What is the dose of Ceftriaxone for the treatment of endocarditis?

Ceftriaxone Dosing for Endocarditis Treatment

For the treatment of endocarditis, ceftriaxone should be administered at a dose of 100 mg/kg/day IV divided every 12 hours or 80 mg/kg/day IV every 24 hours, up to a maximum of 4 g daily. 1

Dosing Recommendations by Patient Population

Adult Patients

• Ceftriaxone 2 g IV every 12 hours or 4 g IV once daily (maximum daily dose) 1
• For HACEK microorganism endocarditis: 2 g IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 1

Pediatric Patients

• Ceftriaxone 100 mg/kg/day IV divided every 12 hours or 80 mg/kg/day IV every 24 hours 1
• Maximum daily dose should not exceed 4 g, regardless of weight 1
• For HACEK microorganism endocarditis: 100 mg/kg/day IV/IM once daily 1

Organism-Specific Considerations

Streptococcal Endocarditis

• For highly penicillin-susceptible streptococci (MBC ≤0.1 μg/mL):
  • Ceftriaxone 100 mg/kg/day IV divided every 12 hours or 80 mg/kg/day IV every 24 hours (up to 4 g daily) for 4 weeks 1
  • Alternative regimen: Ceftriaxone 2 g IV once daily for 4 weeks as monotherapy 2

Enterococcal Endocarditis

• For aminoglycoside-resistant enterococci or aminoglycoside-intolerant patients:
  • Ceftriaxone 2 g IV every 12 hours plus ampicillin 2 g IV every 4 hours 3
  • Note: Once-daily high-dose ceftriaxone (4 g) with ampicillin has been studied for outpatient therapy but may have higher relapse rates 4, 5

HACEK Group Endocarditis

• Ceftriaxone 2 g IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 1
• Alternative: Ampicillin-sulbactam or ciprofloxacin (if unable to tolerate cephalosporins) 1

Gram-Negative Enteric Bacilli

• Ceftriaxone 100 mg/kg/day IV divided every 12 hours or 80 mg/kg/day IV every 24 hours (up to 4 g daily) plus gentamicin 1

Administration Considerations

• Intramuscular (IM) injection of ceftriaxone is painful and should be avoided when possible 1
• For outpatient parenteral antimicrobial therapy (OPAT):
  • Ceftriaxone 2 g IV once daily can be used for penicillin-susceptible streptococcal endocarditis in stable patients 1
  • For enterococcal endocarditis, standard twice-daily dosing (2 g every 12 hours) appears more effective than once-daily high-dose (4 g) regimens 4, 5

Treatment Duration

• Standard treatment duration for endocarditis is 4-6 weeks 1
• Longer therapy may be required for:
  • Prosthetic valve endocarditis (minimum 6 weeks) 1
  • Recurrent endocarditis 1
  • Endocarditis due to uncommon species 1

Important Caveats

• Dosing should be adjusted in patients with severe renal impairment 1
• For patients with culture-negative endocarditis, empiric therapy should include coverage for the most likely pathogens based on clinical presentation 1
• Consultation with infectious disease specialists is recommended for complex cases or when using alternative regimens 1