What is the recommended dose for ceftriaxone (Ceftriaxone is a third-generation cephalosporin antibiotic)?

Ceftriaxone Dosing Recommendations

Pediatric Dosing

For most pediatric infections, ceftriaxone should be dosed at 50-75 mg/kg/day, with meningitis requiring 100 mg/kg/day (maximum 4 grams daily), administered either once daily or divided every 12 hours. 1, 2

Neonatal Dosing (Age-Specific)

• Postnatal age ≤7 days: 50 mg/kg/day given every 24 hours 1
• Postnatal age >7 days and weight ≤2000g: 50 mg/kg/day given every 24 hours 1
• Postnatal age >7 days and weight >2000g: 50-75 mg/kg/day given every 24 hours 1
• Critical caveat: Never use ceftriaxone in hyperbilirubinemic neonates due to risk of bilirubin encephalopathy; IV doses must be given over 60 minutes in neonates 1, 2

Infection-Specific Pediatric Dosing

Meningitis: 100 mg/kg/day (maximum 4g daily) divided every 12 hours or given once daily 1, 2

• Initial loading dose of 100 mg/kg is recommended 2
• Recent pharmacokinetic data supports once-daily dosing (100 mg/kg every 24 hours) over twice-daily dosing for earlier achievement of therapeutic CSF concentrations 3
• Duration: 7-14 days typically 2

Severe infections (pneumonia, sepsis): 50-100 mg/kg/day once daily or divided every 12-24 hours (maximum 2g daily for non-meningitis infections) 1, 2

Less severe infections: 50-75 mg/kg/day once daily or divided every 12-24 hours 1, 2

Acute otitis media: Single IM dose of 50 mg/kg (maximum 1 gram) 2

Gonococcal infections:

• Uncomplicated (weight <45kg): 125 mg IM single dose 4
• Bacteremia/arthritis (weight <45kg): 50 mg/kg/day for 7 days 1, 4
• Meningitis: 50 mg/kg/day for 10-14 days 4

Endocarditis: 100 mg/kg/day divided every 12 hours or 80 mg/kg/day every 24 hours (maximum 4g daily) for 4-6 weeks 5, 1

Adult Dosing

For most adult infections, ceftriaxone should be dosed at 1-2 grams once daily, with meningitis and endocarditis requiring 2 grams every 12 hours (total 4 grams daily). 4, 2

Standard Adult Dosing

• Usual dose: 1-2 grams once daily or divided every 12 hours depending on infection severity 4, 2
• Maximum daily dose: 4 grams 2
• Surgical prophylaxis: 1 gram IV single dose 30 minutes to 2 hours before surgery 2

Infection-Specific Adult Dosing

Bacterial meningitis: 2 grams IV every 12 hours (total 4g daily) 4

• Duration: 10-14 days for most pathogens 4
• Pneumococcal: 10-14 days (longer if slow response) 4
• Meningococcal: 5 days 4
• Haemophilus influenzae: 10 days 4
• Enterobacteriaceae: 21 days 4

Gonococcal infections:

• Uncomplicated: 250 mg IM single dose 4, 2
• Disseminated gonococcal infection (DGI): 1 gram IM/IV every 24 hours for 24-48 hours after improvement, then switch to oral therapy to complete 7 days 4
• Gonococcal meningitis: 1-2 grams IV every 12 hours for 10-14 days 4
• Gonococcal endocarditis: 1-2 grams IV every 12 hours for at least 4 weeks 4

Endocarditis:

• Highly penicillin-susceptible streptococci (MIC ≤0.12 μg/mL): 2 grams IV/IM once daily for 4 weeks (monotherapy) 4
• HACEK organisms: 2 grams IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 4

Lyme disease: 2 grams IV once daily for 2-4 weeks 4

Pyelonephritis: Initial 1 gram dose, then switch to oral therapy 4

Critical Dosing Considerations

Once-Daily vs. Twice-Daily Dosing

For meningitis, once-daily dosing (100 mg/kg in children, 4g total in adults) achieves superior early CSF penetration compared to twice-daily dosing, though both regimens achieve adequate steady-state concentrations. 3

• Once-daily dosing is more convenient and cost-effective for outpatient parenteral therapy 4
• Twice-daily dosing remains standard for meningitis in most guidelines, but emerging evidence supports once-daily administration 3

Common Pitfalls and Caveats

• Never exceed 4 grams daily in any patient 1, 2
• Avoid in hyperbilirubinemic neonates due to displacement of bilirubin from albumin binding sites 1, 2
• Do not mix with calcium-containing solutions (Ringer's, Hartmann's) due to precipitation risk 2
• Administer IV doses over 30 minutes in children and adults, 60 minutes in neonates 2
• For Staphylococcus aureus meningitis, neither standard dosing regimen achieves adequate CSF concentrations (MIC 4 mg/L); alternative therapy required 3
• Treatment failures reported with 250-500 mg doses, particularly for pharyngeal gonococcal infections with elevated MICs 4
• No dose adjustment needed for renal or hepatic impairment up to 2 grams daily 2, 6

Special Populations

• Elderly patients: No dose modification required up to 2 grams daily if no severe renal/hepatic impairment 2
• Dialysis patients: Ceftriaxone not significantly removed by hemodialysis; monitor plasma concentrations in small percentage with reduced elimination 6
• Patients ≥60 years with suspected meningitis: Add amoxicillin 2g IV every 4 hours to cover Listeria monocytogenes 4