Can Ceftriaxone (Ceftriaxone) be administered via intramuscular (IM) injection in the deltoid muscle when the gluteal muscle is not available?

From the Guidelines

Ceftriaxone can be administered via intramuscular (IM) injection in the deltoid muscle when the gluteal muscle is not available, but with careful consideration of the volume and potential for increased pain at the injection site. The deltoid muscle has a smaller mass and can typically accommodate smaller volumes (usually up to 1-2 mL) compared to the gluteal site. For adult ceftriaxone doses, which often require reconstitution to volumes of 2-4 mL, the dose may need to be divided between both deltoid muscles or diluted to a higher concentration when appropriate, as seen in the pharmacokinetics of ceftriaxone where multiple intravenous or IM doses resulted in 15% to 36% accumulation of ceftriaxone above single‑dose values 1.

When using the deltoid site, proper technique is essential:

• locate the densest part of the muscle in the lateral aspect of the upper arm, about 2-3 finger widths below the acromion process
• the injection should be given at a 90-degree angle using an appropriately sized needle (typically 1-1.5 inches) based on patient size. Pain at the injection site may be more pronounced in the deltoid compared to the gluteal muscle. For larger volumes or repeated doses, alternative administration routes such as intravenous infusion should be considered when possible to minimize patient discomfort and ensure proper drug delivery.

Key considerations for administering ceftriaxone via IM in the deltoid muscle include:

• Volume limitations of the deltoid muscle
• Potential for increased pain at the injection site
• Need for proper injection technique to minimize discomfort and ensure effective drug delivery
• Alternative administration routes for larger volumes or repeated doses, as informed by the pharmacokinetics and administration guidelines for ceftriaxone 1.

From the FDA Drug Label

As with all intramuscular preparations, ceftriaxone should be injected well within the body of a relatively large muscle; aspiration helps to avoid unintentional injection into a blood vessel.

The FDA drug label recommends injecting ceftriaxone into a relatively large muscle, but it does not specify the deltoid muscle as an acceptable site for injection. However, it can be inferred that the deltoid muscle may be considered a relatively large muscle. Key points:

• Ceftriaxone should be injected into a relatively large muscle.
• The deltoid muscle can be considered a relatively large muscle, but it is not the preferred site, which is typically the gluteal muscle.
• The label does not provide explicit guidance on injecting ceftriaxone into the deltoid muscle, but it does not prohibit it either. Based on the information provided, it appears that injecting ceftriaxone into the deltoid muscle may be acceptable in rare instances where the gluteal muscle is not available, but this should be done with caution and careful consideration of the potential risks and benefits 2.

From the Research

Ceftriaxone Administration

• Ceftriaxone is typically administered via intramuscular (IM) injection in the gluteal muscle.
• However, there is limited research on the administration of Ceftriaxone in the deltoid muscle.

Bioavailability and Absorption

• A study on cephradine, a cephalosporin antibiotic, found that the vastus lateralis or deltoid muscle groups are preferable to the gluteus maximus as injection sites due to more rapid rates of drug absorption from those muscles 3.
• Studies on paliperidone palmitate and risperidone long-acting injectable have shown that the deltoid and gluteal muscles are not bioequivalent in terms of pharmacokinetic parameters, but some studies suggest that the deltoid muscle can be a suitable alternative injection site 4, 5, 6.

Injection Site Considerations

• The deltoid muscle may be considered as an alternative injection site when the gluteal muscle is not available, but the pharmacokinetic parameters and bioavailability of the drug should be taken into account.
• A study on meperidine administration during labor found that the deltoid muscle is a favored intramuscular site due to higher plasma levels compared to the gluteus muscle 7.

Ceftriaxone Administration in Deltoid Muscle

• There is no direct evidence on the administration of Ceftriaxone in the deltoid muscle, but studies on other drugs suggest that it may be possible in rare instances where the gluteal muscle is not available.
• However, the pharmacokinetic parameters and bioavailability of Ceftriaxone should be carefully considered before administering it in the deltoid muscle 3, 4, 5, 6, 7.