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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic that inhibits bacterial cell wall synthesis. It has a long half-life (approximately 8 hours), allowing for once-daily dosing. It is highly protein-bound and undergoes dual biliary and renal excretion.
## Primary Indications
* Community-acquired pneumonia
* Meningitis (empiric coverage)
* Gonorrhea (uncomplicated urogenital/rectal/pharyngeal)
* Intra-abdominal infections (in combination with metronidazole)
* Pyelonephritis and urinary tract infections
* Skin and soft tissue infections
* Acute otitis media (as a salvage agent)
## Adult Dosing
* **Standard infections:** 1–2 g IV/IM every 24 hours.
* **Meningitis:** 2 g IV every 12 hours (loading dose 2–4 g).
* **Uncomplicated Gonorrhea:** 500 mg IM (as a single dose); 1 g if body weight ≥150 kg.
* **Maximum:** 4 g/day (up to 2 g/dose).
## Pediatric Dosing
* **General infections:** 50–75 mg/kg once daily (max 2 g/day).
* **Meningitis:** 100 mg/kg/day divided every 12 hours (max 4 g/day).
* **Acute Otitis Media:** 50 mg/kg IM as a single dose (max 1 g).
* **Neonates (≤28 days):** 50 mg/kg once daily. Avoid in neonates with hyperbilirubinemia or those requiring calcium-containing IV solutions.
## Dose Adjustments
* **Renal Impairment:** No dosage adjustment indicated for mild-to-severe impairment, provided hepatic function is intact.
* **Hepatic Impairment:** Reduce dose in severe concomitant hepatic AND renal impairment; monitor serum concentrations.
## Contraindications
* Hypersensitivity to cephalosporins or severe hypersensitivity to penicillin (risk of cross-reactivity).
* **Neonates (≤28 days):** Contraindicated if receiving calcium-containing IV products due to the risk of ceftriaxone-calcium precipitates in the lungs and kidneys.
## Adverse Effects
* Eosinophilia and thrombocytosis.
* Biliary sludge or pseudolithiasis (associated with long-term use).
* Injection site reactions (pain/induration).
* *Clostridioides difficile*-associated diarrhea.
* Hypersensitivity reactions (rash, anaphylaxis).
## Key Drug Interactions
* **Calcium-containing products (Neonates):** Severe, life-threatening precipitate formation.
* **Oral Anticoagulants:** May enhance the effects of Vitamin K antagonists (e.g., warfarin); monitor INR.
* **Aminoglycosides:** Potential for synergistic nephrotoxicity (rare).
## Monitoring
* **CBC:** Monitor for leukopenia or neutropenia with prolonged therapy (>10 days).
* **Clinical Response:** Monitor for resolution of infectious symptoms.
* **Hepatic/Renal:** Monitor if therapy exceeds 14 days.
* **Signs of Gallbladder Issues:** Consider ultrasound if symptoms of biliary colic develop.
## Clinical Pearls
* **Biliary Issues:** Ceftriaxone is excreted via bile; it should be used with caution in patients with biliary obstruction.
* **IV/IM Compatibility:** Do not admix or run concurrently with calcium-containing solutions (e.g., Ringer’s Lactate, TPN) in the same IV line.
* **Spectrum:** Excellent coverage against *Streptococcus pneumoniae*, *H. influenzae*, *Neisseria* species, and many Enterobacteriaceae. It lacks activity against *Pseudomonas aeruginosa*, *Enterococcus* species, and MRSA.
* **Dosing protocol:** Always adhere to institutional antimicrobial stewardship guidelines, as local resistance patterns significantly influence empiric utility.
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**Educational Disclaimer:** This information is for educational purposes only and does not constitute medical advice. Clinical decisions must be based on individual patient assessment and local institutional prescribing guidelines. Always verify current dosage, compatibility, and safety information via reliable clinical references (e.g., Lexicomp, UpToDate) or a licensed pharmacist before prescribing or administration.
