Ceftriaxone

Intravenous
Intramuscular
Class
Antibiotics
Subclass
Third-generation cephalosporins
Substance name
cefTRIAXone sodium
Brand names
Easy-Ceft®, Rocephin®
Common formulations
Powder for parenteral solution, Kit
Dosage and administration
Adults patients
Treatment
Acute bacterial meningitis
•
2 g IV q12h for 7-21 days
Acute otitis media
•
Maintenance: 1-2 g IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 4 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
Bone and joint infections
•
Maintenance: 2 g IV q24h, administered over 30 minutes, for 6 weeks
•
Maximum: 4 g per day
Intra-abdominal infections
•
Maintenance: 1-2 g IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 4 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
Lower respiratory tract infections
•
Maintenance: 1-2 g IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 4 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
Pelvic inflammatory disease • Empiric therapy
•
1 g IV q24h for 14 days
Administered in combination with doxycycline 100 mg orally or intravenously BID and metronidazole 500 mg orally or intravenously twice daily for 14 days.
Sepsis
•
Maintenance: 1-2 g IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 4 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
SSTIs
•
Maintenance: 50-75 mg/kg IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 2 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
UTIs
•
Maintenance: 1-2 g IV daily, in 1-2 divided doses, administered over 30 minutes, for 4-14 days
•
Maximum: 4 g per day
Administer longer therapy for complicated infections. Complete at least 10-day therapy for infections caused by S. pyogenes.
Animal bite wounds • Off-label
•
1 g IV q12h
Brucellosis • CNS • Off-label
•
2 g IV q12h for 4-6 weeks
Administered in combination with doxycycline 100 mg orally BID and rifampin 600 mg orally daily for at least 6 weeks.
Catheter-related bloodstream infection • Caused by extended-spectrum β-lactamase-negative E. coli or Klebsiella species • Off-label
•
1-2 g IV daily, in 1-2 divided doses, for 7-14 days
Cellulitis and necrotizing fasciitis • Caused by Vibrio vulnificus • Off-label
•
1 g IV q6h
Administered in combination with doxycycline 100 mg intravenously BID.
Community-acquired pneumonia • Nonsevere, inpatient, no risk factors for MRSA and P. aeruginosa • Off-label
•
1-2 g IV q24h for at least 5 days
Administered in combination with azithromycin 500 mg orally daily or clarithromycin 500 mg orally BID.
Diabetic foot infection • Off-label
•
1-2 g IV daily, in 1-2 divided doses, for 2-4 weeks
Gonococcal infection • Arthritis • Off-label
•
1 g IV q24h for at least 7 days
Gonococcal infection • Meningitis • Off-label
•
1-2 g IV q24h for 10-14 days
Gonococcal infection • Endocarditis • Off-label
•
1-2 g IV q24h for at least 4 weeks
Human bite wounds • Off-label
•
1 g IV q12h
Infective endocarditis • Native valve, caused by HACEK microorganisms • Off-label
•
2 g IV q24h for 4 weeks
Infective endocarditis • Prosthetic valve, caused by highly penicillin-susceptible viridans group streptococci or S. gallolyticus • Off-label
•
2 g IV q24h for 6 weeks
Administered with or without gentamicin sulfate 3 mg/kg intravenously or IM q24h.
Infective endocarditis • Prosthetic valve, caused by penicillin-resistant viridans group streptococci or S. gallolyticus • Off-label
•
2 g IV q24h for 6 weeks
Administered in combination with gentamicin sulfate 3 mg/kg intravenously or IM q24h.
Infective endocarditis • Caused by penicillin-susceptible enterococci • Off-label
•
2 g IV q12h for 6 weeks
Administered in combination with ampicillin 2 g intravenously q4h.
Infective endocarditis • Prosthetic valve, caused by HACEK microorganisms • Off-label
•
2 g IV q24h for 6 weeks
Infective endocarditis in patients without CKD • Native valve, caused by highly penicillin-susceptible viridans group streptococci or S. gallolyticus, uncomplicated • Off-label
•
2 g IV q24h for 4 weeks
Alternative
•
2 g IV q24h for 2 weeks
Administered in combination with gentamicin sulfate 3 mg/kg intravenously or IM q24h. A 2-week treatment regimen that includes gentamicin is reasonable in patients with uncomplicated IE, rapid response to therapy, and no underlying renal disease.
Leptospirosis • Severe • Off-label
•
1 g IV q24h
Lyme disease • Arthritis • Off-label
•
2 g IV q24h for 14-28 weeks
Lyme disease • Neurologic • Off-label
•
2 g IV q24h for 14-21 days
Lyme disease • Carditis • Off-label
•
2 g IV q24h for 14-21 days
Native vertebral osteomyelitis • Caused by oxacillin-susceptible staphylococci, β-hemolytic streptococci, or P. acnes • Off-label
•
2 g IV q24h for 6 weeks
Native vertebral osteomyelitis • Caused by nalidixic acid-resistant Salmonella species • Off-label
•
2 g IV q24h for 6-8 weeks
Neurosyphilis • Off-label
•
1-2 g IV q24h for 10-14 days
Nocardiosis in patients with solid organ transplantation • Off-label
•
2 g IV q12h for 6-12 months
Peritoneal dialysis-associated peritonitis • Off-label
•
1 g intraperitoneal daily
Prosthetic joint infection • Caused by oxacillin-susceptible staphylococci, after debridement and retention of the prosthesis • Off-label
•
1-2 g IV q24h for 4-6 weeks
Prosthetic joint infection • Caused by β-hemolytic streptococci or P. acnes, after debridement and retention of the prosthesis , if penicillins are ineffective or contraindicated • Off-label
•
2 g IV q24h for 4-6 weeks
SBP • Off-label
•
2 g IV q24h for 5-7 days
Tick-borne relapsing fever • Off-label
•
2 g IV q24h for 10 days
Prevention
Surgical site infection
•
1 g IV once, administered over 30 minutes, 0.5-2 hours before surgery
Alternative
•
2 g IV × 1 1 hour before surgery
Infective endocarditis in patients with high or intermediate risk of infective endocarditis • Off-label
•
1 g IV × 1 30-60 minutes before high-risk dental procedures
SBP • Off-label
•
1 g IV q24h for 7 days
Indications for use
Labeled indications
Adults
•
Treatment of acute bacterial meningitis
•
Treatment of acute otitis media
•
Treatment of bone and joint infections
•
Treatment of intra-abdominal infections
•
Treatment of lower respiratory tract infections
•
Treatment of pelvic inflammatory disease (empiric therapy)
•
Treatment of sepsis
•
Treatment of SSTIs
•
Treatment of UTIs
•
Prevention of surgical site infection
Off-label indications
Adults
•
Treatment of Lyme disease (arthritis)
•
Treatment of Lyme disease (carditis)
•
Treatment of Lyme disease (neurologic)
•
Treatment of animal bite wounds
•
Treatment of brucellosis (CNS)
•
Treatment of catheter-related bloodstream infection (caused by extended-spectrum β-lactamase-negative E. coli or Klebsiella species)
•
Treatment of cellulitis and necrotizing fasciitis (caused by Vibrio vulnificus)
•
Treatment of community-acquired pneumonia (nonsevere, inpatient, no risk factors for MRSA and P. aeruginosa)
•
Treatment of diabetic foot infection
•
Treatment of gonococcal infection (arthritis)
•
Treatment of gonococcal infection (endocarditis)
•
Treatment of gonococcal infection (meningitis)
•
Treatment of human bite wounds
•
Treatment of infective endocarditis (caused by penicillin-susceptible enterococci)
•
Treatment of infective endocarditis (native valve, caused by HACEK microorganisms)
•
Treatment of infective endocarditis (prosthetic valve, caused by HACEK microorganisms)
•
Treatment of infective endocarditis (prosthetic valve, caused by highly penicillin-susceptible viridans group streptococci or S. gallolyticus)
•
Treatment of infective endocarditis (prosthetic valve, caused by penicillin-resistant viridans group streptococci or S. gallolyticus)
•
Treatment of infective endocarditis in patients without CKD (native valve, caused by highly penicillin-susceptible viridans group streptococci or S. gallolyticus, uncomplicated)
•
Treatment of leptospirosis (severe)
•
Treatment of native vertebral osteomyelitis (caused by nalidixic acid-resistant Salmonella species)
•
Treatment of native vertebral osteomyelitis (caused by oxacillin-susceptible staphylococci, β-hemolytic streptococci, or P. acnes)
•
Treatment of neurosyphilis
•
Treatment of nocardiosis in patients with solid organ transplantation
•
Treatment of peritoneal dialysis-associated peritonitis
•
Treatment of prosthetic joint infection (caused by oxacillin-susceptible staphylococci), after debridement and retention of the prosthesis
•
Treatment of prosthetic joint infection (caused by β-hemolytic streptococci or P. acnes), after debridement and retention of the prosthesis , if penicillins are ineffective or contraindicated
•
Treatment of SBP
•
Treatment of tick-borne relapsing fever
•
Prevention of infective endocarditis in patients with high or intermediate risk of infective endocarditis
•
Prevention of SBP
Safety risks
Contraindications
Hypersensitivity to ceftriaxone or its components or to other cephalosporins, penicillins, or other β-lactam antibiotics
Mixing with calcium-containing solutions
•
Do not mix calcium-containing intravenous solutions, including continuous infusions such as parenteral nutrition, with ceftriaxone in the same intravenous administration line. Consider administering calcium-containing solutions with ceftriaxone sequentially, thoroughly flushing the infusion lines with saline or dextrose solution between infusions.
Warnings and precautions
Acute pancreatitis
•
Maintain a high level of suspicion, as ceftriaxone has been associated with an increased risk of acute pancreatitis, possibly due to biliary obstruction, especially in patients with risk factors for biliary stasis or sludge.
Antimicrobial resistance
•
Maintain a high level of suspicion, as the use of ceftriaxone in the absence of a proven or strongly suspected bacterial infection increases the risk of developing drug-resistant bacteria.
C. difficile infection
•
Maintain a high level of suspicion, as nearly all antibiotics, including ceftriaxone, are associated with an increased risk of C. difficile-associated diarrhea.
Gallbladder abnormalities
•
Maintain a high level of suspicion, as ceftriaxone has been associated with cases of abnormal gallbladder ultrasound findings, such as sludge or acoustical shadowing, due to the formation of ceftriaxone-calcium salt, which may be misinterpreted as gallstones. Discontinue ceftriaxone if ultrasound findings are observed or symptoms suggesting gallbladder disease develop.
Hemolytic anemia
•
Maintain a high level of suspicion, as ceftriaxone has been associated with an increased risk of immune-mediated hemolytic anemia. Discontinue ceftriaxone if anemia develops during treatment until the etiology is determined.
Neurological adverse events
•
Maintain a high level of suspicion, as ceftriaxone has been associated with cases of serious neurological adverse events, including encephalopathy, seizures, myoclonus, and non-convulsive status epilepticus, especially in patients with severe renal impairment.
Prolonged PT
•
Maintain a high level of suspicion, as ceftriaxone has been associated with alterations in PT. Consider obtaining PT monitoring in patients with impaired vitamin K synthesis or low vitamin K stores may require, and administering vitamin K (10 mg weekly) if the PT is prolonged before or during therapy.
Urolithiasis
•
Maintain a high level of suspicion, as ceftriaxone has been associated with an increased risk of urolithiasis due to ceftriaxone-calcium precipitation in the urinary tract. Discontinue ceftriaxone if ultrasound findings are observed or symptoms suggesting urolithiasis, oliguria, or renal failure develop.
Specific populations
Renal impairment
eGFR 0-90 mL/min/1.73 m²
•
Maximal dose of 2 g per day if both renal and hepatic impairment are present.
Renal replacement therapy
Any modality
•
Maximal dose of 2 g per day if both renal and hepatic impairment are present.
Hepatic impairment
Any severity
•
Use acceptable. No dose adjustment required. Monitor prothrombin time.
Pregnancy and breastfeeding
Pregnancy
All trimesters • Australia Category: B1
•
Use only if clearly needed. Cephalosporins are generally considered safe for use in pregnancy. Ceftriaxone is considered as a first-line option for pyelonephritis in pregnancy.
Breastfeeding
Use only if benefits outweigh potential risks.
•
Use with caution during breastfeeding.
Unknown drug levels in breastfed infants.
No overt adverse effects reported in breastfed infants.
Adverse reactions
Common 1-10%
•
Hemolytic anemia, vulvovaginal candidiasis, colitis, biliary sludge, injection site pain, injection site phlebitis, skin rash, pruritus, chills, fever, ↑ platelet count, ↑ blood eosinophil count, anemia, ↓ WBC count, ↓ platelet count, ↓ blood neutrophil count, ↓ blood lymphocyte count, ↑PT, diarrhea, nausea, vomiting, dysphagia, ↑ serum AST, ↑ serum ALT, ↑ serum ALP, ↑ serum TBIL, ↑ BUN, ↑ serum creatinine, headache, dizziness, skin flushing, diaphoresis, agranulocytosis, abdominal pain, ↑ blood basophils, bronchospasm, dyspepsia, nosebleed, flatulence, ↑ urine glucose, hematuria, jaundice, ↑ WBC count, ↑ blood lymphocyte count, ↑ blood monocyte count, palpitations, urinary casts
Unknown frequency
•
Ceftriaxone-calcium precipitation, urolithiasis, dermatitis, nephrolithiasis, anaphylaxis, hypersensitivity pneumonitis, serum sickness, Stevens-Johnson syndrome, toxic epidermal necrolysis, hepatic dysfunction, aplastic anemia, status epilepticus, hepatitis, seizure, encephalopathy, stomatitis, glossitis, low urine output, urticaria, edema, erythema multiforme, renal dysfunction, hypertonia, ↑ serum LDH, myoclonus
Interactions
Drug(s)
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