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# Ceftriaxone
## Overview
Ceftriaxone is a third-generation cephalosporin antibiotic with broad-spectrum activity against many Gram-positive and Gram-negative bacteria. It is administered intravenously or intramuscularly.
## Primary Indications
* **Serious bacterial infections:** Including pneumonia, meningitis, sepsis, intra-abdominal infections, bone and joint infections, skin and soft tissue infections, and urinary tract infections.
* **Community-acquired pneumonia.**
* **Pelvic inflammatory disease.**
* **Disseminated gonococcal infections.**
* **Surgical prophylaxis.**
## Adult Dosing
* **General infections:** 1 g to 2 g IV or IM every 12 to 24 hours. Daily doses up to 4 g may be used for severe infections.
* **Meningitis:** 2 g IV every 12 hours.
* **Surgical prophylaxis:** 1 g to 2 g IV 30-60 minutes before incision.
* **Uncomplicated gonorrhea:** 500 mg IM as a single dose. For disseminated gonococcal infection, 1 g IV or IM every 24 hours for 7 days is recommended, sometimes with oral azithromycin. Dosing for gonorrhea may vary based on local resistance patterns.
## Pediatric Dosing
* **Neonates (0-14 days):** 25-50 mg/kg IV or IM every 24 hours. Do not exceed 50 mg/kg/day. Do not use diluents containing calcium in neonates.
* **Neonates (>14 days) and Children (<12 years):** 50-100 mg/kg/day IV or IM administered every 12 to 24 hours. Doses may be increased to 150 mg/kg/day in divided doses every 8 to 12 hours for severe infections. Maximum daily dose is 4 g.
* **Children (≥12 years):** Same as adult dosing.
* **Meningitis (pediatric):** 100 mg/kg/day IV every 12 hours. Maximum daily dose is 4 g.
## Dose Adjustments
* **Renal impairment:** No dose adjustment is typically required due to high biliary excretion. However, in patients with severe renal impairment (CrCl <10 mL/min) not undergoing dialysis, maintenance doses may be reduced by 50%.
* **Hepatic impairment:** No dose adjustment is typically required.
* **Combined renal and hepatic impairment:** The total daily dose should not exceed 2 g.
## Contraindications
* Hypersensitivity to ceftriaxone, other cephalosporins, or penicillins.
* **Neonates:** IV administration of ceftriaxone is contraindicated in neonates (term and preterm) receiving concomitant therapy with calcium-containing solutions or parenteral nutrition, due to the risk of precipitation of ceftriaxone-calcium.
## Adverse Effects
* **Common:** Diarrhea, rash, injection site reactions (pain, phlebitis).
* **Serious:** Stevens-Johnson syndrome, anaphylaxis, C. difficile-associated diarrhea, hepatobiliary dysfunction (including biliary sludge and cholelithiasis, particularly with prolonged use or high doses), eosinophilia, thrombocytosis, leukopenia.
## Key Drug Interactions
* **Aminoglycosides:** May increase risk of nephrotoxicity and ototoxicity, especially in patients with renal impairment. Monitor renal function and drug levels.
* **Warfarin:** Ceftriaxone may alter the anticoagulant response. Monitor INR closely.
* **Probenecid:** May increase ceftriaxone serum concentrations.
* **Calcium-containing solutions/products:** Contraindicated for IV coadministration in neonates due to risk of precipitation.
## Monitoring
* Monitor for signs and symptoms of hypersensitivity reactions.
* Monitor for development of C. difficile-associated diarrhea.
* Monitor renal and hepatic function, especially in patients with pre-existing impairment or those receiving concomitant nephrotoxic agents.
* Monitor INR in patients receiving warfarin.
* For prolonged therapy, consider monitoring for biliary sludge.
## Clinical Pearls
* Ceftriaxone has an exceptionally long half-life, allowing for once or twice-daily dosing, which can improve patient compliance.
* IM administration is often less painful than with other cephalosporins if reconstituted with 1% lidocaine hydrochloride. Avoid lidocaine for IV administration.
* The risk of biliary pseudolithiasis is significant, particularly in children and with prolonged treatment. If symptoms occur, management may involve discontinuation of the drug or symptomatic treatment.
* Ceftriaxone is the preferred agent for empirical treatment of community-acquired pneumonia and meningitis in many settings.
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*Prescribing information can change. Always verify current prescribing information with the latest official drug monograph or a reliable drug information resource.*
