What is the recommended dose and treatment duration of Ceftriaxone for bacterial infections?

Ceftriaxone Dosing for Bacterial Infections

For most adult bacterial infections, ceftriaxone should be dosed at 1-2 grams IV/IM once daily, with higher doses (2 grams every 12 hours, total 4 grams daily) reserved specifically for CNS infections like bacterial meningitis. 1, 2

Standard Adult Dosing by Infection Type

Uncomplicated Infections

• Uncomplicated gonococcal infections (cervix, urethra, rectum): 125-250 mg IM as a single dose 3, 1, 2
• Community-acquired pneumonia: 1 gram IV/IM once daily is as effective as 2 grams daily for typical pathogens 4, 5
• Skin/soft tissue infections: 1-2 grams IV/IM once daily 2
• Urinary tract infections: 1-2 grams IV/IM once daily 2

Disseminated/Complicated Infections

• Disseminated gonococcal infection (DGI): 1 gram IM/IV every 24 hours, continue for 24-48 hours after clinical improvement, then switch to oral therapy to complete 7 days total 1
• Gonococcal conjunctivitis: Single dose of 1 gram IM 1
• Endocarditis (highly penicillin-susceptible streptococci): 2 grams IV/IM once daily for 4 weeks 1
• HACEK endocarditis: 2 grams IV/IM once daily for 4 weeks (6 weeks for prosthetic valve) 1

Central Nervous System Infections (Critical Distinction)

• Bacterial meningitis (pneumococcal, meningococcal, H. influenzae): 2 grams IV every 12 hours (total 4 grams daily) for 10-14 days 3, 1, 2
• Gonococcal meningitis: 1-2 grams IV every 12 hours for 10-14 days 1
• Gonococcal endocarditis: 1-2 grams IV every 12 hours for at least 4 weeks 1

The twice-daily dosing for meningitis is essential to maintain adequate CSF concentrations throughout the treatment period, as once-daily dosing is insufficient for CNS penetration. 1

Pediatric Dosing

Neonates (<1 month)

• Standard infections: 50 mg/kg IV/IM once daily 2
• Meningitis: Initial dose 100 mg/kg (max 4 grams), then 100 mg/kg/day (max 4 grams daily) once daily or divided every 12 hours 2
• Gonococcal infections: 25-50 mg/kg IV/IM once daily for 7 days (10-14 days if meningitis) 1
• Administer IV doses over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 2
• Contraindicated in hyperbilirubinemic neonates 6, 2

Infants and Children

• Standard infections: 50-75 mg/kg/day IV/IM once daily or divided every 12 hours (max 2 grams daily) 2
• Meningitis: 100 mg/kg/day (max 4 grams daily) once daily or divided every 12 hours 2
• Acute otitis media: Single IM dose of 50 mg/kg (max 1 gram) 2
• Children ≥45 kg: Use adult dosing regimens 1

Treatment Duration by Infection

• Uncomplicated gonorrhea: Single dose 3, 1
• Community-acquired pneumonia: 4-14 days, typically 5-7 days 2, 7
• Meningitis: 10-14 days (pneumococcal, H. influenzae), 5 days (meningococcal), 21 days (Enterobacteriaceae) 1
• Endocarditis: 4 weeks (native valve), 6 weeks (prosthetic valve) 1
• Streptococcus pyogenes infections: Minimum 10 days 2
• Continue therapy at least 2 days after signs/symptoms resolve 2

Special Populations and Considerations

Elderly Patients

• No dosage adjustment needed up to 2 grams daily unless severe renal/hepatic impairment present 2

Renal/Hepatic Impairment

• No dosage adjustment necessary for isolated renal or hepatic dysfunction 2
• Monitor closely if both severe renal AND hepatic impairment present 2

Resistant Organisms

• Penicillin-resistant pneumococcal meningitis: Add vancomycin 10-20 mg/kg IV every 8-12 hours (target trough 15-20 μg/mL) OR rifampicin 300 mg every 12 hours to ceftriaxone regimen 3, 1
• Ceftriaxone-resistant gonorrhea (elevated MICs): Consider twice-daily dosing of 2 grams, particularly for pharyngeal infections 1
• Patients ≥60 years with suspected meningitis: Add amoxicillin 2 grams IV every 4 hours to cover Listeria monocytogenes (ceftriaxone has no activity against Listeria) 3, 1

Administration Guidelines

Intravenous

• Standard infusion time: 30 minutes 2
• Neonates: Infuse over 60 minutes to reduce bilirubin encephalopathy risk 2
• Concentration: 10-40 mg/mL recommended 2

Intramuscular

• Inject deep into large muscle mass 2
• Aspirate before injection to avoid intravascular administration 2
• Reconstitution concentrations: 250 mg/mL or 350 mg/mL depending on vial size 2

Critical Pitfalls to Avoid

1. Do NOT use once-daily dosing for meningitis - CNS infections require twice-daily dosing (every 12 hours) to maintain adequate CSF levels 3, 1

2. Do NOT use ceftriaxone alone for Listeria - Add ampicillin/amoxicillin for patients ≥60 years or immunocompromised with suspected meningitis 3, 1

3. Do NOT mix with calcium-containing solutions - Can cause fatal precipitates; avoid Ringer's or Hartmann's solution 2

4. Do NOT use in hyperbilirubinemic neonates - Risk of kernicterus from bilirubin displacement 6, 2

5. Treatment failures with 125-250 mg doses for pharyngeal gonorrhea - Consider higher doses for pharyngeal infections, especially with elevated MICs 1

6. Do NOT assume coverage for atypical pneumonia pathogens - Ceftriaxone lacks activity against Legionella, Mycoplasma, and Chlamydia; add appropriate coverage if suspected 5

Outpatient Parenteral Therapy (OPAT)

Once-daily dosing makes ceftriaxone ideal for outpatient therapy after initial stabilization, potentially saving significant hospitalization costs. 7

• Pneumonia: After 24-48 hours of clinical improvement, most children can be discharged on once-daily IM ceftriaxone 7
• DGI: Switch to oral therapy after 24-48 hours of improvement on IV/IM ceftriaxone 1
• Endocarditis (selected cases): After 5 days inpatient with clinical improvement, may continue with 2 grams twice daily IV or 4 grams once daily IV as OPAT 1