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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 exhibits time-dependent bactericidal activity.
## Primary Indications
* Community-acquired pneumonia
* Meningitis
* Complicated intra-abdominal infections
* Gonorrhea (uncomplicated)
* Bacterial septicemia
* Skin and skin structure infections
* Prophylaxis in surgical procedures
## Adult Dosing
* **General infections:** 1 to 2 grams IV/IM every 24 hours.
* **Meningitis:** 2 grams IV every 12 hours.
* **Uncomplicated Gonorrhea:** 500 mg IM as a single dose (for patients weighing <150 kg).
* **Maximum Dose:** Generally 4 grams per day for severe infections.
## Pediatric Dosing
* **General infections:** 50–75 mg/kg/day IV/IM administered once daily.
* **Meningitis:** 100 mg/kg/day (maximum 4 g/day) given in 1 or 2 divided doses.
* **Neonates:** Not recommended in neonates ≤28 days of age if they require calcium-containing IV solutions due to the risk of precipitation. 50 mg/kg/day is typical for substantiated infections.
## Dose Adjustments
* **Renal Impairment:** No dosage adjustment is required for patients with renal impairment, provided hepatic function is normal.
* **Hepatic Impairment:** No dosage adjustment is typically required; however, monitor for biliary symptoms if significant impairment exists.
* **Combined Hepatic/Renal Impairment:** Use with caution and monitor serum concentrations if available.
## Contraindications
* **Hypersensitivity:** Known allergy to ceftriaxone or other cephalosporins (cross-reactivity with penicillin exists but is rare).
* **Neonates (≤28 days):** Risk of ceftriaxone-calcium salt precipitation in the lungs and kidneys if administered with calcium-containing IV solutions (including Ringer’s or Hartmann’s solution).
## Adverse Effects
* **Gastrointestinal:** Diarrhea, *Clostridioides difficile*-associated diarrhea.
* **Hematologic:** Eosinophilia, thrombocytosis, leukopenia.
* **Hepatic:** Elevated liver enzymes, biliary sludge, or "pseudolithiasis."
* **Injection Site:** Pain, induration, or phlebitis.
## Key Drug Interactions
* **Calcium-containing IV solutions:** Risk of fatal precipitation. Do not administer within 48 hours of each other.
* **Warfarin:** May enhance the anticoagulant effect (monitor INR).
* **Aminoglycosides:** Potentially synergistic, but must never be mixed in the same IV line/container.
## Monitoring
* **Clinical Efficacy:** Resolution of symptoms and markers of infection (e.g., WBC, CRP, procalcitonin).
* **Safety:** Monitor for rash, signs of *C. difficile* infection (loose/frequent stools), and biliary symptoms (RUQ pain). In long-term therapy, monitor CBC and LFTs.
## Clinical Pearls
* Ceftriaxone is biliary-excreted; adjust dosing only if there is concurrent severe hepatic and renal dysfunction.
* When giving IM, dilute with 1% lidocaine (if not contraindicated) to reduce injection pain.
* Avoid use in neonates with hyperbilirubinemia, as ceftriaxone displaces bilirubin from albumin binding sites, increasing the risk of kernicterus.
* *Note: Dosing can vary significantly based on local institutional antimicrobial stewardship protocols and specific pathogen minimum inhibitory concentrations (MICs).*
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**Disclaimer:** This information is for educational purposes only. Always verify doses, contraindications, and drug-drug interactions against current institutional protocols, the package insert, or verified clinical databases (e.g., Lexicomp, UpToDate) before prescribing.
