What is the recommended dosage and treatment duration for Ceftriaxone (Ceftriaxone) in treating bacterial infections?

Ceftriaxone Dosing and Treatment Duration for Bacterial Infections

For most adult bacterial infections, administer ceftriaxone 1-2 grams IV/IM once daily for 4-14 days, with specific dosing determined by infection site and severity: use 2 grams every 12 hours (total 4 grams daily) for meningitis, 2 grams once daily for endocarditis (4-6 weeks), and 1 gram once daily for disseminated gonococcal infection. 1, 2

Adult Dosing by Infection Type

Central Nervous System Infections

• Bacterial meningitis requires 2 grams IV every 12 hours (total 4 grams daily), continued for pathogen-specific durations 1, 2
• Pneumococcal meningitis: 10-14 days of treatment, extending duration if clinical response is delayed 1
• Meningococcal meningitis: 5 days of treatment 1
• Gonococcal meningitis: 10-14 days at 1-2 grams IV every 12 hours 1
• Add vancomycin 15-20 mg/kg IV twice daily for penicillin-resistant pneumococci 1
• Add amoxicillin 2 grams IV every 4 hours for patients ≥60 years to cover Listeria monocytogenes 1

Endocarditis

• HACEK organisms: 2 grams IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 3, 1
• Highly penicillin-susceptible viridans streptococci (MIC ≤0.12 μg/mL): 2 grams IV/IM once daily for 4 weeks as monotherapy 1
• Alternative short-course regimen: 2 grams IV/IM once daily for 2 weeks plus gentamicin 3 mg/kg daily, but avoid in patients with cardiac/extracardiac abscess, creatinine clearance <20 mL/min, or eighth cranial nerve dysfunction 1
• Gonococcal endocarditis: 1-2 grams IV every 12 hours for at least 4 weeks 1

Gonococcal Infections

• Uncomplicated infections: 250 mg IM as single dose 1, 2
• Disseminated gonococcal infection (DGI): 1 gram IM/IV every 24 hours, continue for 24-48 hours after improvement begins, then switch to oral therapy to complete 7 days total 1
• Gonococcal conjunctivitis: 1 gram IM single dose with saline lavage of infected eye 1

Other Serious Infections

• Standard dosing for most infections: 1-2 grams once daily or divided twice daily depending on severity 2
• Pyelonephritis: Initial 1 gram dose, then transition to oral therapy 1
• Lyme disease: 2 grams IV once daily for 2-4 weeks 1
• Neurosyphilis (penicillin-allergic patients): 2 grams daily IM or IV for 10-14 days 1

Surgical Prophylaxis

• Single dose of 1 gram IV administered 30 minutes to 2 hours before surgery 2

Pediatric Dosing

Neonates (≤28 days)

• Contraindicated in hyperbilirubinemic neonates and premature infants 4, 2
• Contraindicated if calcium-containing IV solutions are required 2
• Postnatal age ≤7 days: 50 mg/kg/day every 24 hours 4
• Postnatal age >7 days and ≤2000 g: 50 mg/kg/day every 24 hours 4
• Postnatal age >7 days and >2000 g: 50-75 mg/kg/day every 24 hours 4
• Administer IV doses over 60 minutes to reduce bilirubin encephalopathy risk 2
• Gonococcal infections: 25-50 mg/kg/day IV or IM single dose for 7 days (10-14 days if meningitis documented) 1

Infants and Children

• Meningitis: 100 mg/kg/day (maximum 4 grams daily) divided every 12 hours or once daily 4, 2
• Serious infections (non-meningitis): 50-75 mg/kg/day divided every 12 hours (maximum 2 grams daily) 2
• Skin and soft tissue infections: 50-75 mg/kg once daily (maximum 2 grams daily) 2
• Acute otitis media: 50 mg/kg IM single dose (maximum 1 gram) 2
• Community-acquired pneumonia: 50-100 mg/kg/day once daily or divided every 12-24 hours 4
• Endocarditis: 100 mg/kg/day divided every 12 hours or 80 mg/kg/day once daily (maximum 4 grams daily) for 4-6 weeks 1
• Children ≥45 kg: use adult dosing regimens 1
• Children <45 kg with uncomplicated gonococcal infections: 125 mg IM single dose 1
• Children <45 kg with bacteremia/arthritis: 50 mg/kg daily for 7 days (10-14 days for meningitis) 1

Special Populations and Considerations

Renal and Hepatic Impairment

• No dosage adjustment necessary for renal or hepatic impairment alone 2
• Maximum adult dose should not exceed 4 grams daily 2
• Chronic renal failure on hemodialysis: 1 gram every other day has been used 5

Elderly Patients

• No modification required up to 2 grams per day if no severe renal/hepatic impairment 2

Outpatient Parenteral Antibiotic Therapy (OPAT)

• For stable, afebrile patients after 5 days inpatient therapy: 2 grams twice daily IV initially, with option to use 4 grams once daily IV after first 24 hours 1
• Requires reliable IV access and 24-hour access to medical advice 1

Administration Guidelines

Intravenous Administration

• Infuse over 30 minutes for adults and children; 60 minutes for neonates 2
• Recommended concentrations: 10-40 mg/mL 2
• Never use calcium-containing diluents (Ringer's, Hartmann's) due to precipitation risk 2
• In non-neonates, may administer sequentially with calcium-containing solutions if lines thoroughly flushed between infusions 2

Intramuscular Administration

• Reconstitute to 250 mg/mL or 350 mg/mL concentration 2
• Inject deep into large muscle mass with aspiration to avoid vascular injection 2
• IM injection is painful; counsel patients accordingly 1

Treatment Duration by Pathogen

• Streptococcus pyogenes: minimum 10 days 2
• Meningococcal meningitis: 5-7 days 1
• Pneumococcal meningitis: 10-14 days 1
• Listeria monocytogenes: 21 days 1
• Haemophilus influenzae meningitis: 10 days 1
• Enterobacteriaceae in CSF/blood: 21 days 1
• General guideline: continue therapy for at least 2 days after signs and symptoms resolve 2
• Usual duration for most infections: 4-14 days; complicated infections may require longer 2

Critical Pitfalls to Avoid

• Never administer ceftriaxone with calcium-containing solutions in neonates via any route 2
• Avoid in hyperbilirubinemic neonates due to displacement of bilirubin from albumin binding sites 2
• Treatment failures reported with 250-500 mg doses for pharyngeal gonococcal infections with elevated MICs; higher doses critical for such cases 1
• For ceftriaxone-resistant strains, twice-daily dosing of 2 grams may be necessary 1
• Add antichlamydial coverage if Chlamydia trachomatis suspected, as ceftriaxone has no activity against this organism 2

Adverse Effects

Common adverse effects include rash, fever, diarrhea, neutropenia, liver function abnormalities, and gallbladder "sludging" 1. Once-daily dosing offers convenience advantages and potential cost savings through OPAT without compromising efficacy 1, 6, 7, 8.