What is the recommended dosing for ceftriaxone (Ceftriaxone) for pneumonia?

Ceftriaxone Dosing for Pneumonia

For adult patients with pneumonia, ceftriaxone should be dosed at 1 gram intravenously once daily, as this dosage is as effective as 2 grams daily while reducing the risk of Clostridioides difficile infection and shortening hospital length of stay. 1

Adult Dosing Recommendations

• Standard adult dosing is 1 to 2 grams given once daily (or in equally divided doses twice a day) depending on the type and severity of infection, with a maximum total daily dose of 4 grams 2
• For community-acquired pneumonia (CAP), 1 gram once daily is as effective as 2 grams daily, with comparable clinical outcomes 3, 1
• Treatment duration should typically be 5-7 days for patients who become afebrile within 48 hours, or 10-14 days for more severe cases or those with bacteremia 4
• When treating Streptococcus pyogenes infections, therapy should be continued for at least 10 days 2
• No dosage adjustment is necessary for elderly patients up to 2 grams per day, provided there is no severe renal or hepatic impairment 2

Pediatric Dosing Recommendations

• For pediatric community-acquired pneumonia, the recommended dosage is 50-100 mg/kg/day given every 12-24 hours 5
• For penicillin-resistant S. pneumoniae, dosing should be 100 mg/kg/day every 12-24 hours 5
• For severe infections including empyema, consider higher dosing within the recommended range 5
• The total daily dose should not exceed 2 grams for most infections, except meningitis 2

Administration Guidelines

• Intravenous doses should be administered over 30 minutes in adults 2
• In neonates, administer over 60 minutes to reduce the risk of bilirubin encephalopathy 2
• Concentrations between 10 mg/mL and 40 mg/mL are recommended for IV administration 2

Important Clinical Considerations

• Ceftriaxone alone is not effective against atypical pathogens (Mycoplasma, Chlamydophila, Legionella); combination therapy with a macrolide is recommended when these pathogens are suspected 4
• For suspected drug-resistant Streptococcus pneumoniae (DRSP), ceftriaxone may be combined with a macrolide or respiratory fluoroquinolone 4
• When treating MSSA pneumonia, standard 1g daily dosing may be inadequate; consider higher doses (2-4g daily) as recommended in the prescribing information for MSSA infections 6
• Do not use diluents containing calcium, such as Ringer's solution or Hartmann's solution, to reconstitute ceftriaxone due to risk of particulate formation 2

Monitoring and Follow-up

• Assess clinical response within 48-72 hours of initiating therapy 5
• Consider step-down to appropriate oral therapy once clinical improvement is observed 5
• If no improvement is seen within 48-72 hours, reevaluation and possible change in therapy is warranted 5

Evidence Supporting 1g vs 2g Daily Dosing

• A 2023 retrospective cohort study of 3,989 hospitalized CAP patients found that 1g daily ceftriaxone was associated with similar 30-day mortality rates as 2g daily (14.7% vs 16.0%), with decreased rates of C. difficile infection (0.2% vs 0.6%) and shorter hospital stays (median 4 vs 5 days) 1
• A 2019 systematic review with meta-analysis concluded that ceftriaxone 1g daily is as safe and effective as higher doses for community-acquired pneumonia, with an odds ratio for clinical cure of 1.03 (95% CI [0.88-1.20]) compared to other regimens 3