How to manage constipation caused by intravenous (IV) ceftriaxone (a third-generation cephalosporin antibiotic)?

Management of Constipation from IV Ceftriaxone

For constipation caused by intravenous ceftriaxone, the most effective approach is to use a combination of polyethylene glycol (PEG) as an osmotic laxative along with a stimulant laxative such as senna or bisacodyl. This combination therapy addresses the constipation while continuing the necessary antibiotic treatment 1, 2.

Understanding Ceftriaxone-Induced Constipation

Ceftriaxone is a third-generation cephalosporin antibiotic commonly administered intravenously for various infections. While diarrhea is more commonly reported with ceftriaxone 3, constipation can also occur as a side effect.

Management Algorithm

First-Line Treatment:

1. Osmotic Laxative:

   • Polyethylene glycol (PEG) 17g daily mixed in 8 ounces of water 1
   • PEG works by increasing water content in the colon and is recommended with moderate certainty of evidence

2. Add Stimulant Laxative:

   • Senna 8.6-17.2mg at bedtime OR
   • Bisacodyl 10-15mg daily 2

If Inadequate Response After 2-3 Days:

• Increase dose of initial agents
• Ensure both osmotic and stimulant laxatives are being used in combination
• Consider adding a rectal intervention:
  • Bisacodyl suppository (one rectally daily or twice daily) 2

For Severe or Persistent Constipation:

• Consider cholestyramine 4g daily, which has been shown to be effective in preventing constipation in patients receiving long-term intravenous ceftriaxone 1
• Puri et al. reported that daily concomitant treatment with 4g cholestyramine in patients receiving long-term IV ceftriaxone was associated with constipation in only 6.5% of patients compared with 23.1% of those receiving ceftriaxone alone 1

Supportive Measures

Dietary Modifications:

• Increase dietary fiber to approximately 30g/day (fruits, vegetables, whole grains)
• Ensure adequate fluid intake, particularly water 2
• Avoid lactose-containing products, alcohol, and high-osmolar supplements 1

Lifestyle Adjustments:

• Increase physical activity within patient limits
• Optimize toileting position (use footstool to assist with defecation)
• Attempt defecation 30 minutes after meals to utilize gastrocolic reflex 2

Monitoring and Follow-up

• Monitor bowel movements daily
• Goal of treatment is to achieve one non-forced bowel movement every 1-2 days 2
• Assess for any signs of fecal impaction with digital rectal examination if constipation persists

Special Considerations

• Avoid bulk-forming laxatives in non-ambulatory patients with low fluid intake due to increased risk of impaction 2
• Use magnesium-based laxatives cautiously in patients with renal impairment 2
• If the patient is also receiving opioid analgesics, consider adding a peripheral μ-opioid receptor antagonist such as methylnaltrexone 0.15 mg/kg subcutaneously every other day 2

Prevention

For patients requiring prolonged IV ceftriaxone therapy, consider prophylactic use of cholestyramine 4g daily to prevent constipation, as this has been shown to significantly reduce the incidence of constipation in patients on long-term ceftriaxone therapy 1.