What is the recommended treatment for bacterial meningitis in a 10-year-old pediatric patient, specifically the dosage and administration of ceftriaxone (Ceftriaxone)?

Ceftriaxone for Bacterial Meningitis in a 10-Year-Old Child

For bacterial meningitis in a 10-year-old child, administer ceftriaxone 100 mg/kg/day intravenously, which can be given as a single daily dose or divided into 50 mg/kg every 12 hours, with a maximum daily dose of 4 grams. 1

Dosing Regimen

Standard Dosing

• The recommended dose is 100 mg/kg/day for meningitis in children, not to exceed 4 grams daily 1, 2
• This can be administered either:
  • Once daily (100 mg/kg) 1
  • Divided every 12 hours (50 mg/kg per dose) 1

Route and Administration

• Administer intravenously over 60 minutes in pediatric patients 2
• For a 10-year-old, the dosing falls under the "Age 1 month to 18 years" category, requiring ceftriaxone 50 mg/kg every 12 hours (maximum 2 g every 12 hours) or 100 mg/kg once daily 1

Duration of Therapy

• Continue treatment for 10-14 days for pneumococcal meningitis 1
• For meningococcal or H. influenzae meningitis, 7 days is typically sufficient 1
• The usual duration recommended is 7-14 days, with therapy continuing at least 2 days after signs and symptoms resolve 1, 2

Combination Therapy Considerations

Addition of Vancomycin

• Add vancomycin (10-15 mg/kg every 6 hours) or rifampicin (10 mg/kg every 12 hours, maximum 600 mg/day) to ceftriaxone for empiric coverage of resistant Streptococcus pneumoniae 1
• This combination is recommended until susceptibility results are available 1

When to Avoid Combination Therapy

• If the causative organism is identified as fully susceptible N. meningitidis or H. influenzae, ceftriaxone monotherapy is adequate 1

Adjunctive Dexamethasone

• Consider dexamethasone 0.15 mg/kg every 6 hours for 2-4 days, initiated 10-20 minutes before or concurrent with the first antibiotic dose 1
• For H. influenzae type b meningitis, dexamethasone is strongly supported 1
• For pneumococcal meningitis in children, the evidence is controversial, and the decision should weigh potential benefits against risks 1
• Do not give dexamethasone if antibiotics have already been administered, as it is unlikely to improve outcomes 1

Once-Daily vs. Twice-Daily Dosing

Evidence Supporting Once-Daily Dosing

Recent pharmacokinetic data demonstrates important advantages for once-daily dosing:

• A 2024 population pharmacokinetic study showed that 100 mg/kg once daily achieved 88% probability of target attainment at 24 hours compared to only 53% for twice-daily dosing (50 mg/kg every 12 hours) 3
• Both regimens achieved 100% target attainment at steady state, but once-daily dosing reached therapeutic CSF concentrations earlier 3
• Ceftriaxone's long half-life (approximately 8 hours) and high CSF penetration (approximately 20%) support once-daily administration 4, 3

Clinical Experience

• Multiple studies have demonstrated efficacy and safety of once-daily ceftriaxone in pediatric bacterial meningitis, with mortality rates of 4.8% and neurological sequelae in 3.4% of cases 5
• Mean CSF trough concentrations of 3.5 μg/mL and median bactericidal titers of 1:128 support once-daily dosing 4

Critical Contraindications and Precautions

Calcium-Containing Solutions

• Never administer ceftriaxone simultaneously with calcium-containing IV solutions via Y-site in any patient 2
• In neonates ≤28 days, ceftriaxone is absolutely contraindicated if calcium-containing solutions are required 2
• For patients beyond the neonatal period (including your 10-year-old), ceftriaxone and calcium-containing solutions may be given sequentially if lines are thoroughly flushed between infusions 2

Hyperbilirubinemia

• This is not a concern in a 10-year-old, but ceftriaxone is contraindicated in hyperbilirubinemic neonates due to bilirubin displacement risk 2, 6

Monitoring and Follow-Up

• Clinical improvement should be evident within 48-72 hours, with fever defervescence typically occurring within this timeframe 5
• Repeat lumbar puncture is not routinely necessary unless the patient fails to improve clinically 1
• Audiology testing should be performed at 6 weeks and repeated at 3 months if abnormal 5
• Neurodevelopmental assessment at 3 months is recommended 5

Common Pitfalls to Avoid

• Do not use inadequate dosing: The empiric dose for meningitis is 100 mg/kg/day, not the lower 50-75 mg/kg/day used for other infections 1, 2
• Do not delay antibiotic administration: Ceftriaxone should be given immediately after blood cultures and lumbar puncture are obtained 1
• Do not discontinue therapy prematurely: Complete the full 7-14 day course based on the identified pathogen 1
• Do not forget to add coverage for Listeria in immunocompromised patients: While not typically necessary in a healthy 10-year-old, immunocompromised children require addition of ampicillin 1