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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic with broad-spectrum activity against most Gram-positive and Gram-negative organisms. It possesses a long half-life, allowing for once-daily dosing. It is not active against *Enterococcus* spp., *Listeria monocytogenes*, or MRSA.
## Primary Indications
Common indications include community-acquired pneumonia, meningitis, skin and soft tissue infections, complicated intra-abdominal infections, pyelonephritis, gonorrhea (as part of dual therapy), and secondary prophylaxis for bacterial meningitis.
## Adult Dosing
* **Standard infections:** 1–2 g IV/IM every 24 hours.
* **Meningitis:** 2 g IV every 12 hours (loading dose of 2 g often used).
* **Gonorrhea:** 500 mg IM as a single dose (for patients <150 kg; 1 g if >150 kg).
* **Maximum dose:** Typically 4 g/day for severe infections.
## Pediatric Dosing
* **Standard infections:** 50–75 mg/kg/day IV divided every 12–24 hours.
* **Meningitis:** 100 mg/kg/day IV divided every 12 hours (maximum 4 g/day).
* **General maximum:** Do not exceed adult doses.
* **Note:** Dosing protocols vary by institution; always consult local guidelines for complicated pediatric pathologies.
## Dose Adjustments
* **Renal Impairment:** No dosage adjustment is required for patients with renal impairment (including dialysis), provided hepatic function is preserved.
* **Hepatic Impairment:** Dose reduction may be required if severe renal impairment coexists.
* **Safety Note:** Use caution in neonates or patients with hepatic/biliary dysfunction due to risk of biliary sludge/precipitants.
## Contraindications
* Hypersensitivity to ceftriaxone or other cephalosporins.
* **Neonates (≤28 days):** Contraindicated in neonates receiving calcium-containing IV solutions (risk of ceftriaxone-calcium precipitates in lungs/kidneys).
## Adverse Effects
* **Common:** Injection site pain, diarrhea, rash, eosinophilia.
* **Serious:** *Clostridioides difficile*-associated diarrhea, biliary sludging (pseudolithiasis), hemolytic anemia, anaphylaxis, and Jarisch-Herxheimer reaction in syphilis treatment.
## Key Drug Interactions
* **Calcium-containing products:** Ceftriaxone precipitates with calcium in the IV line (do not mix or Y-site simultaneously).
* **Anticoagulants:** May enhance the effects of Vitamin K antagonists (monitor INR).
* **Aminoglycosides:** Potential for synergistic nephrotoxicity (though less common with ceftriaxone than other cephalosporins).
## Monitoring
* Monitor for signs of hypersensitivity.
* Monitor for *C. difficile* diarrhea (loose, frequent stools).
* Assess for evidence of biliary sludge or hemolysis during prolonged therapy (typically >14 days).
## Clinical Pearls
* **Long Half-Life:** The significant protein binding and half-life permit convenient once-daily outpatient administration (OPAT).
* **Biliary Sludge:** Ceftriaxone is excreted primarily in the bile; ultrasound may show gallbladder "pseudolithiasis," which is usually reversible upon discontinuation.
* **Syphilis:** Ceftriaxone is an alternative for syphilis treatment, but consider the risk of the Jarisch-Herxheimer reaction.
* **Preparation:** IV use can be reconstituted with sterile water for injection; IM use is often reconstituted with 1% lidocaine to reduce injection site pain.
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*Disclaimer: This information is for educational purposes and reflects general clinical practice. Always consult institutional protocols, current package inserts, and evidence-based clinical databases (e.g., Lexicomp, UpToDate) before prescribing or administering medication.*
