What is the recommended dose of ceftriaxone (Ceftriaxone) for adults and pediatric patients?

Ceftriaxone Dosing Recommendations

For adults, ceftriaxone is dosed at 1-2 grams IV/IM once daily for most infections, with CNS infections requiring 2 grams IV every 12 hours (total 4 grams daily), and the maximum daily dose should not exceed 4 grams. 1

Adult Dosing by Indication

Central Nervous System Infections

• Bacterial meningitis: 2 grams IV every 12 hours for 10-14 days depending on pathogen and clinical response 2
• Pneumococcal meningitis: 2 grams IV every 12 hours for 10-14 days (extend if slow response) 2
• Meningococcal meningitis: 2 grams IV every 12 hours for 5 days 2
• Gonococcal meningitis: 1-2 grams IV every 12 hours for 10-14 days 2
• Add vancomycin 15-20 mg/kg IV every 8-12 hours if penicillin-resistant pneumococci suspected 2
• Add amoxicillin 2 grams IV every 4 hours for patients ≥60 years to cover Listeria monocytogenes 2

Endocarditis

• Viridans streptococci/S. bovis (MIC ≤0.12 μg/mL): 2 grams IV/IM once daily for 6 weeks (prosthetic valve) or 4 weeks (native valve) 3, 2
• Can add gentamicin 3 mg/kg daily for first 2 weeks for highly susceptible strains, but not recommended if creatinine clearance <30 mL/min 3
• HACEK organisms: 2 grams IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 2
• Gonococcal endocarditis: 1-2 grams IV every 12 hours for at least 4 weeks 2

Gonococcal Infections

• Uncomplicated cervical/urethral/rectal: 250 mg IM single dose (must add antichlamydial coverage if Chlamydia not ruled out) 2, 1
• Disseminated gonococcal infection (DGI): 1 gram IM/IV every 24 hours, continue 24-48 hours after improvement, then switch to oral therapy to complete 7 days total 2
• Gonococcal conjunctivitis: 1 gram IM single dose with saline lavage 2
• For pharyngeal gonorrhea with elevated MICs or treatment failures: consider 2 grams IV twice daily due to high protein binding and variable pharmacokinetics 2

Other Serious Infections

• Complicated intra-abdominal infections (diverticulitis): 2 grams IV once daily with metronidazole for 4-7 days 4
• Skin and soft tissue infections: 1 gram every 12-24 hours depending on severity 2, 1
• Pyelonephritis: 1 gram IV initial dose, then oral therapy 2
• Lyme disease: 2 grams IV once daily for 2-4 weeks 2
• Neurosyphilis: 2 grams IM/IV daily for 10-14 days (penicillin-allergic patients) 2
• Surgical prophylaxis: 1 gram IV single dose 30 minutes to 2 hours before surgery 1

Pediatric Dosing

Neonates (≤28 days)

• Contraindicated in premature neonates and hyperbilirubinemic neonates 1
• Contraindicated if requiring calcium-containing IV solutions 1
• Postnatal age ≤7 days: 50 mg/kg/day IV once daily 5
• Postnatal age >7 days and ≤2000 g: 50 mg/kg/day IV once daily 5
• Postnatal age >7 days and >2000 g: 50-75 mg/kg/day IV once daily 5
• IV doses must be infused over 60 minutes to reduce risk of bilirubin encephalopathy 1
• Gonococcal infections: 25-50 mg/kg IV/IM single dose (maximum 250 mg) for 7 days (10-14 days if meningitis) 2, 5

Infants and Children

• Meningitis: 100 mg/kg/day IV divided every 12 hours or once daily (maximum 4 grams daily) for 7-14 days 5, 1
• Severe infections (pneumonia, sepsis): 50-100 mg/kg/day IV once daily or divided every 12 hours (maximum 4 grams daily) 5
• Less severe infections: 50-75 mg/kg/day IV once daily or divided every 12 hours (maximum 2 grams daily) 5, 1
• Skin and soft tissue infections: 50-75 mg/kg/day IV once daily or divided twice daily (maximum 2 grams daily) 1
• Acute otitis media: 50 mg/kg IM single dose (maximum 1 gram) 1
• Gonococcal infections in children <45 kg: 125 mg IM single dose for uncomplicated infections 2
• Gonococcal bacteremia/arthritis in children <45 kg: 50 mg/kg/day IV/IM for 7 days (10-14 days if meningitis) 2, 5
• Children ≥45 kg: use adult dosing 2
• Pediatric doses should never exceed adult maximum doses 2, 5

Administration Guidelines

Intravenous Administration

• Standard infusion time: 30 minutes 1
• Neonates: infuse over 60 minutes to reduce bilirubin encephalopathy risk 1
• Recommended concentration: 10-40 mg/mL (lower concentrations acceptable) 1
• Never mix with calcium-containing solutions (Ringer's, Hartmann's) - precipitation will occur 1
• In non-neonates, calcium-containing solutions may be given sequentially if lines thoroughly flushed between infusions 1

Intramuscular Administration

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

Special Populations

Renal/Hepatic Impairment

• No dosage adjustment necessary unless severe combined renal and hepatic impairment 1

Elderly Patients

• No modification required up to 2 grams daily if no severe renal/hepatic impairment 1

Treatment Duration

• Continue therapy at least 2 days after signs/symptoms resolve 1
• Usual duration: 4-14 days for most infections 1
• Streptococcus pyogenes infections: minimum 10 days 1
• Meningococcal meningitis: can safely discontinue after 5 days if clinically recovered 2
• Pneumococcal meningitis: can safely discontinue after 10 days if clinically recovered 2

Critical Pitfalls to Avoid

1. Never use lower doses (250-500 mg) for pharyngeal gonorrhea - treatment failures documented, especially with elevated MICs 2

2. Do not underdose CNS infections - twice-daily dosing (2 grams every 12 hours) is essential for adequate CSF penetration throughout dosing interval 2

3. Avoid calcium-containing solutions in all neonates - fatal precipitates can form 1

4. Do not use in hyperbilirubinemic or premature neonates - risk of kernicterus 1

5. Always add antichlamydial coverage for gonococcal infections if Chlamydia not excluded 1

6. Do not use ceftriaxone alone for meningococcal carriage eradication - requires ciprofloxacin unless ceftriaxone was primary treatment 2

7. Monitor for gallbladder sludging - common adverse effect with prolonged therapy 2