What is the recommended dosage of ceftriaxone (Ceftriaxone) for surgical prophylaxis and various infections?

Ceftriaxone Dosage for Surgical Prophylaxis and Infections

For surgical prophylaxis, administer ceftriaxone 2g IV as a single dose 30 minutes to 2 hours before incision, with re-injection of 1g if surgery exceeds 4 hours. 1, 2

Surgical Prophylaxis Dosing by Procedure Type

Cardiovascular Surgery

• Cardiac surgery: 2g IV slow + 1g in priming solution, with 1g re-injection at 4 hours intraoperatively 1
• Vascular surgery (aorta, lower limb arteries, supra-aortic trunks): Alternative to cefazolin when cefamandole/cefuroxime used at 1.5g IV slow, single dose (re-inject 0.75g if duration >2 hours) 1
• Open heart surgery: Single 1g preoperative dose provides adequate prophylaxis 3

Orthopedic Surgery

• Joint prosthesis, foreign material implantation: 2g IV slow cefazolin preferred; ceftriaxone not first-line 1
• Closed fractures: Single preoperative dose of ceftriaxone reduced infection rates from 8.3% to 3.6% (p<0.001) 1

Neurosurgery

• Craniotomy, CSF shunt, spine surgery with implants: 2g IV slow cefazolin preferred; ceftriaxone not first-line 1

Gynecologic/Obstetric Surgery

• Cesarean section: 2g IV cefazolin or 1.5g IV cefamandole/cefuroxime as single dose 1
• Hysterectomy: 2g IV cefazolin or 1.5g IV cefamandole/cefuroxime, single dose (re-inject if duration >4 hours for cefazolin, >2 hours for cefamandole/cefuroxime) 1

Gastrointestinal Surgery

• Esophageal, gastroduodenal surgery: 2g IV slow cefazolin or 1.5g IV cefuroxime/cefamandole, single dose 1
• Biliary tract surgery: 2g IV slow cefazolin or 1.5g IV cefuroxime/cefamandole, single dose 1
• Colorectal surgery: Cefoxitin 2g IV + metronidazole 1g preferred over ceftriaxone 1

General Surgical Prophylaxis Principles

• Timing: Infusion must be completed within 60 minutes before incision, optimally 30 minutes before 1, 2
• Duration: Prophylaxis should be limited to operative period, maximum 24 hours postoperatively 1
• Re-dosing: Re-inject if surgical duration exceeds antibiotic half-life (ceftriaxone: re-dose if >4 hours) 1

Treatment Dosing for Established Infections

Adult Dosing

• Standard infections: 1-2g IV once daily or divided twice daily, not to exceed 4g/day 2
• Severe infections: 2g IV once daily 2
• Meningitis: Initial dose 2g, then 2g once or twice daily (total not exceeding 4g/day) 2
• Uncomplicated gonorrhea: 250mg IM single dose 2

Pediatric Dosing

• Skin/soft tissue infections: 50-75 mg/kg once daily or divided twice daily, not to exceed 2g/day 2
• Acute otitis media: 50 mg/kg IM single dose, not to exceed 1g 2
• Serious infections (non-meningitis): 50-75 mg/kg divided every 12 hours, not to exceed 2g/day 2
• Meningitis: Initial dose 100 mg/kg (not to exceed 4g), then 100 mg/kg/day (not to exceed 4g/day) once daily or divided every 12 hours 2
• Endocarditis: 100 mg/kg/day IV divided every 12 hours or 80 mg/kg/day IV every 24 hours (up to 4g daily) 1, 4

Neonatal Considerations

• Contraindicated in premature neonates and neonates ≤28 days requiring calcium-containing IV solutions 2
• Hyperbilirubinemic neonates: Should not receive ceftriaxone 2
• If used: Administer IV doses over 60 minutes to reduce bilirubin encephalopathy risk 2

Administration Guidelines

Intravenous Administration

• Infusion time: 30 minutes for adults; 60 minutes for neonates 2
• Concentration: 10-40 mg/mL recommended 2
• Reconstitution: Use 2.4 mL diluent for 250mg vial, 4.8 mL for 500mg, 9.6 mL for 1g, 19.2 mL for 2g (yields ~100 mg/mL) 2

Critical Safety Warning

• Never use calcium-containing diluents (Ringer's, Hartmann's) for reconstitution or dilution 2
• Never administer simultaneously with calcium-containing IV solutions via Y-site 2
• In non-neonates: May administer sequentially with calcium solutions if lines thoroughly flushed between infusions 2

Specific Infection Treatment Regimens

Skin and Soft Tissue Infections

• Surgical site infections (intestinal/GU tract): Ceftriaxone 1g every 24 hours + metronidazole 500mg every 8 hours IV 1
• Necrotizing fasciitis: Ceftriaxone + metronidazole as part of broad empiric coverage 1
• Clinical cure rate: 81% with ceftriaxone 1g daily vs 77% with cefazolin 3-4g daily for hospitalized patients 5

HACEK Endocarditis

• Native valve: Ceftriaxone 2g IV/IM once daily for 4 weeks 1
• Prosthetic valve: Ceftriaxone 2g IV/IM once daily for 6 weeks 1

Duration of Therapy

• General principle: Continue for at least 2 days after signs/symptoms resolve 2
• Typical duration: 4-14 days; complicated infections may require longer 2
• Streptococcus pyogenes: Minimum 10 days 2

Common Pitfalls to Avoid

• Do not extend prophylaxis beyond 24 hours postoperatively—this becomes therapeutic treatment, not prophylaxis 1
• Cefazolin is preferred over ceftriaxone for most orthopedic and cardiac prophylaxis per guidelines 1
• Do not use ceftriaxone alone for polymicrobial intra-abdominal infections—add anaerobic coverage with metronidazole 1
• Preincisional timing is critical—late administration reduces efficacy 1, 6
• No dosage adjustment needed for renal or hepatic impairment in adults 2