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

Ceftriaxone Dosing in Pediatric Patients

Standard Dosing Algorithm by Infection Severity

For most pediatric infections beyond the neonatal period, administer ceftriaxone 50-75 mg/kg/day given once daily or divided every 12-24 hours, with a maximum of 2 grams daily for non-meningeal infections. 1, 2

Neonatal Dosing (Critical Age-Specific Considerations)

• Neonates ≤7 days postnatal age: 50 mg/kg/day given every 24 hours 1
• Neonates >7 days and ≤2000 g: 50 mg/kg/day given every 24 hours 1
• Neonates >7 days and >2000 g: 50-75 mg/kg/day given every 24 hours 1
• CRITICAL CONTRAINDICATION: Never use ceftriaxone in hyperbilirubinemic neonates due to risk of bilirubin encephalopathy 1, 2
• Administration requirement: Infuse intravenous doses over 60 minutes in neonates to reduce risk of bilirubin encephalopathy 2

Infection-Specific Dosing for Children Beyond Neonatal Period

Bacterial Meningitis:

• 100 mg/kg/day divided every 12-24 hours (maximum 4 grams daily) 1, 2
• Initial loading dose of 100 mg/kg (not to exceed 4 grams) is recommended 2
• Recent pharmacokinetic data supports once-daily dosing (100 mg/kg) over twice-daily dosing for earlier achievement of CSF therapeutic targets 3
• Duration: 7-14 days typically 2

Severe Infections (Pneumonia, Sepsis, Complicated Infections):

• 50-100 mg/kg/day given once daily or divided every 12-24 hours 1, 2
• Use the higher end (80-100 mg/kg/day) for severe sepsis, life-threatening infections, or documented resistant pneumococcus 1
• Maximum 2 grams daily for non-meningeal severe infections 2

Pneumococcal Pneumonia with Penicillin Resistance:

• 100 mg/kg/day divided every 12-24 hours 1
• This higher dose ensures adequate CNS penetration and treatment of resistant strains 1

Moderate Infections (Skin/Soft Tissue, Uncomplicated Pneumonia):

• 50-75 mg/kg/day given once daily or divided every 12-24 hours 1, 2
• Maximum 2 grams daily 2

Acute Bacterial Otitis Media:

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

Gonococcal Infections:

• Uncomplicated (urethritis, cervicitis, pharyngitis): 125 mg IM single dose for children <45 kg 1
• Bacteremia or arthritis: 50 mg/kg/day (maximum 1 gram) for 7 days 1
• Meningitis: 50 mg/kg/day (maximum 2 grams) for 10-14 days 1
• Children ≥45 kg should receive adult dosing 1

Critical Maximum Dose Limitations

Pediatric doses must never exceed adult maximum doses regardless of weight-based calculations: 1

• Non-meningeal infections: 2 grams daily maximum
• Meningitis and severe infections: 4 grams daily maximum

Administration Guidelines

Intravenous Administration:

• Infuse over 30 minutes for children beyond neonatal period 2
• Infuse over 60 minutes in neonates to reduce bilirubin encephalopathy risk 2
• Concentrations between 10-40 mg/mL are recommended 2

Intramuscular Administration:

• Inject deep into large muscle mass 4
• Counsel families that IM injection is painful 1, 4
• Aspiration helps avoid unintentional vascular injection 2

Critical Compatibility Warning:

• Never use calcium-containing diluents (Ringer's solution, Hartmann's solution) as precipitation can occur 4, 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 1
• Do not use lower dosing range (50 mg/kg/day) for severe sepsis: Use 80-100 mg/kg/day instead 1
• Do not exceed maximum daily doses: Even if weight-based calculations suggest higher doses, cap at 2 grams (non-meningeal) or 4 grams (meningitis) 1, 2
• Do not use in hyperbilirubinemic neonates: This is an absolute contraindication 1, 2

Special Considerations for Critically Ill Children

• Current 100 mg/kg once-daily dosing provides adequate exposure for susceptible pathogens (MIC ≤0.5 mg/L) in most critically ill children 5
• For patients with estimated glomerular filtration rate >80 mL/min/1.73 m² or areas with high prevalence of less-susceptible pathogens (MIC ≥0.5 mg/L), consider 50 mg/kg twice daily to improve target attainment 5
• If staphylococcal infection suspected, add flucloxacillin 50 mg/kg every 6 hours plus gentamicin 7.5 mg/kg daily 1
• If Listeria is a concern, add ampicillin 50 mg/kg every 6 hours 1