Maximum Dose of Ceftriaxone in Pediatrics
The maximum daily dose of ceftriaxone in pediatric patients is 4 grams, regardless of the indication or dosing frequency. 1
Age-Based Maximum Dosing
Neonates
- Postnatal age ≤7 days: Maximum 50 mg/kg/day given every 24 hours 1
- Postnatal age >7 days and ≤2000 g: Maximum 50 mg/kg/day given every 24 hours 1
- Postnatal age >7 days and >2000 g: Maximum 50-75 mg/kg/day given every 24 hours 1
- Critical caveat: Never use ceftriaxone in hyperbilirubinemic neonates due to risk of kernicterus 1
Infants and Children
Pediatric doses should never exceed adult doses, with an absolute maximum of 4 g daily regardless of weight or indication. 1 This means that even for severe infections requiring 100 mg/kg/day, the dose is capped at 4 grams total daily dose.
Indication-Specific Maximum Dosing
Bacterial Meningitis (Highest Dose Indication)
- Dose: 100 mg/kg/day divided every 12-24 hours, with a maximum of 4 g daily 1
- This represents the highest recommended dose for any pediatric indication
- Recent pharmacokinetic data from 2024 supports once-daily dosing (100 mg/kg, max 4 g) over twice-daily for better CSF penetration and target attainment 2
Severe Infections (Pneumonia, Sepsis, Endocarditis)
- Dose: 50-100 mg/kg/day, with a maximum of 4 g daily 1
- For gram-negative enteric bacilli and endocarditis: 100 mg/kg/day divided every 12 hours OR 80 mg/kg/day every 24 hours, up to 4 g daily 1
- For severe sepsis in critically ill children: 80-100 mg/kg/day range is appropriate, but never exceeding 4 g daily 1
Less Severe Infections
- Dose: 50-75 mg/kg/day, with a maximum of 4 g daily 1
- For complicated intra-abdominal infections and standard sepsis: 50-75 mg/kg/day 1
Practical Application Algorithm
For a child weighing 40 kg or more:
- Calculate dose: 100 mg/kg = 4000 mg (4 g)
- Give 4 g maximum (do not exceed even if weight-based calculation is higher)
For a child weighing less than 40 kg with meningitis:
- Calculate dose: 100 mg/kg/day
- Example: 30 kg child = 3000 mg (3 g) daily
- This is below the 4 g maximum, so give the calculated dose
For a child weighing less than 40 kg with severe infection:
- Calculate dose: 50-100 mg/kg/day based on severity
- Cap at 4 g daily maximum
Critical Considerations
Administration Route
- Intramuscular injection is painful and patients should be counseled accordingly 1, 3
- Deep injection into large muscle mass is required 3
- Avoid calcium-containing diluents (Ringer's solution, Hartmann's solution) due to precipitation risk 3
Common Pitfall to Avoid
Do not calculate doses exceeding 4 g daily even for large adolescents or severe infections. The 4 g maximum is an absolute ceiling established by the American Heart Association and other major guidelines 1. This applies regardless of whether dosing is once daily or divided every 12 hours.