What is the recommended dose and administration route of ceftriaxone (Ceftriaxone) for intramuscular (IM) prophylaxis in minor surgical procedures?

Ceftriaxone IM Prophylaxis for Minor Surgical Procedures

For minor surgical procedures, administer ceftriaxone 1 gram intramuscularly as a single dose 30-60 minutes before the procedure. 1, 2, 3

Standard Dosing Protocol

Adults should receive 1 gram IM as a single preoperative dose, administered 30 minutes to 2 hours before the surgical incision. 1, 3 This dosing is based on the FDA-approved labeling for surgical prophylaxis and is supported by multiple international surgical prophylaxis guidelines. 3, 1

• The 1-gram dose provides plasma concentrations exceeding the minimum inhibitory concentrations (MICs) of most staphylococci, streptococci, and Enterobacteriaceae for 12-24 hours after administration. 4
• Peak plasma concentrations of approximately 81 micrograms/ml are achieved after 1 gram IM injection, with a plasma half-life of 8.3 hours. 4
• Plasma concentrations remain therapeutic for the duration of most minor surgical procedures without requiring redosing. 4, 5

Pediatric Dosing

Children should receive 50 mg/kg IM as a single dose (maximum 1 gram), administered 30-60 minutes before the procedure. 1, 2, 3

• The pediatric dose should not exceed the adult dose of 1 gram regardless of weight. 1, 3
• For children weighing ≥45 kg, use the standard adult dose of 1 gram IM. 6

Anatomic Location Considerations

The anatomic site of surgery determines whether monotherapy is sufficient or combination therapy is required:

• For procedures on the trunk or extremities (away from axilla/perineum): Ceftriaxone 1 gram IM alone is adequate. 7, 2
• For procedures in the axilla or perineal region: Add metronidazole 500 mg IV every 8 hours to provide anaerobic coverage, as these areas have higher risk of polymicrobial infection including anaerobes. 7, 2
• For procedures involving intestinal or genitourinary tract: Add metronidazole 500 mg IV every 8 hours for anaerobic coverage. 7

Critical Contraindications and Precautions

Do not use ceftriaxone in patients with history of anaphylaxis, angioedema, or urticaria to penicillins or ampicillin. 1, 2 While cephalosporins can be used in patients with non-severe penicillin allergies, severe IgE-mediated reactions represent an absolute contraindication. 1

Do not use ceftriaxone monotherapy for MRSA coverage. 7, 2 Ceftriaxone has no activity against methicillin-resistant staphylococci; if MRSA is suspected based on local epidemiology or patient risk factors, add vancomycin 15 mg/kg IV every 12 hours. 7, 2

Avoid diluents containing calcium for reconstitution. 3 Do not use Ringer's solution or Hartmann's solution, as precipitation of ceftriaxone-calcium can occur. 3

Administration Technique

Reconstitute the 1-gram vial with 3.6 mL of diluent to achieve a concentration of 250 mg/mL, or with 2.1 mL to achieve 350 mg/mL. 3

• Inject the diluent into the vial and shake thoroughly to form solution. 3
• Withdraw entire contents into syringe to equal the total labeled dose. 3
• Inject deeply into the body of a large muscle mass; aspiration helps avoid unintentional intravascular injection. 3
• Patients should be informed that intramuscular injection of ceftriaxone is painful. 1

Evidence Supporting Single-Dose Prophylaxis

The efficacy of single-dose ceftriaxone prophylaxis is well-established. 8 In open heart surgery, a single 1-gram preoperative dose of ceftriaxone was equivalent to seven doses of cefazolin administered perioperatively, with no significant difference in infectious complications. 8 For closed fractures requiring osteosynthesis, single-dose prophylaxis reduced postoperative infection rates from 8.3% to 3.6% (P < 0.001). 2

Common Pitfalls to Avoid

• Do not extend prophylaxis beyond the operative period. 1, 3 Postoperative administration beyond 24 hours is unnecessary and potentially harmful, increasing antibiotic resistance without improving outcomes. 9
• Do not substitute ceftriaxone monotherapy for proper surgical technique. 2 Antibiotic prophylaxis does not replace adequate aseptic technique and surgical site preparation. 2
• Do not use ceftriaxone for procedures with high pseudomonal risk. 10 While ceftriaxone has some activity against Pseudomonas aeruginosa, it cannot be recommended as sole therapy in pseudomonal infections. 10