Pediatric Dosing of Ceftriaxone
The recommended pediatric dose of ceftriaxone is 50-100 mg/kg/day given once daily or divided every 12-24 hours, with a maximum daily dose of 4 grams for most infections. 1
Dosing by Indication
Standard Infections
- General infections: 50-75 mg/kg/day given once daily or divided every 12 hours
- Maximum daily dose: 2 grams 1
- Skin and skin structure infections: 50-75 mg/kg/day once daily or divided twice daily
- Maximum daily dose: 2 grams 1
- Acute otitis media: Single intramuscular dose of 50 mg/kg
- Maximum dose: 1 gram 1
Severe Infections
- Meningitis: 100 mg/kg as initial dose (not exceeding 4 grams), followed by 100 mg/kg/day
- Can be given once daily or divided every 12 hours
- Maximum daily dose: 4 grams
- Duration: 7-14 days 1
- Bacterial pneumonia: 50-100 mg/kg/day
Administration Methods
Intravenous Administration
- Should be administered over 30 minutes
- Exception: In neonates, administer over 60 minutes to reduce risk of bilirubin encephalopathy 1
- Reconstitute with appropriate IV diluent to concentration between 10-40 mg/mL 1
Intramuscular Administration
- Inject well within the body of a relatively large muscle
- Aspirate to avoid unintentional injection into blood vessel 1
Special Considerations
Age-Specific Dosing
- Neonates:
Renal/Hepatic Impairment
- No dosage adjustment necessary for patients with impairment of renal or hepatic function 1
Once vs. Twice Daily Dosing
The most recent evidence supports different approaches based on the infection type:
- For most infections, once-daily dosing (50-100 mg/kg/day) is effective and convenient 4, 5
- For meningitis, once-daily dosing (100 mg/kg/day) achieves higher 24-hour probability of target attainment (88% vs 53%) compared to twice-daily dosing 6
- For critically ill children with high creatinine clearance or when targeting less susceptible pathogens (MIC ≥0.5 mg/L), twice-daily dosing (50 mg/kg every 12 hours) may provide better target attainment 7, 8
Duration of Therapy
- Generally, ceftriaxone therapy should be continued for at least 2 days after signs and symptoms of infection have disappeared 1
- Usual duration: 4-14 days; longer therapy may be required for complicated infections 1
- For Streptococcus pyogenes infections: minimum 10 days 1
Common Pitfalls to Avoid
- Compatibility issues: Do not use diluents containing calcium (e.g., Ringer's solution) to reconstitute ceftriaxone as particulate formation can result 1
- Inappropriate dosing frequency: Consider twice-daily dosing for critically ill patients with enhanced renal clearance or when targeting less susceptible pathogens 8
- Inadequate duration: Ensure treatment continues for at least 48-72 hours after clinical improvement 3
- Inappropriate use in neonates with hyperbilirubinemia: Ceftriaxone should not be used in hyperbilirubinemic neonates 2
By following these evidence-based dosing recommendations, clinicians can optimize the efficacy and safety of ceftriaxone therapy in pediatric patients while minimizing the risk of treatment failure and antimicrobial resistance.