What is the recommended dose of ceftriaxone (a third-generation cephalosporin antibiotic) for pediatric patients?

Ceftriaxone Dosing in Pediatric Patients

Standard Dosing by Age and Weight

For infants and children beyond the neonatal period, ceftriaxone is dosed at 50-75 mg/kg/day for most infections, given once daily or divided every 12-24 hours, with a maximum daily dose of 2 grams for non-meningeal infections and 4 grams for meningitis. 1, 2

Neonatal Dosing (≤28 days of age)

• Neonates ≤7 days postnatal age: 50 mg/kg/day given every 24 hours 1, 3
• Neonates >7 days and ≤2000 g: 50 mg/kg/day given every 24 hours 1, 3
• Neonates >7 days and >2000 g: 50-75 mg/kg/day given every 24 hours 1, 3
• Critical contraindication: Ceftriaxone should NOT be used in hyperbilirubinemic neonates due to risk of bilirubin encephalopathy 1, 3, 2
• Administration requirement: Intravenous doses must be infused over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 2

Infants and Children (>28 days)

Moderate Infections (skin/soft tissue, pneumonia, UTI, sepsis)

• Dose: 50-75 mg/kg/day, given once daily or divided every 12-24 hours 1, 3, 2
• Maximum: 2 grams daily 2
• Examples: Community-acquired pneumonia, cellulitis, pyelonephritis 3, 4

Severe Infections (severe pneumonia, resistant organisms)

• Dose: 80-100 mg/kg/day, given once daily or divided every 12 hours 3, 5
• Maximum: 4 grams daily 3, 5, 2
• Indications: Severe sepsis, pneumococcal pneumonia with penicillin resistance, empyema 3, 5

Bacterial Meningitis

• Initial loading dose: 100 mg/kg (not to exceed 4 grams) 2
• Maintenance dose: 100 mg/kg/day divided every 12-24 hours (maximum 4 grams daily) 1, 3, 2
• Duration: 7-14 days typically 2
• Recent evidence: Once-daily dosing (100 mg/kg) achieves better CSF target attainment (88% probability) compared to twice-daily dosing (53% probability) for pathogens with MIC ≤1 mg/L 6

Acute Otitis Media

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

Gonococcal Infections

• Uncomplicated infections (children <45 kg): 125 mg IM single dose 3
• Bacteremia or arthritis: 50 mg/kg/day for 7 days (maximum 1 gram) 3
• Meningitis: 50 mg/kg/day for 10-14 days (maximum 2 grams) 3

Critical Dosing Considerations

Maximum Dose Limitations

• Pediatric doses must never exceed adult maximum of 4 grams daily, regardless of weight-based calculations 3, 5, 2
• For non-meningeal infections, maximum is typically 2 grams daily unless severe infection 2

Dosing Frequency: Once Daily vs. Twice Daily

• For meningitis: Recent pharmacokinetic modeling demonstrates once-daily dosing (100 mg/kg) is superior to twice-daily dosing (50 mg/kg every 12 hours) for achieving CSF concentrations above MIC throughout the dosing interval 6
• For severe infections in critically ill children: Twice-daily dosing (50 mg/kg every 12 hours) may be preferred in patients with estimated GFR >80 mL/min/1.73 m² or when treating less-susceptible pathogens (MIC ≥0.5 mg/L) 7
• For most other infections: Once-daily dosing is adequate and more convenient 4, 7

Special Populations

• Children ≥45 kg or >40 kg: Use adult dosing regimens 3, 5
• Critically ill children: Standard 100 mg/kg once daily provides adequate exposure for susceptible pathogens (MIC ≤0.5 mg/L), but consider 50 mg/kg twice daily for augmented renal clearance or resistant organisms 7
• No renal or hepatic dose adjustment needed in most cases 2

Administration Guidelines

Route of Administration

• Intravenous: Infuse over 30 minutes for children; 60 minutes for neonates 2
• Intramuscular: Inject deep into large muscle mass; counsel families that IM injection is painful 3, 8
• Both routes are acceptable, but IV preferred for severe infections 3

Critical Compatibility Warning

• Never use calcium-containing diluents (Ringer's solution, Hartmann's solution) as precipitation can occur 8, 2
• Incompatible with vancomycin, aminoglycosides, and fluconazole in admixtures—must flush lines between administrations 2

Common Pitfalls to Avoid

• Do not underdose severe infections: Always use 100 mg/kg/day for life-threatening infections, empyema, or documented resistant pneumococcus 3
• Do not use in hyperbilirubinemic neonates: Risk of kernicterus from ceftriaxone-bilirubin displacement 1, 3, 2
• Do not exceed maximum daily doses: 2 grams for non-meningeal infections, 4 grams for meningitis, regardless of weight 2
• Do not use rapid IV push in neonates: Must infuse over 60 minutes 2
• Neither once-daily nor twice-daily regimens are adequate for S. aureus meningitis (MIC 4 mg/L)—alternative therapy required 6