What is the dosage and treatment duration of ceftriaxone for various bacterial infections?

Ceftriaxone Dosing and Treatment Duration for Various Bacterial Infections

The standard adult dosing of ceftriaxone is 1-2 grams intravenously or intramuscularly once daily or divided twice daily, with specific dosing based on infection type and severity. 1

Standard Dosing by Infection Type

Meningitis

• For bacterial meningitis: 2g IV every 12 hours (total 4g daily) 2, 1
• For pneumococcal meningitis: 2g IV every 12 hours for 10-14 days (longer if patient takes longer to respond) 2, 1
• For meningococcal meningitis: 2g IV every 12 hours for 5 days 2, 1
• For pediatric meningitis: 100 mg/kg/day (not to exceed 4g daily), administered once daily or in equally divided doses every 12 hours for 7-14 days 3

Respiratory Infections

• For community-acquired pneumonia: 1g daily is as effective as 2g daily regimens 4, 5
• For severe community-acquired pneumonia in children: once-daily intramuscular ceftriaxone (dosage based on weight) for approximately 5 days 6

Gonococcal Infections

• For uncomplicated gonococcal infections: single intramuscular dose of 250mg 3
• For disseminated gonococcal infection: 1g IM or IV every 24 hours, continued for 24-48 hours after improvement begins 1
• For gonococcal meningitis: 1-2g IV every 12 hours for 10-14 days 1
• For gonococcal endocarditis: 1-2g IV every 12 hours for at least 4 weeks 1

Endocarditis

• For HACEK microorganism endocarditis: 2g per 24 hours IV/IM in 1 dose for 4 weeks (6 weeks for prosthetic valve) 2, 1

Other Serious Infections

• For Enterobacteriaceae infections in CSF/blood: 2g IV every 12 hours with treatment continued for 21 days 2, 1
• For Haemophilus influenzae infections: 2g IV every 12 hours for 10 days 2, 1
• For skin and skin structure infections in pediatric patients: 50-75 mg/kg once daily (or in equally divided doses twice a day), not to exceed 2g total daily dose 3

Special Populations

Pediatric Dosing

• For most infections: 50-75 mg/kg/day, not to exceed 2g daily 3
• For meningitis: 100 mg/kg/day (not to exceed 4g daily) 3
• For acute bacterial otitis media: single intramuscular dose of 50 mg/kg (not to exceed 1g) 3

Elderly Patients

• No dosage adjustment necessary up to 2g per day, provided there is no severe renal and hepatic impairment 3

Renal/Hepatic Impairment

• No dosage adjustment necessary for patients with impairment of renal or hepatic function 3

Special Considerations

Resistant Organisms

• For penicillin-resistant pneumococci: Add vancomycin 15-20 mg/kg IV twice daily or rifampicin 600mg twice daily to the ceftriaxone regimen 2, 1
• For ceftriaxone-resistant strains: Higher doses may be required, with twice-daily dosing of 2g potentially needed 1

Age-Specific Considerations

• For patients ≥60 years with suspected meningitis: Add amoxicillin 2g IV every 4 hours to cover Listeria monocytogenes 1
• Ceftriaxone is contraindicated in premature neonates and hyperbilirubinemic neonates 3
• Ceftriaxone is contraindicated in neonates (≤28 days) if they require calcium-containing IV solutions 3

Administration Precautions

• Do not use diluents containing calcium (such as Ringer's solution or Hartmann's solution) 3
• Intravenous doses should be given over 60 minutes in neonates to reduce the risk of bilirubin encephalopathy 3
• For adults, administer intravenously by infusion over a period of 30 minutes 3

Treatment Duration Algorithm

1. Meningococcal infections:

   • Meningitis: 5 days if patient has recovered 2
   • Sepsis: 5 days if patient has recovered 2

2. Pneumococcal meningitis:

   • 10 days if stable
   • Up to 14 days if taking longer to respond 2

3. Haemophilus influenzae infections: 10 days 2

4. Enterobacteriaceae infections: 21 days 2

5. HACEK endocarditis:

   • Native valve: 4 weeks
   • Prosthetic valve: 6 weeks 2, 1

6. No identified pathogen:

   • If recovered by day 10, treatment can be discontinued 2

7. General guidance:

   • Continue therapy for at least 2 days after signs and symptoms of infection have disappeared
   • Usual duration is 4-14 days; longer therapy may be required for complicated infections
   • For Streptococcus pyogenes infections, continue for at least 10 days 3

Common Pitfalls and Caveats

• Treatment failures have been reported with ceftriaxone doses between 250-500mg, particularly for pharyngeal infections 1
• Do not mix ceftriaxone with calcium-containing solutions in the same IV administration line due to risk of precipitation 3
• For outpatient therapy, ensure patients have reliable IV access and can access medical advice/care 24 hours a day 1
• If Chlamydia trachomatis is a suspected pathogen, appropriate antichlamydial coverage should be added, as ceftriaxone has no activity against this organism 3
• Treatment durations may need to be extended if the patient is not responding adequately to therapy 2