Ceftriaxone

General

• Type: 3rd generation Cephalosporin
• Dosage Forms: injectable solution, powder for injection
• Dosage Strengths: injectable solution: 1g/50mL, 2g/50mL; powder for injection: 250mg, 500mg, 1g, 2g, 10g, 100g
• Routes of Administration: IV, IM
• Common Trade Names: Rocephin

Adult Dosing

General

• 1-2g IM/IV q24h
• First ED Dose: 1g IM/IV x 1
• Max: 4g/24h

Indications by Disease

Disease	Dose	Context
Acute cystitis	1gm IV QD	Inpatient
Acute cystitis	250mg IM x1	Urethritis Concern
Acute diarrhea	2g IV once daily x 5 days	Salmonella
Cellulitis	1g (50mg/kg) IV q24hrs	Freshwater
Cervicitis	IM x 1 (500mg if <150kg, 1g if ≥150kg)	GC/Chlamydia, Standard
Discitis	2g IV daily	Inpatient Therapy
Endocarditis	1g (50mg/kg) IM or IV	Dental Procedure Prophylaxis
Epididymitis	500 mg IM in a single dose	STI
Epidural abscess (spinal)	standard dosing	Empiric
Erysipelas	1g (50mg/kg) IV once daily x 10 days	Inpatient
Gonorrheal conjunctivitis	1g IM single dose	Gonococcal Conjunctivitis
Infectious tenosynovitis	1g IV daily	Empiric
Mammalian bites	1g (50mg/kg) IV once	Severe mammalian bite infection
Mastoiditis	1g (50mg/kg) IV once daily	Empiric
Open fracture	2 g IV (immediately x 1 total dose)	Grade III Fractures
Orbital cellulitis	2 g IV q12hr	Inpatient
Pelvic inflammatory disease	500mg IM x1 (1g if >150kg)	Outpatient; combined with Doxycycline and Metronidazole
Pelvic inflammatory disease	1g IV q24hr	Inpatient; combined with Doxycycline and Metronidazole
Peritonitis	1g IV once daily	Primary
Pneumonia (main)	1-2g IV	ICU, Low Risk
Pneumonia (main)	1–2g daily	Inpatient, CAP Non-ICU
Prostatitis	1g IV q12hrs	Septic
Prostatitis	500mg IM x1	STD Associated
Pyelonephritis	1gm IV QD	Adult Inpatient
Sinusitis	1-2g IV q12-24h x 7-10 days	Sinusitis, Severe
Surgical prophylaxis	2g IV within 60 minutes of incision	Surgical prophylaxis
Syphilis	2gm IV once daily for 10-14 days	Neurosyphilis, Alternative
Typhoid fever	2g IV q 24 hrs x 14 days	Quinolone Resistant, Parenteral
Urethritis in men	IM x 1 (500mg if <150kg, 1g if ≥150kg)	Uncomplicated, Gonorrhea

Pediatric Dosing

General (<7 Days Old)

• 50mg/kg IM/IV q24h
• First Dose: 50mg/kg IM/IV x 1

General (7 Days - 1 Month)

• <2000g
  • 50mg/kg IM/IV q24h
  • First Dose: 50mg/kg IM/IV x 1
• >2000g
  • 50-75mg/kg IM/IV q24h
  • First Dose: 50-75mg/kg IM/IV x 1

General (>1 Month - Adult)

• 50-100mg/kg IM/IV divided q12-24h
• First Dose: 50-100mg/kg IM/IV x 1
• Max: 4g/24h

Indications by Disease

Disease	Dose	Context
Acute cystitis	50-75mg/kg IV daily (max 2g)	Pediatric Inpatient
Acute diarrhea	50mg/kg/day once daily x 3 days	Pediatric travelers diarrhea
Acute diarrhea	50mg/kg IM/IV daily x 5 days (max 2g)	Pediatric Shigella Severe
Acute diarrhea	50-75mg/kg IV daily x 5 days (max 2g)	Pediatric Salmonella
Acute diarrhea	50mg/kg/day once daily x 3 days	Pediatric travelers diarrhea
Diarrhea aguda	50mg/kg/day once daily x 3 days	Pediatric travelers diarrhea
Acute otitis media	50mg/kg IM once as single injection x 3 days	Treatment Failure
Endocarditis	100mg/kg/day IV divided q12h (max 4g/day)	Pediatric Empiric
Epidural abscess (spinal)	50-75mg/kg IV daily (max 2g)	Pediatric Empiric
Erysipelas	50mg/kg IV daily (max 2g) x 10 days	Pediatric Inpatient
Gonorrheal conjunctivitis	25-50mg IV or IM, max 125mg	Gonococcal Conjunctivitis, Newborn
Infectious tenosynovitis	100mg/kg IV once daily	Pediatrics
Mammalian bites	50mg/kg IV daily (max 2g)	Pediatric Severe
Mastoiditis	50mg/kg IV daily (max 2g)	Pediatric Empiric
Neonatal conjunctivitis	25-50mg/kg IV or IM x1 (max 125mg)	Gonococcal conjunctivitis
Open fracture	50mg/kg IV (max 2g) x 1	Pediatric Grade III
Orbital cellulitis	50mg/kg IV q12hrs (max 2g/dose)	Pediatric Inpatient
Osteomyelitis	50mg/kg IV once daily	Sickle Cell Disease
Pediatric fever of uncertain source	50-100mg/kg/dose	Neonatal 14-28 days with Ampicillin
Pediatric fever of uncertain source	50-100mg/kg/dose	90 days to 36 months
Peritonitis	50-75mg/kg IV daily (max 2g)	Pediatric
Pneumonia (peds)	50mg/kg/day q24hrs IV (max 2g/dose)	Hospitalized moderately ill not fully immunized
Pyelonephritis	75mg/kg IV QD	Pediatric Inpatient
Sinusitis	50mg/kg IV daily (max 2g); for severe or treatment failure	Pediatric Sinusitis, Severe
Traveler's diarrhea	50mg/kg/day once daily x 3 days	Pediatric travelers diarrhea
Typhoid fever	50-80mg/kg IV daily x 10-14 days (max 2g)	Pediatric, Quinolone Resistant
Ventriculoperitoneal shunt infection	100mg/kg/day IV div q12-24hrs	Empiric with Vancomycin

Special Populations

• Pregnancy Rating: B
• Lactation: Probably safe
• Renal Dosing
  • Adult
    • Renal failure: No initial adjustment, monitor serum levels
    • Hemodialysis: give dose after dialysis, no supplement
    • Peritoneal Dialysis: 750mg q12h
  • Pediatric
    • CrCl <10: give q24h
    • Hemodialysis: 50mg/kg q24, no supplement
    • Peritoneal Dialysis: 50mg/kg q24, no supplement
• Hepatic Dosing
  • Adult
    • Hepatic and renal disease: max 2g/day, unless closely monitoring serum levels
  • Pediatric
    • May requrire dose adjustment but specific dosing not defined

Contraindications

• Allergy to class/drug (see also Cephalosporin Cross-reactivity)
• Patients <1 month old
  • Hyperbillirubinemia
  • IV calcium containing product
  • If a 3rd generation cephalosporin is required, consider using Cefotaxime instead

Adverse Reactions

Serious

• Anaphylaxis
• Broncospasm
• Stevens-Johnson Syndrome
• Toxic Epidermal Necrolysis
• Erythema multiforme
• Serum sickness
• Pneumonitis
• Neutropenia
• Leukopenia
• Hemolytic anemia
• Thrombocytopenia
• Hypoprothrombinemia
• Agranulocytosis
• Superinfection
• Clostridium difficile
• Colitis
• Billiary/gallbladder sludge
• Jaundice
• Pancreatitis
• Seizures
• Nephrolithiasis
• Lung/kidney calcium precipitate (neonates)

Common

• Local infection site reaction
• Eosinophilia
• Thrombocytosis
• Transaminitis
• Diarrhea
• Leukopenia

Pharmacology

• Half-life: 5.8-8.7h, 15h (CrCl 5-15)
• Metabolism: CYP450
• Excretion: Primarily urine
• Mechanism of Action: bactericidal; inhibits cell wall synthesis

Antibiotic Sensitivities

Group	Organism	Sensitivity
Gram Positive	Strep. Group A, B, C, G	S
	Strep. Pneumoniae	S
	Viridans strep	S
	Strep. anginosus gp	X1
	Enterococcus faecalis	R
	Enterococcus faecium	X1
	MSSA	S
	MRSA	R
	CA-MRSA	R
	Staph. Epidermidis	I
	C. jeikeium	R
	L. monocytogenes	R
Gram Negatives	N. gonorrhoeae	I
	N. meningitidis	S
	Moraxella catarrhalis	S
	H. influenzae	S
	E. coli	S
	Klebsiella sp	S
	E. coli/Klebsiella ESBL+	R
	E coli/Klebsiella KPC+	R
	Enterobacter sp, AmpC neg	S
	Enterobacter sp, AmpC pos	R
	Serratia sp	S
	Serratia marcescens	X1
	Salmonella sp	S
	Shigella sp	S
	Proteus mirabilis	S
	Proteus vulgaris	S
	Providencia sp.	S
	Morganella sp.	S
	Citrobacter freundii	S
	Citrobacter diversus	S
	Citrobacter sp.	S
	Aeromonas sp	S
	Acinetobacter sp.	R
	Pseudomonas aeruginosa	R
	Burkholderia cepacia	I
	Stenotrophomonas maltophilia	R
	Yersinia enterocolitica	S
	Francisella tularensis	X1
	Brucella sp.	X1
	Legionella sp.	R
	Pasteurella multocida	S
	Haemophilus ducreyi	S
	Vibrio vulnificus	X1
Misc	Chlamydophila sp	X1
	Mycoplasm pneumoniae	X1
	Rickettsia sp	X1
	Mycobacterium avium	X1
Anaerobes	Actinomyces	S
	Bacteroides fragilis	R
	Prevotella melaninogenica	I
	Clostridium difficile	X1
	Clostridium (not difficile)	S
	Fusobacterium necrophorum	X1
	Peptostreptococcus sp.	S

Key

• S susceptible/sensitive (usually)
• I intermediate (variably susceptible/resistant)
• R resistant (or not effective clinically)
• S+ synergistic with cell wall antibiotics
• U sensitive for UTI only (non systemic infection)
• X1 no data
• X2 active in vitro, but not used clinically
• X3 active in vitro, but not clinically effective for Group A strep pharyngitis or infections due to E. faecalis
• X4 active in vitro, but not clinically effective for strep pneumonia

See Also

• Antibiotics (Main)