What is the recommended intravenous ceftriaxone dosage for pediatric patients, including neonates, and are dose adjustments needed for renal or hepatic impairment?

Intravenous Ceftriaxone Pediatric Dosing

For most pediatric infections beyond the neonatal period, administer ceftriaxone 50–75 mg/kg/day IV once daily or divided every 12 hours (maximum 2 g/day for non-meningeal infections), and for bacterial meningitis use 100 mg/kg/day IV once daily or divided every 12 hours (maximum 4 g/day). 1, 2

Neonatal Dosing (Age-Specific)

Critical contraindication: Never use ceftriaxone in hyperbilirubinemic neonates due to risk of bilirubin encephalopathy. 1, 2

• Postnatal age ≤7 days: 50 mg/kg/day IV every 24 hours 1
• Postnatal age >7 days and weight ≤2000 g: 50 mg/kg/day IV every 24 hours 1
• Postnatal age >7 days and weight >2000 g: 50–75 mg/kg/day IV every 24 hours 1
• Infusion time for neonates: Administer over 60 minutes (not 30 minutes) to reduce risk of bilirubin encephalopathy 2

Infants and Children Beyond Neonatal Period

Standard Dosing by Infection Severity

Moderate infections (skin/soft tissue, uncomplicated pneumonia, UTI):

• 50–75 mg/kg/day IV once daily or divided every 12 hours
• Maximum 2 g/day 1, 2

Severe infections (sepsis, complicated pneumonia, intra-abdominal infections):

• 80–100 mg/kg/day IV once daily or divided every 12 hours
• Maximum 4 g/day 1, 3

Bacterial meningitis:

• Initial loading dose: 100 mg/kg IV (maximum 4 g) 2
• Maintenance: 100 mg/kg/day IV once daily or divided every 12 hours (maximum 4 g/day) 1, 2
• Duration: 7–14 days typically 2
• Once-daily dosing is superior for meningitis: Recent pharmacokinetic modeling demonstrates 100 mg/kg once daily achieves 88% probability of target attainment at 24 hours versus only 53% for 50 mg/kg twice daily, with earlier achievement of therapeutic CSF concentrations 4

Indication-Specific Dosing

Community-acquired pneumonia:

• Standard: 50–100 mg/kg/day IV once daily or divided every 12 hours 1
• Penicillin-resistant Streptococcus pneumoniae: Use 100 mg/kg/day divided every 12–24 hours 1

Gonococcal infections (weight <45 kg):

• Uncomplicated: 125 mg IM single dose 1
• Bacteremia/arthritis: 50 mg/kg/day IV/IM once daily for 7 days (maximum 1 g) 1
• Meningitis: 50 mg/kg/day IV/IM once daily for 10–14 days (maximum 2 g) 1

Gonococcal conjunctivitis:

• 25–50 mg/kg IV or IM single dose (maximum 250 mg) 1

Infective endocarditis (HACEK organisms):

• 100 mg/kg/day IV/IM once daily for 4 weeks (native valve) or 6 weeks (prosthetic valve)
• Maximum 4 g/day 1

Streptococcal endocarditis:

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

Administration Guidelines

Intravenous infusion:

• Standard: Infuse over 30 minutes 2
• Neonates: Infuse over 60 minutes 2
• Concentration: 10–40 mg/mL recommended 2

Intramuscular injection:

• Inject deep into large muscle mass 1
• Counsel families that IM injection is painful 1
• Concentration: 250 mg/mL or 350 mg/mL 2

Renal and Hepatic Impairment

No dose adjustment required for renal or hepatic impairment in pediatric patients, provided there is no severe combined renal and hepatic dysfunction. 2

Critical Dosing Considerations

Do not underdose severe infections:

• Always use 80–100 mg/kg/day for life-threatening infections, empyema, or documented resistant pathogens 3
• For critically ill children with estimated GFR >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 instead of 100 mg/kg once daily to improve target attainment 5

Weight threshold for adult dosing:

• Children weighing ≥45 kg should receive adult dosing regimens 1

Maximum daily doses:

• Non-meningeal infections: 2 g/day 2
• Meningitis: 4 g/day 1, 2

Common Pitfalls to Avoid

• Never use in hyperbilirubinemic neonates — risk of kernicterus 1, 2
• Do not use calcium-containing diluents (Ringer's, Hartmann's) — particulate formation occurs 2
• Do not mix with vancomycin, aminoglycosides, amsacrine, or fluconazole — incompatible in admixtures; flush lines thoroughly between administrations 2
• Do not use lower dosing range (50 mg/kg/day) for severe sepsis — inadequate for critically ill patients 1
• For suspected staphylococcal infection, add flucloxacillin 50 mg/kg every 6 hours plus gentamicin 7.5 mg/kg daily — ceftriaxone alone insufficient for S. aureus meningitis 1, 4
• For suspected Listeria, add ampicillin 50 mg/kg every 6 hours — ceftriaxone has no activity against Listeria 1