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Ceftriaxone Dosage

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Usual Adult Dose for Bacterial Infection

Usual daily dose: 1 to 2 g/day IV or IM in 1 to 2 divided doses, depending on the nature and severity of the infection

For infections caused by Staphylococcus aureus (methicillin-susceptible, MSSA), the recommended dose is 2 to 4 g/day, in order to achieve greater than 90% target attainment.

The total daily dose should not exceed 4 g.

Usual Adult Dose for Bacteremia

2 g IV every 24 hours for 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Chancroid

250 mg IM as a single dose

The causative organism is Haemophilus ducreyi.

HIV-infected patients may require longer treatment. Ceftriaxone should only be given if patient follow-up can be guaranteed.

Patients should be retested for syphilis and HIV in 3 months, if initial tests were negative. The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Conjunctivitis

Gonococcal Conjunctivitis: 1 g IM once

Doxycycline therapy for 7 days (if not pregnant) or single dose azithromycin is also recommended to treat possible concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Endocarditis

Patients with normal renal function:

Native valve infections due to highly penicillin-susceptible viridans Group Streptococci and S bovis (MIC 0.12 mcg/mL or less): Ceftriaxone 2 g IV or IM every 24 hours for 4 weeks plus gentamicin 3 mg/kg IV or IM every 24 hours for 2 weeks

Native valve infections due to relatively resistant S viridans and S bovis (MIC greater than 0.12 mcg/mL and 0.5 mcg/mL or less): Ceftriaxone 2 g IV or IM every 24 hours for 4 weeks plus gentamicin 3 mg/kg IV or IM every 24 hours for 2 weeks

Prosthetic valve infections due to penicillin-susceptible S viridans and S bovis (MIC 0.12 mcg/mL or less): Ceftriaxone 2 g IV or IM every 24 hours for 6 weeks plus gentamicin 3 mg/kg IV or IM every 24 hours for 2 weeks

Prosthetic valve infections due to relatively or fully penicillin-resistant S viridans and S bovis (MIC greater than 0.12 mcg/mL): Ceftriaxone 2 g IV or IM every 24 hours for 6 weeks plus gentamicin 3 mg/kg IV or IM every 24 hours for 6 weeks

Native or prosthetic valve infections due to enterococcal strains resistant to penicillin, aminoglycosides, and vancomycin: Ceftriaxone 2 g IV or IM every 24 hours plus ampicillin 2 g IV every 4 hours for 8 weeks or more

Gonococcal endocarditis: 1 to 2 g IV every 12 hours for at least 4 weeks

Refer to current published guidelines for detailed recommendations.

Usual Adult Dose for Bacterial Endocarditis Prophylaxis

As an alternative in patients unable to take oral medication, with or without penicillin allergy (non-anaphylactoid type): 1 g IV or IM once 30 to 60 minutes before procedure

Usual Adult Dose for Endometritis

2 g IV every 24 hours plus clindamycin

Duration: Parenteral therapy should be continued for at least 24 hours after the patient has remained afebrile, pain free, and the leukocyte count has normalized. Doxycycline therapy for 14 days is recommended if concurrent chlamydial infection is present in late postpartum patients (breast-feeding should be discontinued).

Usual Adult Dose for Epididymitis - Sexually Transmitted

Gonococcal epididymitis: 250 mg IM as a single dose

Doxycycline 100 mg twice daily orally for 10 days should be given to treat a concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Epiglottitis

2 g IV every 24 hours for 7 to 10 days, depending on the nature and severity of the infection

Usual Adult Dose for Gastroenteritis

2 g IV every 24 hours
Duration: 7 to 10 days in immunocompromised patients

Usual Adult Dose for Gonococcal Infection - Disseminated

1 g IV or IM every 24 hours

Duration: Parenteral therapy should be continued for 24 to 48 hours after clinical improvement is demonstrated. Oral therapy with cefixime should then be continued to complete a total course of at least 1 week.

Doxycycline therapy for 7 days (if not pregnant) or single dose azithromycin is also recommended to treat possible concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Gonococcal Infection - Uncomplicated

Uncomplicated infections of the cervix, urethra, rectum, or pharynx: 250 mg IM once

Doxycycline therapy for 7 days (if not pregnant) or single dose azithromycin is also recommended to treat possible concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Intraabdominal Infection

2 g IV every 24 hours for 7 to 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Joint Infection

1 to 2 g IV or IM every 24 hours

Duration: 3 to 4 weeks, depending on the nature and severity of the infection; longer therapy, 6 weeks or more, may be required for prosthetic joint infections

Usual Adult Dose for Lyme Disease - Arthritis

2 g IV or IM every 24 hours

Febrile patients should also be evaluated/treated for human granulocytic ehrlichiosis (HGE) and babesiosis.

Duration: 14 days for arthritis, up to 21 days for carditis, and up to 30 days for neurologic Lyme disease

Usual Adult Dose for Lyme Disease - Carditis

2 g IV or IM every 24 hours

Febrile patients should also be evaluated/treated for human granulocytic ehrlichiosis (HGE) and babesiosis.

Duration: 14 days for arthritis, up to 21 days for carditis, and up to 30 days for neurologic Lyme disease

Usual Adult Dose for Lyme Disease - Neurologic

2 g IV or IM every 24 hours

Febrile patients should also be evaluated/treated for human granulocytic ehrlichiosis (HGE) and babesiosis.

Duration: 14 days for arthritis, up to 21 days for carditis, and up to 30 days for neurologic Lyme disease

Usual Adult Dose for Meningitis

2 g IV every 12 hours for 14 days, depending on the nature and severity of the infection

Gonococcal meningitis: 1 to 2 g IV every 12 hours for 10 to 14 days

Usual Adult Dose for Meningococcal Meningitis Prophylaxis

250 mg IM once

Usual Adult Dose for Neurosyphilis

2 g IV or IM every 24 hours for 10 to 14 days

Aqueous crystalline penicillin G is considered the drug of choice by the CDC.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Osteomyelitis

1 to 2 g IV or IM every 24 hours

Duration: 4 to 6 weeks, depending on the nature and severity of the infection; additional oral antibiotic therapy may be required for up to 6 months for chronic osteomyelitis

Usual Adult Dose for Pelvic Inflammatory Disease

Outpatient treatment of mild PID: 250 mg IM once plus oral doxycycline with or without metronidazole
Severe: 1 to 2 g IV or IM every 24 hours for 14 days, depending on the nature and severity of the infection

Doxycycline therapy for 14 days (if not pregnant) is also recommended to treat possible concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Peritonitis

2 g IV every 24 hours

Peritoneal dialysis-related peritonitis:
Continuous: 1 g/2 L dialysate intraperitoneally, followed by 250 to 500 mg/2 L dialysate
Intermittent: 1 g/2 L dialysate intraperitoneally every 24 hours

Duration: 10 to 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Pneumonia

1 to 2 g IV or IM every 24 hours for 7 to 21 days, depending on the nature and severity of the infection

Usual Adult Dose for Prostatitis

Gonococcal prostatitis: 250 mg IM once

Doxycycline 100 mg twice daily orally for 10 days should be given to treat a concurrent chlamydial infection.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Pyelonephritis

1 to 2 g IV or IM every 24 hours
Duration: 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Salmonella Gastroenteritis

2 g IV every 24 hours
Duration: Up to 14 days in immunocompromised patients, or longer if a relapse occurs

Usual Adult Dose for Sepsis

Severe: 2 g IV every 24 hours for 14 days, depending on the nature and severity of the infection

Usual Adult Dose for Skin or Soft Tissue Infection

Severe: 1 to 2 g IV or IM every 24 hours

Duration: 7 to 10 days, depending on the nature and severity of the infection; diabetic soft tissue infections may require treatment for 14 to 21 days

Usual Adult Dose for STD Prophylaxis

STD prophylaxis, sexual assault: 250 mg IM once, in combination with metronidazole and azithromycin or doxycycline
Sexual partner(s) of patients with chancroid: 250 mg IM once

Usual Adult Dose for Surgical Prophylaxis

1 g IV once 30 to 120 minutes before surgery
Third generation cephalosporins are generally not recommended for routine surgical prophylaxis.

Usual Adult Dose for Syphilis - Early

1 g IV or IM every 24 hours for 10 to 14 days

Benzathine penicillin G is considered the drug of choice by the CDC.

The patient's sexual partner(s) should also be evaluated/treated.

Usual Adult Dose for Typhoid Fever

2 g IV every 24 hours

Duration: 7 to 10 days; if the patient is immunocompromised or a relapse occurs, 14 days or more of treatment may be required

Usual Adult Dose for Urinary Tract Infection

Severe: 1 to 2 g IV or IM every 24 hours
Duration: 2 to 3 weeks for complicated infections

Usual Pediatric Dose for Bacterial Infection

Less than 1 week: 50 mg/kg IV or IM every 24 hours
1 to 4 weeks, 2000 g or less: 50 mg/kg IV or IM every 24 hours
1 to 4 weeks, greater than 2000 g: 50 to 75 mg/kg IV or IM every 24 hours

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

1 month or older:
Severe: 50 to 75 mg/kg IV in divided doses every 12 to 24 hours (maximum dose: 2 g/24 hours)
Life-threatening: 80 to 100 mg/kg IV in 1 or 2 divided doses (maximum dose: 4 g/24 hours)

Usual Pediatric Dose for Gonococcal Infection - Uncomplicated

Infants of mothers with gonococcal infection (gonococcal prophylaxis): 25 to 50 mg/kg (maximum dose: 125 mg) IV or IM once

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

Infant and mother should be evaluated/treated for possible concurrent chlamydial infection. The mother's sexual partner(s) should also be evaluated/treated.

Children with uncomplicated infections of the vulva and vagina, cervix, urethra, rectum, or pharynx:
45 kg or less: 125 mg IM once
Greater than 45 kg: 250 mg IM once

Patients should be evaluated/treated for possible concurrent syphilis and/or chlamydial infections.

Usual Pediatric Dose for Gonococcal Infection - Disseminated

0 to 4 weeks: 25 to 50 mg/kg (maximum dose: 125 mg) IV or IM every 24 hours for 7 days, up to 10 to 14 days if meningitis is documented

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

1 month or older:
45 kg or less:
Arthritis or bacteremia: 50 mg/kg (maximum dose: 1 g) IV or IM every 24 hours for 7 days

Greater than 45 kg: 1 g IV or IM once a day for 7 days

Patients should be evaluated/treated for possible concurrent syphilis and/or chlamydial infections.

Usual Pediatric Dose for Meningitis

0 to 4 weeks: 50 to 75 mg/kg every 24 hours

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

1 month or older:
Initial dose: 100 mg/kg IV at the start of therapy (maximum dose: 4 g)
Maintenance dose: 100 mg/kg/day IV once a day or in divided doses every 12 hours for 7 to 14 days (maximum dose: 4 g/24 hours)

Gonococcal infection:
45 kg or less: 50 mg/kg/day IV or IM divided every 12 hours for 10 to 14 days (maximum dose: 2 g/day)
Greater than 45 kg: 1 to 2 g IV or IM every 12 hours for 10 to 14 days

Usual Pediatric Dose for Meningococcal Meningitis Prophylaxis

Less than 15 years: 125 mg IM once
15 years or older: 250 mg IM once

Usual Pediatric Dose for Endocarditis

Gonococcal infection:
45 kg or less: 50 mg/kg/day IV or IM divided every 12 hours for at least 28 days (maximum dose: 2 g/day)
Greater than 45 kg: 1 to 2 g IV or IM every 12 hours for at least 28 days

Usual Pediatric Dose for Bacterial Endocarditis Prophylaxis

As an alternative in patients unable to take oral medication, with or without penicillin allergy (non-anaphylactoid type): 50 mg/kg (maximum dose: 1 g) IV or IM once 30 to 60 minutes before procedure

Usual Pediatric Dose for Otitis Media

Acute bacterial otitis media: 50 mg/kg IM once (maximum dose: 1 g)
Persistent or relapsing acute otitis media: 50 mg/kg IV or IM once a day for 3 days (maximum dose: 1 g/day)

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

Usual Pediatric Dose for Epiglottitis

1 month or older: 50 to 100 mg/kg IV or IM once a day
Duration: Has been reported to range from 2 to 14 days

Usual Pediatric Dose for Skin and Structure Infection

1 month or older: 50 to 75 mg/kg/day IV or IM in 1 to 2 divided doses (maximum dose: 2 g/day)

Usual Pediatric Dose for Typhoid Fever

1 month or older: 75 to 80 mg/kg IV once a day for 5 to 14 days

Usual Pediatric Dose for Lyme Disease

Persistent arthritis, meningitis, encephalitis: 75 to 100 mg/kg/day (maximum dose: 2 g) IV or IM for 2 to 4 weeks

Usual Pediatric Dose for Salmonella Gastroenteritis

50 to 75 mg/kg/day IV for 2 to 5 days

Treat immunocompromised patients for up to 10 days.

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

Usual Pediatric Dose for Shigellosis

50 to 75 mg/kg/day IV for 2 to 5 days

Treat immunocompromised patients for up to 10 days.

Ceftriaxone should be avoided in neonates with hyperbilirubinemia.

Usual Pediatric Dose for STD Prophylaxis

STD prophylaxis, sexual assault:
13 years or older: 250 mg IM once, in combination with metronidazole and azithromycin or doxycycline

Usual Pediatric Dose for Conjunctivitis

Gonococcal infection:
Neonates: 25 to 50 mg/kg (maximum dose: 125 mg) IV or IM once

1 month or older:
45 kg or less: 50 mg/kg (maximum dose: 1 g) IV or IM once
Greater than 45 kg: 1 g IM once

Usual Pediatric Dose for Chancroid

1 month or older: 50 mg/kg (maximum dose: 250 mg) IM as a single dose

Usual Pediatric Dose for Epididymitis - Non-Specific

250 mg IM as a single dose

Renal Dose Adjustments

Renal dysfunction alone: In general, no adjustment recommended; however, serum concentrations should be monitored in patients with severe renal dysfunction.

Significant renal dysfunction plus hepatic dysfunction: Dosage should not exceed 2 g/day without serum concentration monitoring.

If drug accumulation occurs, dosage should be decreased accordingly.

Liver Dose Adjustments

Hepatic dysfunction alone: No adjustment recommended.

Hepatic dysfunction plus significant renal dysfunction: Dosage should not exceed 2 g/day without serum concentration monitoring.

If drug accumulation occurs, dosage should be decreased accordingly.

Precautions

Ceftriaxone should not be used to treat hyperbilirubinemic newborns, particularly premature newborns. In vitro studies have shown bilirubin displacement from serum albumin by ceftriaxone and bilirubin encephalopathy may develop in these patients.

Ceftriaxone is contraindicated in neonates requiring (or expected to require) treatment with intravenous solutions containing calcium due to the risk of precipitation of ceftriaxone-calcium. Ceftriaxone should not be administered concomitantly (even via separate infusion lines at separate sites) or mixed with products or solutions containing calcium due to the risk of precipitation of ceftriaxone-calcium salt. Instances of fatal reactions with ceftriaxone-calcium precipitate in lungs and kidneys in term and premature newborns have been reported, even in cases when ceftriaxone and calcium-containing solutions were infused different times and infusion lines.

Diluents containing calcium (such as Ringer's solution or Hartmann's solution) should not be used to reconstitute ceftriaxone vials or further dilute a reconstituted vial for intravenous administration because a precipitate may form. Precipitation of ceftriaxone-calcium can occur when ceftriaxone is mixed in the same intravenous line as calcium-containing solutions. Ceftriaxone should not be administered simultaneously with intravenous solutions containing calcium via a Y-site. However, in patients other than neonates, ceftriaxone and intravenous solutions containing calcium may be administered sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid.

Serious and occasionally fatal hypersensitivity reactions have been reported with antibiotics. The drug should be discontinued immediately at the first appearance of a skin rash or other signs of hypersensitivity. Severe, acute hypersensitivity reactions may require treatment with epinephrine and other resuscitative measures including oxygen, intravenous fluids, antihistamines, corticosteroids, cardiovascular support and airway management as clinically indicated.

Cephalosporins may be associated with a fall in prothrombin activity. Risk factors include renal or hepatic impairment, poor nutritional state, a protracted course of antimicrobial therapy, and chronic anticoagulation therapy. Prothrombin times should be monitored and vitamin K therapy initiated if indicated.

Clostridium difficile associated diarrhea (CDAD) has been reported with almost all antibiotics and may potentially be life-threatening. Therefore, it is important to consider this diagnosis in patients who present with diarrhea following cephalosporin therapy. Mild cases generally improve with discontinuation of the drug, while severe cases may require supportive therapy and treatment with an antimicrobial agent effective against C difficile. Hypertoxin producing strains of C difficile cause increased morbidity and mortality; these infections can be resistant to antimicrobial treatment and may necessitate colectomy.

Severe cases of immune mediated hemolytic anemia, including fatalities, have been reported during treatment with cephalosporins, including ceftriaxone. If a patient develops anemia during treatment, cephalosporin associated anemia should be considered and ceftriaxone should be stopped until the cause can be determined.

Ceftriaxone has been associated with reversible symptomatic gallbladder disease and/or sonographic gallbladder abnormalities, and should be discontinued if such signs or symptoms occur.

Cephalosporins have been known to occasionally induce a positive direct Coombs' test and a false-positive urine glucose test (with Clinitest(R), Benedict's or Fehling's solution).

Caution is recommended for patients with both significant renal disease and hepatic impairment and the ceftriaxone dose should not exceed 2 grams per day. Some cephalosporins have been associated with seizures in renally impaired patients with elevated serum concentrations. The drug should be discontinued if seizures occur.

To reduce the development of drug-resistant organisms, antibiotics should only be used for prophylaxis or treatment of infections that are proven or strongly suspected to be due to bacteria.

Dialysis

Hemodialysis: Doses should be administered after dialysis sessions.
CVVH: 1 to 2 g IV every 24 hours

Other Comments

The maximum recommended dose for life-threatening infections is 4 g/day.

Generally, ceftriaxone therapy should be continued for at least 2 days after the signs and symptoms of infection have disappeared. The usual duration of therapy is 4 to 14 days. In complicated infections, longer therapy may be required. When treating infections caused by Streptococcus pyogenes, therapy should be continued for at least 10 days.

If Chlamydia trachomatis is a suspected pathogen, appropriate antichlamydial coverage should be added, because ceftriaxone sodium has no activity against the organism.

The IV route is preferred for severe or life-threatening infections such as sepsis/septicemia, bacteremia, meningitis, peritonitis, and for patients with reduced resistance (i.e., malnutrition, trauma, surgery, heart failure, malignancy, or shock). The maximum concentration for IM injection is 350 mg/mL. Ceftriaxone may be diluted with 1% lidocaine.

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