What is the recommended dosage of ceftriaxone for adults and pediatric patients with varying degrees of impaired renal function?

Ceftriaxone Dosage Recommendations

For adults with renal impairment, no dosage adjustment is necessary—use the standard dose of 1-2 grams every 12-24 hours regardless of creatinine clearance, as ceftriaxone has dual hepatic and renal elimination. 1

Adult Dosing by Indication

Standard Infections

• 1-2 grams once daily (or divided every 12 hours) for most infections including pneumonia, UTI, skin/soft tissue infections 2, 1
• Maximum daily dose: 4 grams 1
• Administer IV over 30 minutes 1

Severe/Specific Infections

• Meningitis: 2 grams IV every 12 hours (4 grams total daily) regardless of renal function to ensure adequate CSF penetration 3, 4
• Endocarditis: 2 grams IV/IM once daily for 4 weeks without adjustment 3, 4
• Complicated intra-abdominal infections: 1-2 grams every 12-24 hours 2
• Uncomplicated gonorrhea: 250 mg IM single dose 1
• Surgical prophylaxis: 1 gram IV single dose 30 minutes to 2 hours before surgery 1

Renal Impairment Considerations

The critical point: ceftriaxone requires NO dose adjustment for isolated renal impairment because it has unique dual elimination (33% renal, 67% biliary). 3, 1, 5

• Moderate renal impairment (CrCl 31-60 mL/min): Standard dosing 1, 5
• Severe renal impairment (CrCl 15-30 mL/min): Standard dosing 1, 5
• End-stage renal disease (CrCl <15 mL/min): Standard dosing 1, 5
• Combined severe hepatic AND renal dysfunction: This is the ONLY scenario requiring dose adjustment—maximum 2 grams daily 1

The pharmacokinetic data confirm this: patients with CrCl <15 mL/min have a half-life of 15.6 hours versus 11.9 hours for CrCl 31-60 mL/min, but plasma concentrations remain therapeutic (mean 20.2 mcg/mL at 24 hours) across all groups. 5

Pediatric Dosing

Standard Infections

• 50-75 mg/kg/day IV divided every 12-24 hours (maximum 2 grams/day) 6, 1
• Acute otitis media: 50 mg/kg IM single dose (maximum 1 gram) 1
• Skin/soft tissue infections: 50-75 mg/kg once daily (maximum 2 grams/day) 1

Severe Infections

• Meningitis: 100 mg/kg/day (maximum 4 grams/day), given once daily or divided every 12 hours 6, 1
  • Initial loading dose: 100 mg/kg (maximum 4 grams) 1
  • Continue for 7-14 days 1
• Endocarditis: Up to 100 mg/kg/day in patients with normal renal function 6

Pediatric Renal Impairment

• For ceftriaxone alone: NO adjustment needed regardless of renal function 1
• If using ceftriaxone-sulbactam combination: Adjust sulbactam component only—50% reduction for moderate impairment (CrCl 15-30 mL/min), 75% reduction for severe impairment (CrCl <15 mL/min) 6

Critical Safety Considerations

Neonates (≤28 days)

• CONTRAINDICATED if receiving or expected to receive IV calcium-containing solutions due to risk of fatal ceftriaxone-calcium precipitation 1
• Administer over 60 minutes (not 30 minutes) to reduce risk of bilirubin encephalopathy 1
• Avoid in hyperbilirubinemic or premature neonates 1

Administration Pitfalls

• Never mix with calcium-containing solutions (Ringer's, Hartmann's)—can cause fatal particulate formation 1
• Flush lines thoroughly between ceftriaxone and calcium-containing solutions in non-neonates 1
• Compatible with metronidazole (5-7.5 mg/mL concentration) in 0.9% saline or D5W for 24 hours at room temperature only 1
• Incompatible with vancomycin, aminoglycosides, fluconazole in admixtures 1

Duration of Therapy

• Most infections: 4-7 days after source control 2
• Streptococcus pyogenes: Minimum 10 days 1
• Complicated infections: May require longer therapy 1
• Prosthetic valve endocarditis: 6 weeks 6