Is it okay to give Rocephin (Ceftriaxone) intramuscularly (IM) to a patient with fever, chills, elevated neutrophil count, and impaired renal function (Blood Urea Nitrogen (BUN) elevation, Creatinine elevation)?

Administering Ceftriaxone IM in a Patient with Fever, Elevated Neutrophils, and Impaired Renal Function

Ceftriaxone IM can be administered to a patient with fever, chills, and elevated neutrophils despite renal impairment (BUN 25, Creatinine 1.7), but dose adjustment is not required as ceftriaxone is primarily eliminated through biliary excretion. 1

Assessment of Fever with Elevated Neutrophils

• Fever and chills with elevated neutrophils suggest an infectious process requiring prompt antibiotic therapy 2
• Blood cultures should be obtained before antibiotic administration, as these symptoms are specific indications for blood cultures 2
• Elevated neutrophils with left shift is a clinical parameter independently correlated with bacteremia 2

Ceftriaxone Use in Renal Impairment

• Ceftriaxone is excreted via both biliary and renal pathways, with biliary excretion being the predominant route 1
• Patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered 1
• For patients with both hepatic dysfunction and significant renal disease, caution should be exercised and the ceftriaxone dosage should not exceed 2g daily 1

Monitoring Considerations

• Close clinical monitoring for safety and efficacy is advised in patients with both severe renal and hepatic dysfunction 1
• Monitor for potential side effects including:
  • Gallbladder pseudolithiasis (ceftriaxone-calcium precipitates) 1
  • Urolithiasis and potential post-renal acute renal failure 1
  • Alterations in prothrombin time, especially in patients with impaired vitamin K synthesis 1

Efficacy in Febrile Patients

• Ceftriaxone has demonstrated efficacy in treating infections in patients with fever and neutrophilia 3, 4
• Once-daily dosing of ceftriaxone (2g) has been shown to be effective in treating febrile episodes in patients with various conditions 3
• In low-risk febrile neutropenia, ceftriaxone monotherapy has shown favorable response rates of approximately 70.8% 4

Important Caveats

• Ensure adequate hydration in patients receiving ceftriaxone to minimize risk of urolithiasis 1
• Although no dose adjustment is typically needed for renal impairment alone, the patient should be monitored for signs of drug accumulation 5
• Research has shown that non-renal clearance may be decreased in patients with acute renal failure, suggesting that biliary excretion might also be impaired in these patients 5
• If the patient shows signs of gallbladder disease or urolithiasis during treatment, discontinuation of ceftriaxone should be considered 1

Treatment Duration Considerations

• If the patient becomes afebrile and neutrophil count normalizes (≥0.5 × 10^9/L), antibiotics can typically be discontinued after 48 hours of being afebrile 2
• For persistent fever despite appropriate therapy, consider broadening antibiotic coverage or seeking infectious disease consultation 2

In conclusion, ceftriaxone IM is appropriate for this patient with fever, chills, and elevated neutrophils despite the elevated BUN and creatinine levels, but close monitoring is recommended due to the renal impairment.