What is the recommended dose of ceftriaxone (Ceftriaxone) in pediatrics?

Recommended Dose of Ceftriaxone in Pediatrics

For most pediatric infections, ceftriaxone should be dosed at 50-75 mg/kg/day given once daily or divided every 12 hours, with a maximum of 2 grams daily for non-meningeal infections, while meningitis requires 100 mg/kg/day (maximum 4 grams daily). 1, 2

Age-Specific Dosing for Neonates

Critical neonatal considerations:

• Neonates ≤7 days postnatal age: 50 mg/kg/day every 24 hours 1
• Neonates >7 days and ≤2000 g: 50 mg/kg/day every 24 hours 1
• Neonates >7 days and >2000 g: 50-75 mg/kg/day every 24 hours 1
• Administer intravenously over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 2
• Never use ceftriaxone in hyperbilirubinemic neonates 1

Infection-Specific Dosing Beyond the Neonatal Period

Meningitis (Highest Priority Dosing)

• Initial dose: 100 mg/kg (not to exceed 4 grams) 2
• Maintenance: 100 mg/kg/day divided every 12-24 hours (maximum 4 grams daily) 1, 2
• Duration: 7-14 days typically 2

Severe Infections (Pneumonia, Sepsis, Complicated Intra-abdominal Infections)

• 50-100 mg/kg/day given once daily or divided every 12-24 hours 1
• For severe sepsis specifically, use the higher end: 80-100 mg/kg/day 1
• Do not use the lower dosing range (50 mg/kg/day) for severe sepsis 1
• Maximum 2 grams daily for non-meningeal severe infections 2

Less Severe Infections (Skin/Soft Tissue)

• 50-75 mg/kg/day given once daily or divided every 12 hours 1, 2
• Maximum 2 grams daily 2

Acute Otitis Media

• Single intramuscular dose of 50 mg/kg (maximum 1 gram) 2

Uncomplicated Gonococcal Infections

• Patients <45 kg: 125 mg IM single dose 1
• Gonococcal conjunctivitis: 25-50 mg/kg IV/IM single dose (maximum 250 mg) 1
• Gonococcal bacteremia/arthritis: 50 mg/kg/day for 7 days 1

Pathogen-Specific Considerations

When specific pathogens are identified or suspected:

• Penicillin-resistant Streptococcus pneumoniae (MIC ≥4.0 μg/mL): 100 mg/kg/day every 12-24 hours 3
• Streptococcus pneumoniae with penicillin MIC <2.0 μg/mL: 50-100 mg/kg/day every 12-24 hours 3
• Gram-negative enteric bacilli: 100 mg/kg/day divided every 12 hours OR 80 mg/kg/day every 24 hours (maximum 4 grams daily) 1
• HACEK organisms (endocarditis): 100 mg/kg/day IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 1

Critical Administration Details

Route and timing considerations:

• Intravenous doses should be infused over 30 minutes in children 2
• Neonates require 60-minute infusion to reduce bilirubin encephalopathy risk 2
• Intramuscular injection is painful; counsel patients and families accordingly 1
• IM injections should be administered deep into large muscle mass 2

Maximum Dose Limitations

Absolute maximums regardless of weight:

• Non-meningeal infections: 2 grams daily 2
• Meningitis and severe infections: 4 grams daily 1, 2
• Pediatric doses should never exceed adult maximum doses 1

Common Pitfalls to Avoid

• Never mix ceftriaxone with calcium-containing solutions (Ringer's, Hartmann's) due to precipitation risk 2
• Do not use in hyperbilirubinemic neonates due to kernicterus risk 1
• Avoid underdosing severe sepsis—use 80-100 mg/kg/day, not the lower 50 mg/kg/day range 1
• For suspected staphylococcal sepsis, add flucloxacillin 50 mg/kg every 6 hours plus gentamicin 7.5 mg/kg daily 1
• For suspected Listeria, add ampicillin 50 mg/kg every 6 hours 1
• When treating Streptococcus pyogenes infections, continue therapy for at least 10 days 2

Special Populations

Renal/hepatic impairment:

• No dosage adjustment necessary unless both severe renal AND hepatic impairment are present 2

High-risk scenarios requiring twice-daily dosing:

• Patients with estimated glomerular filtration rate >80 mL/min/1.73 m² may benefit from 50 mg/kg twice daily rather than 100 mg/kg once daily for improved target attainment 4
• Areas with high prevalence of less-susceptible pathogens (MIC ≥0.5 mg/L) should consider twice-daily dosing 4