 12–24 hours.
* **Meningitis:** 100 mg/kg/day IV divided every 12 hours (maximum 4 g/day).
* **Gonorrhea (neonatal):** 25–50 mg/kg IV/IM as a single dose.
* **Note:** Avoid in neonates (≤28 days) if requiring calcium-containing IV solutions due to risk of precipitation.
## Dose Adjustments
* **Renal/Hepatic:** No adjustment required for mild-to-moderate impairment. When severe renal and hepatic impairment coexist, monitor serum concentrations.
* **Elderly:** No routine adjustment needed.
## Contraindications
* Hypersensitivity to cephalosporins.
* **Neonates (≤28 days):** Do not administer with calcium-containing IV solutions, including total parenteral nutrition (TPN), due to the risk of ceftriaxone-calcium salt precipitation in the lungs and kidneys.
## Adverse Effects
* **Common:** Injection site reactions (if IM), diarrhea, rash.
* **Serious:** Biliary sludge/pseudolithiasis (often reversible), Clostridioides difficile-associated diarrhea, hemolytic anemia, anaphylaxis.
## Key Drug Interactions
* **Calcium-containing products:** Absolute contraindication in neonates; in adults, ensure separate IV lines or flush lines thoroughly between administrations.
* **Oral Contraceptives:** Potential for reduced efficacy (rare, but counseling is advised for long-term courses).
* **Warfarin:** May increase INR; monitor closely during therapy.
## Monitoring
* Baseline and periodic assessment of renal and hepatic function in prolonged therapy.
* Monitor for signs of *C. difficile* (persistent diarrhea).
* Monitor INR if patient is on warfarin.
* Assess for biliary symptoms (RUQ pain) in extended therapy.
## Clinical Pearls
* **Biliary Sludge:** Ceftriaxone is excreted primarily through bile; prolonged use can lead to biliary sludge or stones, which usually resolve upon discontinuation.
* **IM Administration:** If administering 1 g or greater, consider splitting doses or using 1% lidocaine for reconstitution to reduce pain (per local pharmacy protocol).
* **Not for Enterococcus:** Ceftriaxone lacks activity against *Enterococcus* species.
* **Spectrum:** While it has superior Gram-negative coverage, it is less active against *Staphylococcus aureus* than first-generation cephalosporins (e.g., cefazolin).
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**Educational Disclaimer:** This information is for educational purposes only. Clinical guidelines and local antimicrobial stewardship protocols may vary based on institutional susceptibility patterns. Always verify specific dosing, safety, and compatibility with current hospital-approved references and prescribing information before administration.
