Ceftriaxone Dosing for Prosthetic Joint Infection
For prosthetic joint infection, ceftriaxone should be dosed at 1-2 g IV every 24 hours for methicillin-susceptible staphylococci, which is the most common pathogen-specific indication for this agent in PJI. 1
Pathogen-Specific Dosing
Methicillin-Susceptible Staphylococci (MSSA)
- Ceftriaxone 1-2 g IV every 24 hours is a preferred treatment option for MSSA PJI according to IDSA guidelines 1
- This represents a third-line choice after nafcillin/oxacillin and cefazolin, but offers the convenience of once-daily dosing 1, 2
- Ceftriaxone susceptibility can be reliably inferred from oxacillin susceptibility testing in OSSA isolates from PJI 3
Propionibacterium Species
- Ceftriaxone is commonly used at standard dosing (1-2 g IV daily) for Propionibacterium PJI, with 17% of surveyed infectious disease physicians preferring this agent 2
Culture-Negative PJI
- For culture-negative shoulder PJI specifically, the combination of vancomycin plus ceftriaxone is the most commonly used empirical regimen 2
- This combination provides coverage for both staphylococci and less common pathogens
Treatment Duration
- Standard duration is 4-6 weeks of IV therapy for most PJI cases with prosthesis removal 1
- For staphylococcal PJI with retained prosthesis, extend therapy to 3 months for hip infections and 6 months for knee infections 1
- Duration should be guided by clinical response and inflammatory markers (ESR, CRP) 2
Combination Therapy Considerations
When Prosthesis is Retained
- Add rifampin to ceftriaxone for staphylococcal PJI when hardware remains in place 2
- Rifampin must never be used as monotherapy due to rapid resistance development 1
Chronic Suppression
- After completing IV therapy with retained hardware, transition to oral suppressive therapy 1
- For MSSA: cephalexin 500 mg PO three to four times daily is preferred 1
Administration Route Options
Subcutaneous Administration
- Ceftriaxone can be administered subcutaneously for long-term suppressive therapy in outpatient settings 4
- Therapeutic drug monitoring (TDM) with PK/PD-guided dosing is essential when using SC route to ensure adequate drug exposure 4
- Dose intervals can potentially be extended to thrice weekly with TDM guidance while maintaining PK/PD targets 4
Critical Caveats
- Obtain 3-6 intraoperative tissue samples before initiating antibiotics whenever possible to guide definitive therapy 5, 1
- Ceftriaxone is not appropriate for empirical therapy in early PJI (≤1 year post-surgery) where broader coverage including MRSA and Pseudomonas is needed 5
- For early/nosocomial PJI, use cefepime 2 g IV every 8 hours (not ceftriaxone) combined with vancomycin and gentamicin 5
- Adjust dosing for renal and hepatic dysfunction 1
- IM injection of ceftriaxone is painful; IV route is preferred 6