What is the dosing regimen for Rocephin (ceftriaxone)?

Rocephin (Ceftriaxone) Dosing Guidelines

For most adult infections, ceftriaxone is dosed at 1-2 grams IV or IM once daily, though serious central nervous system infections require 2 grams IV every 12 hours to ensure adequate tissue penetration throughout the dosing interval. 1, 2

Standard Adult Dosing by Indication

Uncomplicated Infections

• Uncomplicated gonococcal infections: 250 mg IM as a single dose 1, 2
• Skin and soft tissue infections: 1 gram every 12-24 hours depending on severity 1
• Urinary tract infections: 1 gram IM/IV once daily 1

Serious Infections Requiring Higher/More Frequent Dosing

Central Nervous System Infections (requires twice-daily dosing):

• Bacterial meningitis: 2 grams IV every 12 hours (total 4 grams daily) for 10-14 days 1, 2
• Pneumococcal meningitis: 2 grams IV every 12 hours for 10-14 days, extending treatment if clinical response is delayed 1
• Meningococcal meningitis: 2 grams IV every 12 hours for 5 days 1
• Gonococcal meningitis: 1-2 grams IV every 12 hours for 10-14 days 1

The twice-daily dosing for meningitis is critical during the first 24 hours to achieve rapid CSF sterilization; once-daily dosing may be considered only for stable patients after this period. 1

Endocarditis:

• HACEK organisms: 2 grams IV/IM once daily for 4 weeks (6 weeks for 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
• Gonococcal endocarditis: 1-2 grams IV every 12 hours for at least 4 weeks 1

Disseminated Gonococcal Infection (DGI):

• 1 gram IM or IV every 24 hours initially, continuing for 24-48 hours after clinical improvement, then switch to oral therapy to complete one week total 1

Maximum Daily Dose

The total daily dose should not exceed 4 grams in adults. 2

Pediatric Dosing

Neonates

• Age ≤7 days: 50 mg/kg/day given every 24 hours 4
• Age >7 days and ≤2000 g: 50 mg/kg/day given every 24 hours 4
• Age >7 days and >2000 g: 50-75 mg/kg/day given every 24 hours 4
• Neonatal gonococcal infections: 25-50 mg/kg/day IV or IM once daily for 7 days (10-14 days if meningitis documented) 1

Critical contraindication: Ceftriaxone is contraindicated in hyperbilirubinemic neonates and premature infants, and in neonates ≤28 days requiring calcium-containing IV solutions. 4, 2

Infants and Children

• General infections: 50-75 mg/kg/day divided every 12-24 hours (maximum 2 grams daily) 4, 2
• Meningitis: Initial dose 100 mg/kg (not to exceed 4 grams), then 100 mg/kg/day (maximum 4 grams daily) given once daily or divided every 12 hours for 7-14 days 2
• Acute otitis media: Single IM dose of 50 mg/kg (not to exceed 1 gram) 2
• Children ≥45 kg: Use adult dosing regimens 1

Pediatric doses should never exceed adult dosing even when weight-based calculations suggest higher amounts. 1

Special Populations and Considerations

Elderly Patients

No dosage adjustment necessary up to 2 grams per day, provided there is no severe renal and hepatic impairment. 2

Renal/Hepatic Impairment

No dosage adjustment necessary for isolated renal or hepatic dysfunction with doses up to 2 grams daily. 2, 5 Adjustment may be needed only with combined severe hepatic and renal dysfunction. 2

Patients ≥60 Years with Suspected Meningitis

Add amoxicillin 2 grams IV every 4 hours to ceftriaxone 2 grams every 12 hours to cover Listeria monocytogenes. 1

Penicillin-Resistant Pneumococci

Add vancomycin 15-20 mg/kg IV (targeting trough levels of 15-20 mg/mL) or rifampicin 600 mg twice daily to the ceftriaxone regimen. 1

Administration Guidelines

Intravenous

• Administer by infusion over 30 minutes for adults 2
• Neonates require 60-minute infusion to reduce risk of bilirubin encephalopathy 2
• Recommended concentrations: 10-40 mg/mL 2

Intramuscular

• Inject well within the body of a relatively large muscle 2
• Patients should be informed that IM injection is painful 3
• Completely absorbed after IM administration with bioequivalence to IV route by 2.5 hours 6

Critical Pitfalls to Avoid

1. Never use calcium-containing diluents (Ringer's solution, Hartmann's solution) as particulate formation can result 2
2. Do not use in neonates receiving calcium-containing IV solutions due to risk of fatal ceftriaxone-calcium precipitation 2
3. Avoid underdosing CNS infections: Once-daily dosing is insufficient for meningitis and other CNS infections during initial therapy 1
4. Treatment failures documented with 250-500 mg doses for pharyngeal gonorrhea with elevated MICs; higher doses required 1
5. Always add antichlamydial coverage for gonococcal infections if Chlamydia trachomatis not ruled out 1, 2

Duration of Therapy

Generally continue for at least 2 days after signs and symptoms of infection have disappeared, with usual duration 4-14 days depending on infection type. 2 For Streptococcus pyogenes infections, continue for at least 10 days. 2