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

Ceftriaxone Pediatric Dosing

For most serious pediatric infections beyond the neonatal period, administer ceftriaxone 50-75 mg/kg/day once daily or divided every 12 hours, with a maximum of 2 grams daily for non-meningeal infections; for bacterial meningitis, use 100 mg/kg/day (maximum 4 grams daily). 1

Neonatal Dosing (Critical Age and Weight Considerations)

Ceftriaxone is contraindicated in hyperbilirubinemic neonates due to risk of bilirubin encephalopathy. 1

• For neonates ≤7 days postnatal age: 50 mg/kg/day every 24 hours 1
• For neonates >7 days and ≤2000 g: 50 mg/kg/day every 24 hours 1
• For neonates >7 days and >2000 g: 50-75 mg/kg/day every 24 hours 1
• Administer intravenous doses over 60 minutes in neonates to reduce bilirubin encephalopathy risk 2

Standard Pediatric Dosing Algorithm (Beyond Neonatal Period)

Mild to Moderate Infections

• 50-75 mg/kg/day once daily or divided every 12-24 hours 1, 2
• Maximum daily dose: 2 grams 1, 2
• Indications include: uncomplicated pneumonia, cellulitis, urinary tract infections, sepsis, complicated intra-abdominal infections 1

Severe Infections

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

Bacterial Meningitis (Highest Dose Required)

• Initial dose: 100 mg/kg (not to exceed 4 grams) 2
• Maintenance: 100 mg/kg/day divided every 12-24 hours 1, 2
• Maximum daily dose: 4 grams 1, 2
• Duration: typically 7-14 days 2

Indication-Specific Dosing

Community-Acquired Pneumonia

• 50-100 mg/kg/day once daily or divided every 12-24 hours 1
• For penicillin-resistant Streptococcus pneumoniae: 100 mg/kg/day every 12-24 hours 1

Gonococcal Infections

• Uncomplicated infections (urethritis, cervicitis, pharyngitis, proctitis): 125 mg IM single dose 1
• Bacteremia or arthritis: 50 mg/kg/day (maximum 1 g) for 7 days 1
• Meningitis: 50 mg/kg/day (maximum 2 g) for 10-14 days 1
• Gonococcal conjunctivitis in children ≤45 kg: 25-50 mg/kg IM single dose (not to exceed 250 mg) 1

Acute Otitis Media

• Single intramuscular dose of 50 mg/kg (not to exceed 1 gram) 2

Endocarditis

• For HACEK organisms: 100 mg/kg/day IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve) 1
• For streptococcal infections: 100 mg/kg/day divided every 12 hours or 80 mg/kg/day every 24 hours (maximum 4 g daily) 1

Gram-Negative Enteric Bacilli

• 100 mg/kg/day divided every 12 hours or 80 mg/kg/day every 24 hours (maximum 4 g daily) 1

Administration Guidelines

Intravenous Administration

• Administer over 30 minutes in children 2
• Administer over 60 minutes in neonates to reduce bilirubin encephalopathy risk 2
• Recommended concentrations: 10-40 mg/mL 2

Intramuscular Administration

• Inject deep into large muscle mass with aspiration to avoid intravascular injection 2
• IM injection is painful; counsel patients and families accordingly 1
• Available concentrations: 250 mg/mL or 350 mg/mL 2

Critical Considerations and Pitfalls

Maximum Dose Limitations

• Pediatric doses should never exceed adult maximum doses (4 g daily) 1
• For non-meningeal infections: maximum 2 grams daily 1, 2
• For meningitis: maximum 4 grams daily 1, 2

Contraindications

• Absolute contraindication in hyperbilirubinemic neonates 1
• Do not use diluents containing calcium (Ringer's solution, Hartmann's solution) due to precipitation risk 2

Drug Incompatibilities

• Do not mix with vancomycin, aminoglycosides, fluconazole, or amsacrine 2
• Administer sequentially with thorough line flushing when these drugs are needed 2
• Compatible with metronidazole at concentrations 5-7.5 mg/mL (ceftriaxone 10 mg/mL) for 24 hours at room temperature only 2

When to Use Higher Doses

• Always use 100 mg/kg/day for meningitis, life-threatening infections, empyema, or documented resistant pneumococcus 1
• Use 80-100 mg/kg/day for severe sepsis rather than the lower 50 mg/kg/day range 1

Duration of Therapy

• Continue for at least 2 days after signs and symptoms resolve 2
• Typical duration: 4-14 days for most infections 2
• Streptococcus pyogenes infections: minimum 10 days 2
• Meningitis: 7-14 days 2

Clinical Evidence Supporting Once-Daily Dosing

Research demonstrates that once-daily ceftriaxone (50-80 mg/kg) achieves 94-97% clinical cure rates for serious pediatric infections including meningitis, pneumonia, cellulitis, and osteomyelitis 3, 4. The long half-life (5-8 hours) allows for serum levels that exceed MIC90 for common pathogens throughout 24 hours even with once-daily dosing 5. This makes ceftriaxone particularly suitable for outpatient parenteral antibiotic therapy (OPAT), with studies showing successful outpatient treatment in 77% of serious infections 6.