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cefTRIAXone

Class: Third Generation Cephalosporins
VA Class: AM117
Chemical Name: [6R-[6α,7β(Z)]]-7-[[(2-Amino-4-thiazolyl) (methoxyimino)acetyl]amino]-8-oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-1,2,4-triazin-3-yl)thio]methyl]-5-thia-1-azabicyclo[4.2.0]octo-2-ene-2-carboxylic acid disodium salt
CAS Number: 74578-69-1

Medically reviewed by Drugs.com on Sep 21, 2021. Written by ASHP.

Introduction

Antibacterial; β-lactam antibiotic; third generation cephalosporin.

Uses for cefTRIAXone

Acute Otitis Media (AOM)

Treatment of AOM caused by Streptococcus pneumoniae, Haemophilus influenzae (including β-lactamase-producing strains), or Moraxella catarrhalis (including β-lactamase-producing strains).

When anti-infectives indicated, AAP recommends high-dose amoxicillin or amoxicillin and clavulanate as drugs of choice for initial treatment of AOM; certain cephalosporins (cefdinir, cefpodoxime, cefuroxime, ceftriaxone) recommended as alternatives for initial treatment in penicillin-allergic patients without a history of severe and/or recent penicillin-allergic reactions.

Has been effective for initial or repeat treatment of AOM; good choice when patient has persistent vomiting or cannot otherwise tolerate an oral regimen.

A single-dose regimen can be used, but manufacturer cautions that potentially lower cure rate should be balanced against the advantages of a single-dose regimen. AAP states a 1- or 3-day regimen can be used for initial treatment of AOM, but cautions that more than a single dose may be required to prevent recurrence.

AAP recommends a 3-day regimen for retreatment of AOM in patients who failed to respond to an initial anti-infective regimen.

Consult current AAP clinical practice guidelines for AOM for additional information on diagnosis and management of AOM.

Bone and Joint Infections

Treatment of bone and joint infections (e.g., osteomyelitis, septic arthritis) caused by susceptible Staphylococcus aureus, S. pneumoniae, Enterobacter, Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.

IDSA recommends nafcillin (or oxacillin), cefazolin, or ceftriaxone as drugs of choice for treatment of native vertebral osteomyelitis or prosthetic joint infections caused by oxacillin-susceptible staphylococci. If caused by β-hemolytic streptococci, IDSA recommends penicillin G or ceftriaxone. If caused by Cutibacterium acnes (formerly Propionibacterium acnes), IDSA recommends penicillin G or ceftriaxone.

Ceftriaxone recommended as an alternative to ciprofloxacin for treatment of native vertebral osteomyelitis caused by susceptible Salmonella.

Consult current clinical practice guidelines from IDSA available at [Web] for additional information on management of bone and joint infections.

Endocarditis

Treatment of endocarditis caused by viridans group streptococci (e.g., S. milleri group, S. mutans, S. salivarius, S. sanguis) or nonenterococcal group D streptococci (e.g., S. gallolyticus [formerly S. bovis]) involving native valves or prosthetic valves or other prosthetic material.

Treatment of endocarditis caused by S. pneumoniae, S. pyogenes (group A β-hemolytic streptococci; GAS), S. agalactiae (group B streptococci; GBS), or streptococci groups C, F, or G involving native valves or prosthetic valves or other prosthetic material.

Treatment of endocarditis caused by enterococci (e.g., Enterococcus faecalis, E. faecium) involving native valves or prosthetic valves or other prosthetic material.

Treatment of endocarditis caused by fastidious gram-negative bacilli of the HACEK group (i.e., Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, Kingella).

AHA recommends treatment of endocarditis be managed in consultation with an infectious disease expert, especially when endocarditis is caused by S. pneumoniae, β-hemolytic streptococci, staphylococci, or enterococci.

Consult current guidelines from AHA for additional information on management of endocarditis.

GI Infections

Treatment of Salmonella gastroenteritis. Anti-infectives not generally used in otherwise healthy individuals with uncomplicated (noninvasive) gastroenteritis caused by nontyphoidal Salmonella (e.g., Salmonella serovars Enteritidis or Typhimurium); anti-infective treatment recommended in those with severe Salmonella gastroenteritis and those at increased risk for invasive disease. When considered necessary, select anti-infective based on in vitro susceptibility.

Treatment of shigellosis caused by susceptible Shigella sonnei or S. flexneri. Anti-infectives generally indicated in addition to fluid and electrolyte replacement in patients with severe shigellosis, dysentery, or underlying immunosuppression. Empiric treatment regimen can be used initially, but in vitro susceptibility testing indicated since resistance is common. Ceftriaxone is a drug of choice for shigellosis caused by ampicillin- or co-trimoxazole-resistant strains and when in vitro susceptibility unknown.

Empiric treatment of infectious diarrhea. Alternative for empiric treatment of severe bacterial diarrhea in HIV-infected adults and adolescents pending results of diagnostic studies; ciprofloxacin is drug of choice.

Intra-abdominal Infections

Treatment of intra-abdominal infections caused by susceptible E. coli, K. pneumoniae, Bacteroides fragilis, Clostridium, or Peptostreptococcus.

May be used alone for initial empiric treatment of mild to moderate community-acquired biliary tract infections (acute cholecystitis or cholangitis), but should be used in conjunction with metronidazole for initial empiric treatment of mild to moderate extrabiliary community-acquired intra-abdominal infections.

Consult current clinical practice guidelines from IDSA available at [Web] for additional information on management of intra-abdominal infections.

Meningitis and Other CNS Infections

Treatment of meningitis caused by susceptible H. influenzae, Neisseria meningitidis, or S. pneumoniae. A drug of choice for meningitis caused by these bacteria. Consider that S. pneumoniae with reduced susceptibility to cephalosporins have been reported with increasing frequency and susceptibility can no longer be assumed.

Treatment of meningitis and other CNS infections caused by susceptible Enterobacteriaceae (e.g., E. coli, Klebsiella).

Used with or without other anti-infectives (e.g., ampicillin, gentamicin, vancomycin) for empiric treatment of meningitis pending results of CSF culture and in vitro susceptibility testing. Do not use alone for empiric treatment of meningitis when Listeria monocytogenes, enterococci, staphylococci, or Pseudomonas aeruginosa may be involved.

A drug of choice for treatment of healthcare-associated ventriculitis and meningitis caused by susceptible β-lactamase-producing H. influenzae, S. pneumoniae, or Enterobacteriaceae. Alternative to penicillin G for treatment of healthcare-associated ventriculitis and meningitis caused by susceptible C. acnes (formerly P. acnes).

Respiratory Tract Infections

Treatment of respiratory tract infections (including pneumonia) caused by susceptible S. aureus, S. pneumoniae, H. influenzae, H. parainfluenzae, E. aerogenes, E. coli, K. pneumoniae, P. mirabilis, or Serratia marcescens.

Treatment of community-acquired pneumonia (CAP). Recommended by ATS and IDSA as an alternative for treatment of CAP caused by penicillin-susceptible S. pneumoniae and as a preferred drug for treatment of CAP caused by penicillin-resistant S. pneumoniae, provided in vitro susceptibility demonstrated. A preferred drug for treatment of CAP caused by β-lactamase-producing H. influenzae. Also recommended in certain combination regimens used for empiric treatment of CAP. Select regimen for empiric treatment of CAP based on most likely pathogens and local susceptibility patterns; after pathogen is identified, modify to provide more specific therapy (pathogen-directed therapy).

Alternative for treatment of acute bacterial sinusitis. Oral amoxicillin or fixed combination of amoxicillin and clavulanate usually recommended for empiric treatment. In children who are vomiting, unable to tolerate or unlikely to adhere to initial oral therapy, treatment can be initiated with ceftriaxone and then switched to an oral regimen if clinical improvement observed at 24 hours. Also an alternative for severe sinusitis requiring hospitalization.

Consult current clinical practice guidelines from IDSA available at [Web] for additional information on management of respiratory tract infections, including CAP.

Septicemia

Treatment of septicemia caused by susceptible S. aureus, S. pneumoniae, E. coli, H. influenzae, or K. pneumoniae.

Skin and Skin Structure Infections

Treatment of skin and skin structure infections caused by susceptible S. aureus, S. epidermidis, S. pyogenes, viridans group streptococci, E. cloacae, E. coli, K. oxytoca, K. pneumoniae, P. mirabilis, Morganella morganii, S. marcescens, Acinetobacter calcoaceticus, B. fragilis, or Peptostreptococcus.

Has been used for treatment of some skin and skin structure infections caused by Ps. aeruginosa. Consider that many strains of Ps. aeruginosa are only susceptible to high ceftriaxone concentrations in vitro and resistant strains have developed during therapy with the drug. Do not use alone in any infection where Ps. aeruginosa may be present.

Used in multiple-drug anti-infective regimens for empiric treatment of necrotizing infections of the skin, fascia, and muscle. Broad-spectrum coverage important since necrotizing fasciitis (including Fornier gangrene) may be polymicrobial (e.g., mixed aerobic-anaerobic infections) or monomicrobial (e.g., S. pyogenes, S. aureus, Vibrio vulnificus, Aeromonas hydrophila, Peptostreptococcus).

Empiric treatment of certain surgical site infections. Used in conjunction with metronidazole for infections following GI or GU surgery; used alone or in conjunction with vancomycin for infections following procedures involving axilla or peritoneum.

Empiric treatment of infected animal bite wounds or empiric treatment of moderate or severe diabetic foot infections.

Consult current clinical practice guidelines from IDSA available at [Web] for additional information on management of skin and skin structure infections.

Urinary Tract Infections (UTIs)

Treatment of complicated and uncomplicated UTIs caused by susceptible E. coli, K. pneumoniae, M. morganii, P. mirabilis, or P. vulgaris.

May be a drug of choice for treatment of complicated UTIs caused by susceptible Enterobacteriaceae, including susceptible strains of E. coli, K. pneumoniae, P. rettgeri, M. morganii, P. vulgaris, or P. stuartii; an aminoglycoside usually used concomitantly in severe infections.

Ceftriaxone (like other third generation cephalosporins) generally should not be used for treatment of uncomplicated UTIs when other anti-infectives with a narrower spectrum of activity could be used.

Actinomycosis

Has been used for treatment of infections caused by Actinomyces. Penicillin G generally drug of choice for initial treatment of all forms of actinomycosis, including thoracic, abdominal, genitourinary, CNS, and cervicofacial infections.

Bartonella Infections

Treatment of bacteremia caused by Bartonella quintana (in conjunction with oral erythromycin or oral azithromycin). Optimum anti-infective regimens for treatment of infections caused by B. quintana not identified; various drugs have been used or are recommended. Infections tend to persist or recur and prolonged therapy (several months or longer) usually necessary.

Possible role of ceftriaxone in treatment of infections caused by Bartonella henselae (e.g., cat scratch disease, bacillary angiomatosis, peliosis hepatitis) not determined. Cat scratch disease generally is self-limited in immunocompetent individuals and may resolve spontaneously in 2–4 months; some clinicians suggest that anti-infective therapy be considered for acutely or severely ill patients with systemic symptoms, particularly those with hepatosplenomegaly or painful lymphadenopathy, and such therapy probably is indicated in immunocompromised patients. Anti-infectives also indicated in patients with B. henselae infections who develop bacillary angiomatosis, neuroretinitis, or Parinaud’s oculoglandular syndrome. Optimum anti-infective regimens for treatment of cat scratch disease or other B. henselae infections not identified.

Capnocytophaga Infections

Treatment of infections caused by Capnocytophaga canimorsus.

Optimum regimens for treatment of Capnocytophaga infections not identified; some clinicians recommend penicillin G or, alternatively, a third generation cephalosporin (cefotaxime, ceftriaxone), a carbapenem (imipenem, meropenem), vancomycin, a fluoroquinolone, or clindamycin.

Chancroid

Treatment of chancroid (genital ulcers caused by H. ducreyi).

CDC and others recommend azithromycin, ceftriaxone, ciprofloxacin, or erythromycin as drugs of choice for treatment of chancroid. HIV-infected patients and uncircumcised patients may not respond to treatment as well as those who are HIV-negative or circumcised.

Gonorrhea and Associated Infections

Treatment of uncomplicated cervical, urethral, rectal, or pharyngeal infections caused by susceptible Neisseria gonorrhoeae in adults, adolescents, and children. Dual combination treatment with ceftriaxone and azithromycin is regimen of choice for most patients.

Treatment of gonococcal conjunctivitis in adults and adolescents; dual combination treatment with ceftriaxone and azithromycin is regimen of choice. Because only limited data available regarding treatment of gonococcal conjunctivitis, consider consultation with an infectious disease specialist.

Initial treatment of disseminated gonococcal infections. Drug of choice for initial parenteral treatment in adults, adolescents, and children, especially when meningitis, endocarditis, or conjunctivitis is involved.

Empiric treatment of acute epididymitis. Used in conjunction with doxycycline if infection most likely caused by sexually transmitted N. gonorrhoeae and Chlamydia trachomatis; used in conjunction with levofloxacin or ofloxacin if infection most likely caused by sexually transmitted chlamydia, gonorrhea, and enteric bacteria.

Presumptive treatment of proctitis prior to availability of diagnostic laboratory test results; used in conjunction with doxycycline.

Parenteral prophylaxis and presumptive treatment of gonorrhea in neonates born to mothers with gonorrhea. Also recommended in other neonates if topical erythromycin prophylaxis is unavailable, especially for neonates born to women who are at risk for gonococcal infection or received no prenatal care.

Treatment of ophthalmia neonatorum caused by N. gonorrhoeae. A single-dose ceftriaxone regimen is adequate for treatment of gonococcal conjunctivitis, but infants with ophthalmia neonatorum should be hospitalized and evaluated for signs of disseminated infection (e.g., sepsis, arthritis, meningitis). CDC recommends that infants with gonococcal ophthalmia be managed in consultation with an infectious disease specialist.

Treatment of disseminated gonococcal infections (e.g., sepsis, arthritis, meningitis) and gonococcal scalp abscesses in neonates. Contraindicated in certain neonates (see Pediatric Use under Cautions). AAP recommends cefotaxime in infants with hyperbilirubinemia.

Remain vigilant for treatment failures (evidenced by persistent symptoms or positive follow-up test despite treatment). Consider that N. gonorrhoeae with reduced susceptibility to ceftriaxone and/or cefixime or other cephalosporins reported in US and elsewhere.

If infection persists (treatment failure) and reinfection unlikely, culture relevant clinical specimens and perform in vitro susceptibility tests. Also consult infectious disease specialist, STD/HIV Prevention Training Center ([Web]), local or state health department STD program, or CDC (404-639-8659) for advice on obtaining cultures, in vitro susceptibility testing, and treatment. Report suspected treatment failures to CDC through local or state health departments within 24 hours of diagnosis.

Empiric anti-infective prophylaxis in sexual assault victims; 3-drug prophylaxis regimen of ceftriaxone, azithromycin and metronidazole (or tinidazole) provides coverage against gonorrhea, chlamydia, trichomoniasis, and bacterial vaginosis.

Leptospirosis

Treatment of severe leptospirosis caused by Leptospira.

Leptospirosis is a spirochete infection that may range in severity from a self-limited systemic illness to a severe, life-threatening illness that includes jaundice, renal failure, hemorrhage, cardiac arrhythmias, pneumonitis, and hemodynamic collapse (Weil syndrome).

Penicillin G generally considered drug of choice for treatment of moderate to severe leptospirosis; doxycycline has been used in less severe infections. Cephalosporins (ceftriaxone, cefotaxime), aminopenicillins (ampicillin, amoxicillin), tetracyclines (doxycycline, tetracycline), or macrolides (azithromycin) also have been recommended for severe infections.

Lyme Disease

Treatment of early neurologic Lyme disease with acute neurologic manifestations such as meningitis or radiculopathy. IV ceftriaxone is drug of choice; alternatives are IV cefotaxime or IV penicillin G. Although an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) may be effective for early localized or early disseminated Lyme disease associated with erythema migrans in the absence of specific neurologic manifestations or advanced atrioventricular (AV) heart block, a parenteral regimen usually recommended when there are acute neurologic manifestations.

Treatment of Lyme carditis when a parenteral regimen indicated. IV ceftriaxone is drug of choice; alternatives are IV cefotaxime or IV penicillin G. Although a parenteral regimen usually recommended for initial treatment of hospitalized patients, an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) can be used to complete therapy and for outpatients.

Treatment of Lyme arthritis when a parenteral regimen indicated. IV ceftriaxone is drug of choice; alternatives are IV cefotaxime or IV penicillin G. Although comparative safety and efficacy of oral versus IV anti-infectives for treatment of Lyme arthritis not fully evaluated, those with concomitant neurologic disease generally should receive a parenteral regimen.

Treatment of late neurologic Lyme disease affecting CNS or peripheral nervous system (e.g., encephalopathy, neuropathy). IV ceftriaxone is drug of choice; alternatives are IV cefotaxime or IV penicillin G.

Neisseria meningitidis Infections

Treatment of invasive infections, including meningitis, caused by N. meningitidis; a drug of choice for empiric treatment of suspected meningococcal disease. (See Meningitis and Other CNS Infections under Uses.)

Elimination of nasopharyngeal carriage of N. meningitidis in patients with invasive meningococcal disease who did not receive treatment with ceftriaxone or other third generation cephalosporin. Recommended regimens are ceftriaxone, rifampin, or ciprofloxacin; all are 90–95% effective.

Chemoprophylaxis to prevent meningococcal disease in household or other close contacts of patients with invasive meningococcal disease. Recommended regimens are ceftriaxone, rifampin, or ciprofloxacin; all are 90–95% effective.

Outbreak control of meningococcal disease when outbreak involves a limited population (e.g., a single school), especially when meningococcal strain involved is not represented in currently available meningococcal vaccines. Mass chemoprophylaxis not recommended to control large outbreaks.

Nocardia Infections

Treatment of nocardiosis caused by Nocardia.

Co-trimoxazole (fixed combination of sulfamethoxazole and trimethoprim) generally is drug of choice for treatment of nocardiosis. Other drugs that have been used alone or in combination regimens for treatment of nocardiosis include a sulfonamide alone (sulfamethoxazole [not commercially available in the US], sulfadiazine), amikacin, tetracyclines, cephalosporins (ceftriaxone, cefotaxime, cefuroxime), cefoxitin, carbapenems (imipenem or meropenem), fixed combination of amoxicillin and clavulanate, clarithromycin, cycloserine, or linezolid.

Alternative to co-trimoxazole for treatment of skin and skin structure infections caused by Nocardia (e.g., N. farcinica, N. brasiliensis). Prolonged anti-infective treatment (6–24 months) and/or multiple-drug anti-infective regimen may be necessary for severe or disseminated infections or in patients with immunosuppression.

Pelvic Inflammatory Disease (PID)

Treatment of PID caused by N. gonorrhoeae.

When IV treatment indicated, regimens of cefoxitin (or cefotetan) in conjunction with doxycycline or regimen of clindamycin in conjunction with gentamicin recommended. CDC states ceftriaxone may be effective, but is less active than cefotetan or cefoxitin against anaerobic bacteria.

When IM and oral regimen used for treatment of mild to moderately severe acute PID, CDC recommends a single IM dose of ceftriaxone, cefoxitin (with oral probenecid), or other parenteral third-generation cephalosporin (e.g., cefotaxime) given in conjunction with oral doxycycline (with or without oral metronidazole).

Because ceftriaxone (like other cephalosporins) not active against Chlamydia, concomitant use of a drug active against Chlamydia (e.g., doxycycline) is necessary when these organisms are suspected pathogens.

Relapsing Fever

Treatment of relapsing fever caused by Borrelia recurrentis; other drugs (e.g., tetracyclines, penicillin G) usually considered drugs of choice.

Syphilis

Alternative for treatment of primary or secondary syphilis in penicillin-allergic nonpregnant adults and adolescents.

Alternative for treatment of latent syphilis in penicillin-allergic nonpregnant adults and adolescents.

Alternative for treatment of neurosyphilis in penicillin-allergic nonpregnant adults and adolescents.

CDC recommends that a specialist be consulted when making decisions regarding treatment of syphilis in penicillin-allergic patients.

Optimal dosage and duration of ceftriaxone for treatment of primary, secondary, or latent syphilis or neurosyphilis not defined and close follow-up is essential. Consider possibility of cross-sensitivity between penicillin and ceftriaxone. If compliance or follow-up with alternative regimens cannot be ensured, CDC recommends desensitization and treatment with the appropriate penicillin G preparation.

CDC states that ceftriaxone is a possible alternative for treatment of infants or children with clinical evidence of congenital syphilis in certain circumstances when penicillin G not available (i.e., during a penicillin shortage). Use in consultation with a specialist in treatment of infants with congenital syphilis and with close clinical, serologic, and CSF follow-up.

Consult current CDC sexually transmitted diseases treatment guidelines available at [Web] for additional information on management of syphilis.

Typhoid Fever and Other Invasive Salmonella Infections

Treatment of typhoid fever or paratyphoid fever (enteric fever) or septicemia caused by Salmonella serovars Typhi or Paratyphi, respectively, including multidrug-resistant strains. A drug of choice for empiric treatment of enteric fever pending results of in vitro susceptibility tests.

Treatment of invasive infections (bacteremia, osteomyelitis) caused by nontyphoidal Salmonella, including Salmonella serovar Typhimurium.

For treatment of Salmonella gastroenteritis, see GI Infections under Uses.

Whipple’s Disease

Treatment of Whipple’s disease, a progressive systemic infection caused by Tropheryma whipplei (formerly Tropheryma whippelii). Optimal regimens not identified; some clinicians recommend initial parenteral regimen (e.g., ceftriaxone or penicillin G used with or without streptomycin) followed by long-term (1–2 years) treatment with oral co-trimoxazole.

For treatment of encephalitis caused by T. whipplei, IDSA recommends initial treatment with ceftriaxone for 2–4 weeks followed by co-trimoxazole or cefixime for 1–2 years.

Empiric Therapy in Febrile Neutropenic Patients

Empiric anti-infective therapy of presumed bacterial infections in febrile neutropenic patients; used in conjunction with an aminoglycoside.

Ceftriaxone monotherapy not usually recommended since it may not provide adequate coverage against some potential pathogens (e.g., Ps. aeruginosa).

Consult published protocols on treatment of infections in febrile neutropenic patients for specific recommendations regarding selection of initial empiric regimen, when to change initial regimen, possible subsequent regimens, and duration of therapy in these patients. Consultation with an infectious disease expert knowledgeable about infections in immunocompromised patients also advised.

Prevention of Bacterial Endocarditis

Alternative for prevention of α-hemolytic (viridans group) streptococcal endocarditis in individuals undergoing certain dental or upper respiratory tract procedures who have cardiac conditions that put them at highest risk of adverse outcome from endocarditis.

Oral amoxicillin is usual drug of choice for such prophylaxis; ceftriaxone (or cefazolin) is an alternative in penicillin-allergic individuals or when an oral anti-infective cannot be used. Should not be used in those with a history of anaphylaxis, angioedema, or urticaria after receiving a penicillin.

Consult current AHA recommendations for information on which cardiac conditions are associated with highest risk of adverse outcomes from endocarditis and additional information regarding prophylaxis for prevention of bacterial endocarditis.

Perioperative Prophylaxis

Perioperative prophylaxis to reduce the incidence of infection in patients undergoing contaminated or potentially contaminated surgical procedures, including biliary tract procedures (e.g., cholecystectomy), colorectal procedures, intra-abdominal surgery, or vaginal or abdominal hysterectomy, and in those undergoing clean surgical procedures in which the development of infection at the surgical site would represent a serious risk, including coronary artery bypass, open heart surgery, thoracic surgery, or orthopedic surgery. Also has been used perioperatively in patients undergoing transurethral resection of the prostate or renal transplantation.

First and second generation cephalosporins (cefazolin, cefuroxime) generally preferred when a cephalosporin used for perioperative prophylaxis. Third generation cephalosporins (cefotaxime, ceftriaxone, ceftazidime) and fourth generation cephalosporins (cefepime) not usually recommended for routine perioperative prophylaxis since they are expensive, some are less active than first or second generation cephalosporins against staphylococci, they have spectrums of activity wider than necessary for organisms encountered in elective surgery, and their use for prophylaxis may promote emergence of resistant organisms.

cefTRIAXone Dosage and Administration

Administration

Administer by IV infusion or deep IM injection.

Should not be administered intrathecally.

Do not use diluents containing calcium (e.g. Ringer’s/lactated Ringer’s injection, Hartmann’s injection) to reconstitute or further dilute ceftriaxone because a precipitate can form.

Because precipitation of ceftriaxone-calcium can occur, ceftriaxone must not be admixed with calcium-containing solutions and must not be administered simultaneously with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition, even via different infusion lines at different sites in any patient (irrespective of age). (See Interaction with Calcium-containing Products under Cautions.)

Contraindicated in neonates (≤28 days of age) if they are receiving (or expected to require) treatment with calcium-containing IV solutions, including continuous calcium-containing infusions such as parenteral nutrition.

In adult and pediatric patients >28 days of age, ceftriaxone and calcium-containing solutions may be administered sequentially if the infusion lines are thoroughly flushed between infusions with a compatible fluid (e.g., 0.9% sodium chloride injection, 5% dextrose injection).

Ensure that patients receiving ceftriaxone are adequately hydrated.

IV Infusion

The recommended concentration for IV infusion is 10–40 mg of ceftriaxone/mL; lower concentrations may be used if desired.

Do not use diluents containing calcium (e.g., Ringer’s/lactated Ringer’s injection, Hartmann’s injection) to reconstitute or further dilute ceftriaxone because a precipitate can form.

For solution and drug compatibility information, see Compatibility under Stability.

Reconstitution and Dilution

Reconstitute vials containing 250 mg, 500 mg, 1 g, or 2 g of ceftriaxone with 2.4, 4.8, 9.6, or 19.2 mL, respectively, of a compatible IV solution to provide solutions containing approximately 100 mg/mL. Then, further dilute to desired concentration in a compatible IV solution.

Reconstitute ADD-Vantage vials containing 1 or 2 g of ceftriaxone with 0.9% sodium chloride or 5% dextrose injection in ADD-Vantage flexible containers according to the manufacturer’s directions.

Reconstitute (activate) commercially available Duplex drug delivery system containing 1 or 2 g of ceftriaxone and 50 mL of 3.74 or 2.22% dextrose injection, respectively, in separate chambers according to the manufacturer's directions. If refrigerated after reconstitution (see Storage under Stability), allow solution to reach room temperature prior to administration.

Reconstitute 10-g pharmacy bulk package by adding 95 mL of a compatible IV solution to provide a solution containing approximately 100 mg/mL and then further dilute in a compatible IV infusion solution. Dilution to a concentration of 10–40 mg/mL usually recommended; lower concentrations may be used if desired.

Thaw commercially available premixed injection (frozen) at room temperature (25°C) or in a refrigerator (5°C); do not thaw by immersion in a water bath or by exposure to microwave radiation. A precipitate may have formed in the frozen injection, but should dissolve with little or no agitation after reaching room temperature. Discard thawed injection if an insoluble precipitate is present or if container seals or outlet ports are not intact or leaks are found. Do not use in series connections with other plastic containers; such use could result in air embolism from residual air being drawn from the primary container before administration of fluid from secondary container is complete.

Rate of Administration

Give intermittent IV infusions over 30 minutes (except neonates).

Give intermittent IV infusions over 60 minutes in neonates. (See Pediatric Use under Cautions.)

IM Administration

Inject IM deeply into a large muscle mass using usual techniques and precautions.

Do not use IM solutions reconstituted with bacteriostatic water containing benzyl alcohol in neonates. (See Pediatric Use under Cautions.)

Do not use diluents containing calcium (e.g., Ringer’s/lactated Ringer’s injection, Hartmann’s injection) to reconstitute or further dilute ceftriaxone because a precipitate can form.

Reconstitution

Prepare IM injections by adding 0.9, 1.8, 3.6, or 7.2 mL of sterile water for injection, 0.9% sodium chloride injection, 5% dextrose injection, bacteriostatic water for injection containing 0.9% benzyl alcohol, or 1% lidocaine hydrochloride (without epinephrine) to a vial containing 250 mg, 500 mg, 1 g, or 2 g of ceftriaxone, respectively, to provide solutions containing approximately 250 mg/mL or by adding 1, 2.1, or 4.2 mL of one of these diluents to a vial containing 500 mg, 1 g, or 2 g of ceftriaxone, respectively, to provide solutions containing approximately 350 mg/mL.

More dilute solutions of the drug may be used for IM injection if required.

Dosage

Available as ceftriaxone sodium; dosage expressed in terms of ceftriaxone.

Do not use ceftriaxone available in Duplex drug delivery system in patients who require less than the entire 1- or 2-g dose in the container.

Pediatric Patients

General Pediatric Dosage
Infections in Neonates ≤28 Days of Age
IV or IM

AAP recommends 50 mg/kg once daily, regardless of weight.

Mild to Moderate Infections in Children Beyond Neonatal Period
IV or IM

AAP recommends 50–75 mg/kg once daily.

Severe Infections in Children Beyond Neonatal Period
IV or IM

AAP recommends 100 mg/kg daily given in 1 or 2 divided doses.

Manufacturers recommend 50–75 mg/kg daily (up to 2 g daily) given in 2 equally divided doses every 12 hours.

Acute Otitis Media (AOM)
IM

Single 50-mg/kg dose (maximum 1 g) recommended by manufacturers.

For initial treatment, AAP recommends 50 mg/kg daily given for 1 or 3 days. More than a single dose may be required to prevent recurrence.

For retreatment, AAP recommends 50 mg/kg daily given for 3 days.

Endocarditis†
Native Valve Endocarditis Caused by Viridans Group Streptococci, S. gallolyticus, or Other Streptococci†
IV or IM

Highly penicillin-susceptible strains (penicillin MIC ≤0.1 mcg/mL): 100 mg/kg daily in divided doses every 12 hours for 4 weeks recommended by AHA. Alternatively, 80 mg/kg once daily (up to 4 g daily), but give doses >2 g in divided doses every 12 hours.

Strains relatively resistant to penicillin (penicillin MIC >0.1 mcg/mL but <0.5 mcg/mL): 100 mg/kg daily in divided doses every 12 hours for 4 weeks in conjunction with gentamicin (3–6 mg/kg daily IV in divided doses every 8 hours during first 2 weeks of ceftriaxone treatment) recommended by AHA. Alternatively, ceftriaxone dosage of 80 mg/kg once daily (up to 4 g daily) can be used in the regimen.

Prosthetic Valve Endocarditis Caused by Viridans Group Streptococci, S. gallolyticus, or Other Streptococci†
IV or IM

Highly penicillin-susceptible strains (penicillin MIC ≤0.1 mcg/mL): 100 mg/kg daily in divided doses every 12 hours for 6 weeks in conjunction with gentamicin (3–6 mg/kg daily IV in divided doses every 8 hours during first 2 weeks of ceftriaxone treatment) recommended by AHA. Alternatively, ceftriaxone dosage of 80 mg/kg once daily (up to 4 g daily) can be used in the regimen.

Strains relatively or highly resistant to penicillin (penicillin MIC >0.1 mcg/mL): 100 mg/kg daily in divided doses every 12 hours for 6 weeks in conjunction with gentamicin (3–6 mg/kg daily IV in divided doses every 8 hours during entire 6 weeks of ceftriaxone treatment) recommended by AHA. Alternatively, ceftriaxone dosage of 80 mg/kg once daily (up to 4 g daily) can be used in the regimen.

Native or Prosthetic Valve Endocarditis Caused by the HACEK Group†
IV or IM

100 mg/kg daily in divided doses every 12 hours for 4 weeks recommended by AHA. Alternatively, 80 mg/kg once daily (up to 4 g daily) for 4 weeks.

GI Infections†
Salmonella Gastroenteritis†
IV

HIV-infected adolescents: 1 g every 24 hours.

Recommended duration is 7–14 days if CD4+ T-cells ≥200 cells/mm3 (≥14 days if patient is bacteremic or infection is complicated) or 2–6 weeks if CD4+ T-cells <200 cells/mm3.

Shigellosis†
IV or IM

50 mg/kg once daily for 2–5 days has been used.

Empiric Treatment of Infectious Diarrhea†
IV

HIV-infected adolescents: 1 g every 24 hours. If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.

Intra-abdominal Infections
IV or IM

50–75 mg/kg once or twice daily has been recommended.

May be used alone for initial empiric treatment of community-acquired biliary tract infections (cholecystitis or cholangitis); use in conjunction with metronidazole for initial empiric treatment of extrabiliary community-acquired intra-abdominal infections.

Meningitis and Other CNS Infections
Meningitis
IV

Initial dose of 100 mg/kg (up to 4 g) followed by 100 mg/kg daily (up to 4 g daily) given as a single daily dose or in equally divided doses every 12 hours recommended by manufacturers and some clinicians. Other clinicians recommend 80–100 mg/kg daily (up to 4 g daily) given as a single daily dose or in divided doses every 12 hours. Twice-daily regimen may be preferred for S. pneumoniae.

Duration of 7 days may be adequate for uncomplicated meningitis caused by susceptible H. influenzae or N. meningitidis; at least 10–14 days suggested for complicated meningitis caused by S. pneumoniae; at least 21 days suggested for Enterobacteriaceae (e.g., E. coli, Klebsiella). In neonates, some experts recommend continuing treatment for 2 weeks beyond first sterile CSF culture or for at least 3 weeks, whichever is longer.

Healthcare-associated Ventriculitis and Meningitis
IV

100 mg/kg daily as a single dose or in divided doses every 12 hours recommended by IDSA.

Treatment duration depends on causative organism and patient characteristics. Duration of 10–14 days recommended for infections caused by gram-negative bacilli (with or without significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features); some experts recommend a duration of 21 days.

Respiratory Tract Infections
Acute Bacterial Rhinosinusitis†
IV

Severe infections requiring hospitalization: 50 mg/kg daily in divided doses every 12 hours recommended by IDSA.

Community-acquired Pneumonia
IV or IM

Pediatric patients ≥3 months of age with CAP caused by S. pneumoniae: 50–100 mg/kg daily as a single dose or in divided doses every 12 hours for penicillin-susceptible strains or 100 mg/kg daily as a single dose or in divided doses every 12 hours for penicillin-resistant strains. Treatment usually continued for 10 days.

Pediatric patients ≥3 months of age with CAP caused by S. pyogenes or H. influenzae: 50–100 mg/kg daily as a single dose or in divided doses every 12 hour. Treatment usually continued for 10 days.

Skin and Skin Structure Infections
IV or IM

50–75 mg/kg daily as a single dose or in divided doses every 12 hours.

Chancroid†
IM

Infants and children weighing <45 kg: Single 50-mg/kg dose (up to 250 mg).

Infants and children weighing ≥45 kg; Single 250-mg dose.

Adolescents: Single 250-mg dose.

Gonorrhea and Associated Infections
Parenteral Prophylaxis or Presumptive Treatment in Neonates Born to Mothers with Gonococcal Infection†
IV or IM

Single dose of 25–50 mg/kg (up to 125 mg) recommended by CDC and AAP.

Gonococcal Ophthalmia Neonatorum†
IV or IM

Single dose of 25–50 mg/kg (up to 125 mg) recommended by CDC and AAP.

Disseminated Gonococcal Infection and Gonococcal Scalp Abscess in Neonates†
IV or IM

25–50 mg/kg once daily for 7 days recommended by CDC and AAP; if meningitis documented, continue for 10–14 days.

Uncomplicated Urethral, Cervical, Rectal, or Pharyngeal Gonorrhea in Infants and Children
IV or IM

Children beyond neonatal age (prepubertal) weighing <45 kg: AAP recommends single 125-mg IM dose.

Children beyond neonatal age (prepubertal) weighing ≥45 kg: AAP recommends single 250-mg IM dose and azithromycin (single 1-g oral dose).

Children weighing ≤45 kg: CDC recommends single dose of 25–50 mg/kg IV or IM (up to 125 mg IM). CDC states data not available regarding use of dual combination regimen in such children.

Children weighing >45 kg: CDC recommends single 250-mg IM dose and azithromycin (single 1-g oral dose).

Disseminated or Complicated Gonorrhea in Infants and Children†
IV or IM

Children beyond neonatal age (prepubertal) weighing <45 kg: AAP recommends 50 mg/kg once daily (up to 1 g daily) for 7 days and erythromycin (30 mg/kg daily orally in 4 divided doses [up to 2 g daily] for 14 days). If meningitis or endocarditis present, increase ceftriaxone dosage to 50 mg/kg every 12–24 hours and continue for 10–14 days.

Children beyond neonatal age (prepubertal) weighing ≥45 kg: AAP recommends 1 g once daily for 7 days and azithromycin (single 1-g oral dose). If meningitis or endocarditis present, increase ceftriaxone dosage to 1–2 g every 12–24 hours and continue for 10–14 days.

Children weighing ≤45 kg with gonococcal bacteremia or arthritis: CDC recommends 50 mg/kg (up to 1 g) once daily for 7 days. CDC states data not available regarding use of dual combination regimens in such children.

Children weighing >45 kg with gonococcal bacteremia or arthritis: CDC recommends 1 g once daily for 7 days. CDC states data not available regarding use of dual combination regimen in such children.

Uncomplicated Cervical, Urethral, Anorectal, or Pharyngeal Gonorrhea in Adolescents
IM

Single 250-mg dose and azithromycin (single 1-g oral dose).

Gonococcal Conjunctivitis in Adolescents†
IM

Single 1-g dose and azithromycin (single 1-g oral dose).

Disseminated Gonococcal Infections in Adolescents†
IV or IM

Gonococcal arthritis and arthritis-dermatitis syndrome: 1 g once daily and azithromycin (single 1-g oral dose). Continue ceftriaxone for 24–48 hours after substantial clinical improvement; treatment may then be switched to an oral antibacterial (selected based on in vitro susceptibility testing) to complete total treatment duration of at least 7 days.

Gonococcal meningitis or endocarditis: 1–2 g IV every 12–24 hours and azithromycin (single 1-g oral dose). Continue ceftriaxone for 10–14 days in those with meningitis and for at least 4 weeks in those with endocarditis.

Prophylaxis in Adolescent Sexual Assault Victims†
IM

Single 250-mg dose in conjunction with azithromycin (single 1-g oral dose) and either metronidazole (single 2-g oral dose) or tinidazole (single 2-g oral dose) recommended by CDC.

Lyme Disease†
Early Neurologic Lyme Disease†
IV

50–75 mg/kg (up to 2 g) once daily for 14 days (range: 10–28 days) recommended by IDSA and AAP for early Lyme disease in children with acute neurologic manifestations (e.g., meningitis, radiculopathy).

Lyme Carditis†
IV

50–75 mg/kg (up to 2 g) once daily for 14 days (range: 14–21 days) recommended by IDSA for children with AV heart block and/or myopericarditis associated with early Lyme disease when parenteral regimen indicated (e.g., hospitalized patients).

Parenteral regimen can be switched to an oral regimen (doxycycline, amoxicillin, or cefuroxime axetil) to complete therapy and for outpatients.

Lyme Arthritis†
IV

50–75 mg/kg (up to 2 g) once daily for 14 days (range: 14–28 days) recommended by IDSA and AAP for children with evidence of neurologic disease or when arthritis has not responded to an oral regimen.

Late Neurologic Lyme Disease†
IV

50–75 mg/kg (up to 2 g) once daily for 2–4 weeks recommended by IDSA and AAP for children with late neurologic disease affecting CNS or peripheral nervous system.

Neisseria meningitidis Infections
Meningitis
IV

Initial dose of 100 mg/kg (up to 4 g) followed by 100 mg/kg daily (up to 4 g daily) given as a single daily dose or in equally divided doses every 12 hours recommended by manufacturers.

Some clinicians recommend 80–100 mg/kg daily (up to 4 g daily) given as a single daily dose or in divided doses every 12 hours.

Usual duration is 7–14 days; AAP states 5–7 days may be adequate for meningococcal disease.

Elimination of Nasopharyngeal Carrier State†
IM

Children and adolescents <15 years of age: Single 125-mg dose.

Adolescents ≥15 years of age: Single 250-mg dose.

Chemoprophylaxis in Household or Other Close Contacts†
IV or IM

Children and adolescents <15 years of age: Single 125-mg dose.

Adolescents ≥15 years of age: Single 250-mg dose.

Pelvic Inflammatory Disease
IM

Adolescents: Single 250-mg dose followed by 14-day regimen of doxycycline (100 mg orally twice daily) with or without metronidazole (500 mg orally twice daily).

If no clinical response within 72 hours, reevaluate patient to confirm diagnosis and administer an IV regimen if indicated.

Syphilis†
Congenital Syphilis When Penicillin Unavailable†
IV or IM

Infants ≥30 days of age with clinical evidence of congenital syphilis: 75 mg/kg once daily for 10–14 days recommended by CDC. Dosage adjustments may be needed based on weight.

Children: 100 mg/kg once daily for 10–14 days recommended by CDC.

Use for treatment of congenital syphilis only when necessary (i.e., during a penicillin shortage); use in consultation with a specialist in treatment of infants with congenital syphilis and with close clinical, serologic, and CSF follow-up.

Consider that ceftriaxone is contraindicated in certain neonates. (See Pediatric Use under Cautions.)

Syphilis in Penicillin-allergic Nonpregnant Adolescents†
IV or IM

Primary or secondary syphilis: 1–2 g once daily for 10–14 days suggested by CDC and others.

Early latent syphilis: 1–2 g once daily for 10–14 days suggested by some clinicians.

Neurosyphilis: 2 g daily for 10–14 days suggested by CDC and others based on limited data.

Consider that optimal dosage and duration of ceftriaxone for treatment of syphilis not defined; close follow-up is essential.

Typhoid Fever and Other Invasive Salmonella Infections†
IV or IM

50–75 mg/kg once daily.

May be effective for treatment of typhoid fever when given for 3–7 days, but anti-infective treatment usually continued for ≥14 days to prevent relapse. A duration at least 4–6 weeks may be necessary in immunocompromised individuals (including HIV-infected individuals) or for treatment of Salmonella meningitis.

Empiric Therapy in Febrile Neutropenic Patients†
IV

80 mg/kg (up to 2 g) once daily in conjunction with IV amikacin (20 mg/kg daily) has been used.

Prevention of Bacterial Endocarditis†
Patients Undergoing Certain Dental or Upper Respiratory Tract Procedures
IV or IM

Single 50-mg/kg dose given 30–60 minutes prior to the procedure recommended by AHA.

Adults

General Adult Dosage
IV or IM

1–2 g once daily or in equally divided doses twice daily.

One manufacturer recommends 50–75 mg/kg every 12 hours (up to 2 g daily) for treatment of serious infections other than meningitis.

Bone and Joint Infections
Native Vertebral Osteomyelitis
IV

Infections caused by susceptible staphylococci, β-hemolytic streptococci, or C. acnes: 2 g once daily for 6 weeks recommended by IDSA.

Infections caused by susceptible Salmonella (nalidixic acid-resistant strains): 2 g once daily for 6–8 weeks recommended by IDSA.

Prosthetic Joint Infections
IV

Infections caused by susceptible staphylococci: 1–2 g once daily for 2–4 weeks in conjunction with rifampin (300–450 mg orally twice daily) recommended by IDSA. Use oral anti-infective regimen (e.g., rifampin and ciprofloxacin or levofloxacin) to complete a total treatment duration of 3 months for infections related to total hip arthroplasty or 6 months for infections related to total knee arthroplasty.

Infections caused by susceptible β-hemolytic streptococci or C. acnes: 2 g once daily for 4–6 weeks recommended by IDSA.

Endocarditis†
Native Valve Endocarditis Caused by Viridans Group Streptococci or S. gallolyticus†
IV or IM

Highly penicillin-susceptible strains (penicillin MIC ≤0.12 mcg/mL): 2 g once daily for 4 weeks recommended by AHA for most patients.

Highly penicillin-susceptible strains (penicillin MIC ≤0.12 mcg/mL): 2 g once daily for 2 weeks in conjunction with gentamicin (3 mg/kg daily IV or IM as a single daily dose or as 1 mg/kg every 8 hours for 2 weeks) recommended by AHA for selected patients. May be considered in adults with uncomplicated endocarditis who are at low risk for gentamicin adverse effects; do not use in those with known cardiac or extracardiac abscess, Clcr <20 mL/minute, impaired eighth cranial nerve function, or infection caused by Abiotrophia, Granulicatella, or Gemella.

Prosthetic Valve Endocarditis Caused by Viridans Streptococci or S. gallolyticus†
IV or IM

Highly penicillin-susceptible strains (penicillin MIC ≤0.12 mcg/mL): 2 g once daily for 6 weeks with or without gentamicin (3 mg/kg daily IV or IM as a single daily dose or as 1 mg/kg every 8 hours during first 2 weeks of ceftriaxone treatment) recommended by AHA.

Strains relatively or highly resistant to penicillin (penicillin MIC >0.12 mcg/mL): 2 g once daily for 6 weeks in conjunction with gentamicin (3 mg/kg daily IV or IM as a single daily dose or as 1 mg/kg every 8 hours during entire 6 weeks of ceftriaxone treatment) recommended by AHA.

Native or Prosthetic Valve Endocarditis Caused by Enterococci†
IV

2 g every 12 hours in conjunction with ampicillin (2 g IV every 4 hours). Continue this double β-lactam regimen for 6 weeks.

Native or Prosthetic Valve Endocarditis Caused by the HACEK Group†
IV or IM

2 g once daily recommended by AHA. Treatment duration of 4 weeks for native valve endocarditis or 6 weeks for endocarditis involving prosthetic valves or other prosthetic material.

GI Infections†
Salmonella Gastroenteritis†
IV

HIV-infected: 1 g every 24 hours.

Recommended duration is 7–14 days if CD4+ T-cells ≥200 cells/mm3 (≥14 days if patient is bacteremic or infection is complicated) or 2–6 weeks if CD4+ T-cells <200 cells/mm3.

Empiric Treatment of Infectious Diarrhea†
IV

HIV-infected: 1 g every 24 hours. If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.

Intra-abdominal Infections
IV or IM

1–2 g once or twice daily.

May be used alone for initial empiric treatment of community-acquired biliary tract infections (cholecystitis or cholangitis); use in conjunction with metronidazole for initial empiric treatment of extrabiliary community-acquired intra-abdominal infections.

Meningitis and Other CNS Infections
Meningitis
IV

2 g every 12 hours. Some manufacturers and clinicians suggest 50–100 mg/kg (up to 4 g) once daily or in 2 equally divided doses every 12 hours; others suggest 4 g daily in 1 or 2 equally divided doses.

While 7 days may be adequate for uncomplicated meningitis caused by susceptible H. influenzae or N. meningitidis, ≥10–14 days suggested for complicated meningitis caused by S. pneumoniae and ≥21 days suggested for meningitis caused by susceptible Enterobacteriaceae (e.g., E. coli, Klebsiella).

Healthcare-associated Ventriculitis and Meningitis
IV

4 g daily in divided doses every 12 hours recommended by IDSA.

Treatment duration depends on causative organism and patient characteristics. Duration of 10–14 days recommended for infections caused by gram-negative bacilli (with or without significant CSF pleocytosis, CSF hypoglycorrhachia, or clinical symptoms or systemic features); some experts recommend a duration of 21 days.

Respiratory Tract Infections
Acute Bacterial Rhinosinusitis†
IV

Severe infections requiring hospitalization: 1–2 g every 12–24 hours.

Skin and Skin Structure Infections
IV or IM

50–75 mg/kg daily (up to 2 g) given as single daily dose or in 2 divided doses every 12 hours.

Infected Animal Bite
IV

1 g IV every 12 hours recommended by IDSA.

Necrotizing Fasciitis†
IV

Infections involving A. hydrophila: 1–2 g once daily in conjunction with doxycycline (100 mg IV every 12 hours) recommended by IDSA.

Infections involving V. vulnificus: 1 g once daily in conjunction with doxycycline (100 mg IV every 12 hours) recommended by IDSA.

Surgical Site Infections
IV or IM

Following GI or GU surgery: 1 g once daily in conjunction with metronidazole (500 mg IV every 8 hours) recommended by IDSA.

Following procedures involving axilla or perineum: 1 g once daily recommended by IDSA; concomitant vancomycin (15 mg/kg every 12 hours) may also be needed.

Urinary Tract Infections
IV

Empiric treatment of acute pyelonephritis (e.g., pending results of in vitro susceptibility testing): Single 1-g dose followed by an appropriate oral anti-infective given for 7–14 days.

Chancroid†
IM

Single 250-mg dose recommended by CDC and others.

Gonorrhea and Associated Infections
Uncomplicated Cervical, Urethral, Anorectal, or Pharyngeal Gonorrhea
IM

Single 250-mg dose and azithromycin (single 1-g oral dose).

Gonococcal Conjunctivitis†
IM

Single 1-g dose and azithromycin (single 1-g oral dose).

Disseminated Gonococcal Infections†
IV or IM

Gonococcal arthritis and arthritis-dermatitis syndrome: 1 g once daily and azithromycin (single 1-g oral dose). Continue ceftriaxone for 24–48 hours after substantial clinical improvement; treatment may then be switched to an oral antibacterial (selected based on in vitro susceptibility testing) to complete total treatment duration of at least 7 days.

Gonococcal meningitis or endocarditis: 1–2 g IV every 12–24 hours and azithromycin (single 1-g oral dose). Continue ceftriaxone for 10–14 days in those with meningitis and for at least 4 weeks in those with endocarditis.

Epididymitis†
IM

Presumptive treatment when most likely caused by chlamydia and gonorrhea: Single 250-mg dose in conjunction with doxycycline (100 mg orally twice daily for 10 days).

Presumptive treatment when most likely caused by chlamydia, gonorrhea, and enteric bacteria (e.g., E. coli): Single 250-mg dose in conjunction with levofloxacin (500 mg orally once daily for 10 days) or ofloxacin (300 mg orally twice daily for 10 days).

Proctitis†
IM

Presumptive treatment: Single 250-mg dose in conjunction with doxycycline (100 mg orally twice daily for 7 days).

Prophylaxis in Sexual Assault Victims†
IM

Single 250-mg dose in conjunction with azithromycin (single 1-g oral dose) and either metronidazole (single 2-g oral dose) or tinidazole (single 2-g oral dose) recommended by CDC.

Leptospirosis†
IV

1 g once daily for 7 days has been used for treatment of severe infections.

Lyme Disease†
Early Neurologic Lyme Disease†
IV

2 g once daily for 14 days (range: 10–28 days) recommended by IDSA for adults with acute neurologic manifestations (e.g., meningitis, radiculopathy).

Lyme Carditis†
IV

2 g once daily for 14 days (range: 14–21 days) recommended by IDSA and others for adults with AV heart block and/or myopericarditis associated with early Lyme disease when parenteral regimen indicated (e.g., hospitalized patients).

Parenteral regimen can be switched to oral regimen (doxycycline, amoxicillin, or cefuroxime axetil) to complete therapy and for outpatients.

Lyme Arthritis†
IV

2 g once daily for 14 days (range: 14–28 days) recommended by IDSA and others for adults with evidence of neurologic disease or when arthritis has not responded to an oral regimen.

Late Neurologic Lyme Disease†
IV

2 g once daily for 2–4 weeks recommended by IDSA and others for adults with late neurologic disease affecting the CNS or peripheral nervous system.

Neisseria meningitidis Infections
Meningitis
IV

2 g every 12 hours. Usual duration is 7–14 days.

Elimination of Nasopharyngeal Carrier State†
IM

Single 250-mg dose.

Postexposure Chemoprophylaxis in Household or Other Close Contacts†
IM

Single 250-mg dose.

Pelvic Inflammatory Disease
IM

Single 250-mg dose followed by 14-day regimen of doxycycline (100 mg orally twice daily) with or without metronidazole (500 mg orally twice daily).

If no clinical response within 72 hours, reevaluate patient to confirm diagnosis and administer an IV regimen if indicated.

Syphilis†
Penicillin-allergic Nonpregnant Adults†
IV or IM

Primary or secondary syphilis: 1–2 g once daily for 10–14 days suggested by CDC and others.

Early latent syphilis: 1–2 g once daily for 10–14 days suggested by some clinicians.

Neurosyphilis: 2 g daily for 10–14 days suggested by CDC and others based on limited data.

CDC cautions that optimal dosage and duration not defined; close follow-up is essential.

Typhoid Fever and Other Invasive Salmonella Infections†
IV or IM

2–4 g once daily.

May be effective for treatment of typhoid fever when given for 3–7 days, but anti-infective treatment usually continued for ≥14 days to prevent relapse. A duration of ≥4–6 weeks may be necessary in immunocompromised individuals (including those with HIV infection) or for the treatment of Salmonella meningitis.

Whipple's Disease†
IV

2 g once daily for 2–4 weeks followed by oral co-trimoxazole given for 1–2 years has been recommended. For treatment of encephalitis caused by T. whipplei, IDSA recommends initial treatment with ceftriaxone for 2–4 weeks followed by co-trimoxazole or cefixime for 1–2 years.

Empiric Therapy in Febrile Neutropenic Patients†
IV

30 mg/kg (up to 2 g) once daily in conjunction with IV amikacin.

Perioperative Prophylaxis
IV

Single 1-g dose given 0.5–2 hours prior to surgery.

Cholecystectomy: Single 1-g dose has been given 0.5–2 hours prior to surgery.

Colorectal procedures: Some experts recommend single 2-g dose in conjunction with metronidazole (single 500-mg IV dose) given within 1 hour prior to surgery.

Prevention of Bacterial Endocarditis†
Patients Undergoing Certain Dental or Upper Respiratory Tract Procedures†
IV or IM

Single 1-g dose given 30–60 minutes prior to the procedure recommended by AHA.

Prescribing Limits

Pediatric Patients

Endocarditis or meningitis: Maximum 4 g daily.

Most other infections: Maximum 2 g daily.

Adults

Maximum 4 g daily.

Special Populations

Hepatic Impairment

Dosage adjustments not usually necessary in patients with impaired hepatic function receiving dosage up to 2 g daily.

In those with hepatic dysfunction and clinically significant renal disease, use caution and do not exceed dosage of 2 g daily.

Some clinicians recommend monitoring serum concentrations.

Renal Impairment

Dosage adjustments not usually necessary in patients with impaired renal function receiving dosage up to 2 g daily.

In those with clinically significant renal impairment and hepatic dysfunction, use caution and do not exceed dosage of 2 g daily.

Some clinicians recommend monitoring serum concentrations in patients with severe renal impairment (e.g., dialysis patients) or with both hepatic impairment and clinically important renal impairment.

Additional supplemental doses not needed in patients undergoing dialysis.

Cautions for cefTRIAXone

Contraindications

  • Known hypersensitivity to ceftriaxone, any other cephalosporin, or any ingredient in the formulation. (See Sensitivity Reactions under Cautions.)

  • History of anaphylaxis to ceftriaxone, cephalosporins, penicillins, or other β-lactam anti-infectives. (See Sensitivity Reactions under Cautions.)

  • Certain neonates (e.g., premature or hyperbilirubinemic, those requiring calcium-containing IV solutions). (See Pediatric Use under Cautions.)

  • Commercially available premixed (frozen) injection in dextrose may be contraindicated in patients with known allergy to corn or corn products. (See Sensitivity Reactions under Cautions.)

Warnings/Precautions

Warnings

Interaction with Calcium-containing Products

Fatalities reported in some neonates receiving ceftriaxone and calcium-containing IV solutions; a crystalline material was observed in the lungs and kidneys at autopsy. In some cases, the same IV infusion line had been used for both ceftriaxone and the calcium-containing fluid and, in some, a precipitate was observed in the IV infusion line. At least 1 fatality occurred in a neonate who received ceftriaxone and calcium-containing fluids administered at different times and through different infusion lines; no crystalline material was observed at autopsy in this neonate.

No similar reports to date in patients other than neonates treated with ceftriaxone and calcium-containing IV solutions.

There is some evidence that neonates have an increased risk for precipitation of ceftriaxone-calcium. In vitro studies evaluating the combination of ceftriaxone and calcium in adult plasma and neonatal plasma from umbilical cord blood indicate that recovery of ceftriaxone from plasma was reduced with calcium concentrations ≥24 mg/dL in adult plasma or ≥16 mg/dL in neonatal plasma. This may reflect ceftriaxone-calcium precipitation.

Ceftriaxone must not be admixed with calcium-containing IV solutions and must not be administered simultaneously with calcium-containing IV solutions, including calcium-containing infusions such as parenteral nutrition, even via different infusion lines at different sites in any patient (irrespective of age). (See Administration under Dosage and Administration.)

No reports to date of an interaction between ceftriaxone and oral calcium-containing products or between IM ceftriaxone and calcium-containing products (IV or oral).

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible organisms with prolonged therapy, especially Candida, enterococci, Bacteroides fragilis, or Pseudomonas aeruginosa. Resistant strains of Ps. aeruginosa and Enterobacter have developed during ceftriaxone therapy. Careful observation of the patient is essential. Institute appropriate therapy if superinfection occurs.

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile. C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including ceftriaxone, and may range in severity from mild diarrhea to fatal colitis. C. difficile produces toxins A and B which contribute to the development of CDAD; hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.

Consider CDAD if diarrhea develops during or after therapy and manage accordingly. Obtain careful medical history since CDAD may occur as late as 2 months or longer after anti-infective therapy is discontinued.

If CDAD is suspected or confirmed, discontinue anti-infectives not directed against C. difficile as soon as possible. Initiate anti-infective therapy directed against C. difficile (e.g., vancomycin, fidaxomicin, metronidazole), appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), and surgical evaluation as clinically indicated.

Hemolytic Anemia

Immune-mediated hemolytic anemia reported. Severe cases, including fatalities, have occurred in both adults and children. Some cases occurred shortly after administration of a ceftriaxone dose; some reactions have consisted of severe intravascular hemolysis and anemia, decreased hemoglobin concentrations, reticulocytosis, hemoglobinuria, and cardiac arrest.

Consider diagnosis of cephalosporin-associated anemia if anemia occurs in a patient receiving ceftriaxone. Discontinue ceftriaxone until etiology of the anemia determined.

Sensitivity Reactions

Hypersensitivity Reactions

Serious, occasionally fatal, hypersensitivity reactions (anaphylaxis or anaphylactoid) reported.

Other hypersensitivity reactions, including rash (maculopapular or erythematous), pruritus, fever, eosinophilia, urticaria, bronchospasm, serum sickness, generalized exanthematous pustulosis, and severe cutaneous reactions (erythema multiforme, Stevens-Johnson syndrome, Lyell’s syndrome/toxic epidermal necrolysis) reported.

Although it has not been proven that allergic reactions to antibiotics are more frequent in atopic individuals, some manufacturers state use ceftriaxone with caution in patients with history of allergy, particularly to drugs.

Hypersensitivity reactions, including anaphylaxis, reported with dextrose-containing solutions; usually reported in patients receiving high dextrose concentrations (i.e., 50% dextrose), but also reported when corn-derived dextrose solutions administered to patients with or without history of hypersensitivity to corn products.

If a severe hypersensitivity reaction occurs, immediately discontinue drug and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, maintenance of an adequate airway and oxygen).

Cross-hypersensitivity

Partial cross-sensitivity among cephalosporins and other β-lactam antibiotics, including penicillins and cephamycins.

Prior to initiation of therapy, make careful inquiry concerning previous hypersensitivity reactions to cephalosporins, penicillins, other β-lactam anti-infectives, or other drugs.

General Precautions

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of ceftriaxone and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing. In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.

Prolonged PT

Prolonged PT reported rarely.

Monitor PT in patients with impaired vitamin K synthesis or low vitamin K stores (e.g., chronic hepatic disease, malnutrition). Administer vitamin K when indicated.

Possible increased risk of bleeding if used concomitantly with vitamin K antagonists. (See Specific Drugs under Interactions.)

Gallbladder Pseudolithiasis

Ceftriaxone-calcium precipitates in the gallbladder reported rarely; symptoms of gallbladder disease (e.g., colic, nausea, vomiting, anorexia) can occur.

The precipitates appear on sonography as an echo without acoustical shadowing (suggesting sludge) or as an echo with acoustical shadowing and may be misinterpreted as gallstones.

Probability of gallbladder precipitates associated with ceftriaxone therapy appears to be greatest in pediatric patients.

Discontinue ceftriaxone in patients with manifestations suggestive of gallbladder disease and/or if sonographic abnormalities characteristic of ceftriaxone-calcium precipitates are detected.

The condition appears to be transient and generally resolves following discontinuance of the drug and conservative management. The time to resolution may range from a few days to several months.

Consider upper abdominal ultrasonography for patients who develop biliary colic while receiving ceftriaxone therapy; biliary precipitates of ceftriaxone may be detected by ultrasonography after only 4 days of ceftriaxone therapy. The risk of precipitation may depend on the dose and rate of IV administration of ceftriaxone, occurring more frequently with relatively high dosages and rapid (e.g., over several minutes) rates of administration.

Urolithiasis and Post-renal Acute Renal Failure

Ceftriaxone-calcium precipitates in urine reported and may be detected as sonographic abnormalities. Patients may be asymptomatic or may develop symptoms of urolithiasis, ureteral obstruction, and post-renal acute renal failure.

Probability of such precipitates appears to be greatest in pediatric patients.

The condition appears to be reversible following discontinuance of the drug and conservative management.

Ensure that patients are adequately hydrated during ceftriaxone therapy.

Discontinue ceftriaxone in patients with signs and symptoms suggestive of urolithiasis, oliguria or renal failure, and/or if sonographic abnormalities characteristic of ceftriaxone-calcium precipitates are detected.

Pancreatitis

Pancreatitis, possibly secondary to biliary obstruction, reported rarely. Most had preexisting risk factors for biliary stasis and biliary sludge (e.g., preceding major therapy, severe illness, total parenteral nutrition).

Co-factor role of ceftriaxone-related biliary precipitation cannot be ruled out.

Seizures

Seizures reported with some cephalosporins, particularly in patients with renal impairment who did not receive dosage adjustment based on renal function.

Discontinue ceftriaxone if seizures occur; administer anticonvulsant therapy if clinically indicated.

Patients with Diabetes

Like other dextrose-containing solutions, use Duplex drug delivery system containing 1 or 2 g of lyophilized ceftriaxone and 50 mL of dextrose 3.74 or 2.22% injection, respectively, with caution in patients with overt or known subclinical diabetes mellitus or in patients with carbohydrate intolerance for any reason.

Lidocaine

Although IM injections can be prepared using 1% lidocaine hydrochloride (see Reconstitution under Dosage and Administration), consider all contraindications to lidocaine before administering such injections.

IV administration of ceftriaxone solutions containing lidocaine is contraindicated.

Sodium Content

Contains approximately 83 mg (3.6 mEq) of sodium per g of ceftriaxone.

Specific Populations

Pregnancy

Reproduction studies in mice, rats, and primates have not revealed evidence of embryotoxicity, fetotoxicity, or teratogenicity.

No adequate or controlled studies in pregnant women. Use during pregnancy only when clearly needed.

Lactation

Distributed into milk in low concentrations; use with caution.

Pediatric Use

Contraindicated in premature neonates up to postmenstrual age 41 weeks (i.e., time elapsed since first day of the mother’s last menstrual period to birth plus time elapsed after birth).

Contraindicated in hyperbilirubinemic neonates, particularly those who are premature. Ceftriaxone can displace bilirubin from serum albumin; possible risk of bilirubin encephalopathy.

Contraindicated in neonates (≤28 days of age) who are receiving (or are expected to require) treatment with calcium-containing IV solutions, including continuous infusions of calcium-containing solutions such as parenteral nutrition; risk of precipitation of ceftriaxone-calcium salt. Fatalities reported in neonates who received ceftriaxone and calcium-containing IV solutions. (See Interaction with Calcium-containing Products under Cautions.)

To reduce risk of bilirubin encephalopathy, give IV infusions of ceftriaxone over 60 minutes in neonates. (See Rate of Administration under Dosage and Administration.)

Do not use ceftriaxone IM injections prepared using bacteriostatic water for injection containing benzyl alcohol in neonates. Although causal relationship not established, administration of injections preserved with benzyl alcohol has been associated with toxicity in neonates. Toxicity appears to have resulted from administration of large amounts (i.e., about 100–400 mg/kg daily) of benzyl alcohol in these neonates.

To avoid unintentional overdosage, do not use ceftriaxone available in Duplex drug delivery system in pediatric patients who require less than entire 1- or 2-g dose in the container.

Geriatric Use

No overall differences in safety and efficacy in those ≥60 years of age compared with younger adults, but the possibility of increased sensitivity in some geriatric individuals cannot be ruled out.

Pharmacokinetics only minimally altered in geriatric patients compared with healthy younger adults. Dosage adjustments based solely on age not needed in those receiving up to 2 g daily.

Substantially eliminated by the kidneys; risk of adverse effects may be greater in those with impaired renal function. Select dosage with caution and consider monitoring renal function because of age-related decreases in renal function.

Hepatic Impairment

Hepatic impairment generally does not affect ceftriaxone pharmacokinetics; dosage adjustments not usually needed unless both hepatic and renal function are impaired.

In those with hepatic dysfunction and clinically significant renal disease, use caution and do not exceed a dosage of 2 g daily. Some manufacturers and clinicians suggest monitoring serum ceftriaxone concentrations periodically and adjusting dosage if there is evidence of accumulation.

Renal Impairment

Since ceftriaxone is eliminated by both biliary and renal routes, dosage adjustments not usually needed in patients with renal impairment alone.

In those with clinically significant renal disease and hepatic impairment, use caution and do not exceed a dosage of 2 g daily. Some clinicians suggest monitoring serum ceftriaxone concentrations periodically in patients with severe renal impairment (e.g., dialysis patients) or with both renal and hepatic impairment; adjust dosage if there is evidence of accumulation.

Common Adverse Effects

Local reactions at the administration site (warmth, tightness, induration, phlebitis); hematologic effects (eosinophilia, thrombocytosis, leukopenia); hypersensitivity reactions.

Interactions for cefTRIAXone

Specific Drugs and Laboratory Tests

Drug or Test

Interaction

Comments

Aminoglycosides

Nephrotoxicity reported with concomitant use of some cephalosporins and aminoglycosides

In vitro evidence of additive or synergistic antibacterial activity against some Enterobacteriaceae and Pseudomonas aeruginosa

Anticoagulants (warfarin)

Possible increased risk of bleeding if used concomitantly with vitamin K antagonists

Increased INR reported in patients receiving warfarin and ceftriaxone concomitantly

Warfarin: Monitor coagulation parameters frequently during and after ceftriaxone treatment; adjust anticoagulant dosage as needed

Chloramphenicol

Antagonism reported in vitro

Probenecid

Concomitant use of oral probenecid (500 mg daily) does not appear to affect the pharmacokinetics of ceftriaxone, presumably because ceftriaxone is excreted principally by glomerular filtration and nonrenal mechanisms

Higher dosages of oral probenecid (1 or 2 g daily) may partially block biliary secretion of ceftriaxone as well as displace the drug from plasma proteins resulting in increased clearance and decreased half-life of ceftriaxone

Quinolones

In vitro evidence of synergistic antibacterial effect between ceftriaxone and trovafloxacin (not commercially available in the US) against penicillin-susceptible and penicillin-resistant S. pneumoniae, including some strains resistant to ceftriaxone alone

Clinical importance unknown

Tests for glucose

Possible false-positive reactions in nonenzymatic urine glucose tests (e.g., Clinitest, Benedict’s solution)

Possible falsely low estimated blood glucose with some blood glucose monitoring systems

Use urinary glucose tests based on enzymatic glucose oxidase reactions (e.g., Clinistix, Tes-Tape)

Consult manufacturer's instructions for glucose monitoring systems; use alternative testing methods if needed

cefTRIAXone Pharmacokinetics

Absorption

Bioavailability

Not appreciably absorbed from GI tract; must be given parenterally.

Appears to be completely absorbed following IM administration in healthy adults; peak serum concentrations attained 1.5–4 hours after the dose.

Multiple-dose studies in healthy adults indicate serum concentrations at steady state on day 4 of therapy are 15–36% higher than serum concentrations attained with a single dose.

Distribution

Extent

Following IM or IV administration, widely distributed into body tissues and fluids including the gallbladder, lungs, bone, heart, bile, prostate adenoma tissue, uterine tissue, atrial appendage, sputum, tears, middle ear fluid, and pleural, peritoneal, synovial, ascitic, and blister fluids.

Generally diffuses into CSF following IM or IV administration; CSF concentrations are higher in patients with inflamed meninges.

Crosses the placenta and is distributed into amniotic fluid. Distributed into milk.

Plasma Protein Binding

Degree of protein binding is concentration dependent; decreases nonlinearly with increasing concentrations of the drug. Principally binds to albumin.

93–96% bound to plasma proteins at <70 mcg/mL, 84–87% at 300 mcg/mL, and ≤58% at 600 mcg/mL.

Protein binding is lower in neonates and children than in adults because of decreased plasma albumin concentrations in this age group. Also less protein bound in patients with renal or hepatic impairment as the result of decreased plasma albumin concentrations or displacement from protein binding sites by bilirubin and other endogenous compounds that may accumulate.

Elimination

Metabolism

Metabolized to a small extent in the intestines after biliary elimination.

Elimination Route

Eliminated by renal and nonrenal mechanisms.

33–67% eliminated in urine by glomerular filtration as unchanged drug; remainder eliminated in feces via bile as unchanged drug and microbiologically inactive metabolites.

Half-life

Adults with normal renal and hepatic function: Distribution half-life 0.12–0.7 hours and elimination half-life 5.4–10.9 hours.

Neonates: 16.2 hours in those 1–4 days of age and 9.2 hours in those 9–30 days of age.

Children 2–42 months of age: Distribution half-life 0.25 hours and elimination half-life 4 hours.

Special Populations

Patients with moderately impaired renal function: Elimination half-life averages 10–16 hours.

Elimination half-life averages 12.2–18.2 hours in patients with creatinine clearances <5 mL/min and 15–57 hours in uremic patients.

Stability

Storage

Parenteral

Powder for IM Injection or IV Infusion

20–25°C; protect from light. No need to protect reconstituted solutions from normal light.

IV solutions containing 10–40 mg/mL prepared using sterile water, 0.9% sodium chloride, or 5 or 10% dextrose are stable for 3 days at room temperature (25°C) or 10 days refrigerated at 4°C. Those containing 10–40 mg/mL prepared using 5% dextrose and 0.45 or 0.9% sodium chloride are stable for 2 days at 25°C; do not refrigerate.

IM solutions containing 100 mg/mL prepared using sterile water, 0.9% sodium chloride, or 5% dextrose are stable for 2 days at room temperature (25°C) or 10 days refrigerated at 4°C; those containing 250 or 350 mg/mL are stable for 24 hours at 25°C or 3 days at 4°C.

IM solutions containing 100 mg/mL prepared using 1% lidocaine hydrochloride (without epinephrine) or bacteriostatic water (containing 0.9% benzyl alcohol) are stable for 24 hours at 25°C or 10 days at 4°C; those containing 250 or 350 mg/mL are stable for 24 hours at 25°C or 3 days at 4°C.

For Injection, for IV Infusion

Pharmacy bulk package: 20–25°C; protect from light. Following reconstitution, further dilute in compatible IV infusion solution without delay; discard unused portions of reconstituted solution after 4 hours. No need to protect reconstituted solution from normal light.

ADD-Vantage vials: 20–25°C; protect from light. Following reconstitution, IV solutions containing 10–40 mg/mL are stable for 2 days at room temperature (25°C) or 10 days refrigerated at 4°C.

Duplex drug delivery: 20–25°C (may be exposed to 15–30°C). Following reconstitution (activation), use within 24 hours if stored at room temperature or within 7 days if stored in refrigerator; do not freeze.

Injection (Frozen) for IV Infusion

−20° C or lower. Thawed solutions are stable for 48 hours at room temperature (25°C) or 21 days under refrigeration (5°C).

Do not refreeze after thawing.

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Do not use calcium-containing diluents to reconstitute or further dilute reconstituted ceftriaxone because a precipitate forms.

Compatible

Dextrose 5% in sodium chloride 0.45%

Dextrose 5 or 10% in water

FreAmine III

Ionosol B in dextrose 5%

Normosol M in dextrose 5%

Sodium chloride 0.9%

Sodium lactate 1/6 M

Incompatible

Hartmann’s solution

Ringer’s injection

Ringer’s injection, lactated

Drug Compatibility
Admixture CompatibilityHID

Compatible

Amikacin sulfate

Mannitol

Metronidazole

Sodium bicarbonate

Incompatible

Aminoglycosides

Aminophylline

Calcium chloride

Calcium gluconate

Clindamycin phosphate

Fluconazole

Linezolid

Theophylline

Vancomycin

Variable

Gentamicin sulfate

Y-Site CompatibilityHID

Compatible

Acetaminophen

Acyclovir sodium

Allopurinol sodium

Amifostine

Amiodarone HCl

Anidulafungin

Aztreonam

Bivalirudin

Cangrelor tetrasodium

Ceftolozane sulfate-tazobactam sodium

Cisatracurium besylate

Cloxacillin sodium

Daptomycin

Defibrotide sodium

Dexmedetomidine HCl

Diltiazem HCl

Docetaxel

Doxorubicin HCl liposomal

Drotrecogin alfa (activated)

Etoposide phosphate

Famotidine

Fenoldopam mesylate

Fludarabine phosphate

Foscarnet sodium

Gallium nitrate

Gemcitabine HCl

Granisetron HCl

Heparin sodium

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Linezolid

Melphalan HCl

Meperidine HCl

Meropenem-vaborbactam

Methotrexate sodium

Morphine sulfate

Paclitaxel

Pantoprazole sodium

Pemetrexed disodium

Propofol

Remifentanil HCl

Sargramostim

Sodium bicarbonate

Tacrolimus

Tedizolid

Telavancin HCl

Teniposide

Theophylline

Thiotepa

Tigecycline

Zidovudine

Incompatible

Amphotericin B cholesteryl sulfate complex

Amsacrine

Azithromycin

Caspofungin

Filgrastim

Fluconazole

Isavuconazonium sulfate

Labetalol HCl

Pentamidine isethionate

Vinorelbine tartrate

Variable

Anakinra

Vancomycin HCl

Actions and Spectrum

  • Based on spectrum of activity, classified as a third generation cephalosporin. Usually less active in vitro against susceptible staphylococci than first generation cephalosporins, but has expanded spectrum of activity against gram-negative bacteria compared with first and second generation cephalosporins.

  • Usually bactericidal.

  • Like other β-lactam antibiotics, antibacterial activity results from inhibition of bacterial cell wall synthesis.

  • Spectrum of activity includes many gram-positive aerobic bacteria, many gram-negative aerobic bacteria, and some anaerobic bacteria; inactive against Chlamydia, fungi, and viruses.

  • Gram-positive aerobes: Active in vitro and in clinical infections against Streptococcus pneumoniae, S. pyogenes (group A β-hemolytic streptococci; GAS), Staphylococcus aureus (including penicillinase-producing strains), S. epidermidis, and viridans streptococci. Also active in vitro against S. agalactiae (group B streptococci; GBS). Methicillin-resistant (oxacillin-resistant) staphylococci and most enterococci (e.g., Enterococcus faecalis) are resistant.

  • Strains of staphylococci resistant to penicillinase-resistant penicillins (methicillin-resistant [oxacillin-resistant] staphylococci) should be considered resistant to ceftriaxone, although results of in vitro susceptibility tests may indicate that the organisms are susceptible to the drug.

  • Active in vitro against some strains of Nocardia, including some strains of N. asteroides and N. brasiliensis. Resistance to ceftriaxone reported in some environmental isolates of N. asteroides and clinical isolates of N. farcinica.

  • Gram-negative aerobes: Active in vitro and in clinical infections against Acinetobacter calcoaceticus, Enterobacter (including E. aerogenes, E. cloacae), Escherichia coli, Haemophilus influenzae (including ampicillin-resistant and β-lactamase-producing strains), H. parainfluenzae, Klebsiella pneumoniae, K. oxytoca, Moraxella catarrhalis (including β-lactamase-producing strains), Morganella morganii, Neisseria gonorrhoeae, N. meningitidis, Proteus mirabilis, P. vulgaris, Pseudomonas aeruginosa , and Serratia marcescens. Also active in vitro against Bartonella, Capnocytophaga, Citrobacter, Providencia, Salmonella, and Shigella. Less active than ceftazidime against Ps. aeruginosa.

  • Anaerobes: Active in vitro and in clinical infections against Clostridium (except C. difficile) and Peptostreptococcus. Also active in vitro against Prevotella and Porphyromonas melaninogenicus. Most strains of Bacteroides fragilis are resistant.

  • Spirochetes: Has some activity against Treponema pallidum when tested in a rabbit model. Active in vitro against Borrelia burgdorferi, causative agent of Lyme disease. Active in vitro against Leptospira, including L. interrogans and L. weilii.

Advice to Patients

  • Advise patients that antibacterials (including ceftriaxone) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).

  • Importance of completing full course of therapy, even if feeling better after a few days.

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with ceftriaxone or other antibacterials in the future.

  • Advise patients that allergic reactions, including serious allergic reactions, can occur and that serious reactions require immediate treatment and discontinuance of ceftriaxone. Importance of informing clinicians of any previous allergic reactions to ceftriaxone, cephalosporins, penicillins, or similar antibacterials.

  • Inform patients that adverse neurologic reactions can occur with ceftriaxone in dextrose injection and importance of immediately informing a healthcare provider of any neurologic signs and symptoms, including encephalopathy (disturbance of consciousness including confusion, hallucinations, stupor, and coma), myoclonus, and seizures. In such situations, immediate treatment, dosage adjustment, or discontinuance of the drug is indicated.

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued. Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.

  • Advise patients that ceftriaxone and calcium-containing products can interact with each other and cause life-threatening reactions. Importance of informing clinicians of all medicines that have been given, especially those given IV within the past 2 days.

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.

  • Importance of women informing clinician if they are or plan to become pregnant or plan to breast-feed.

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

cefTRIAXone Sodium

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection

250 mg (of ceftriaxone)*

cefTRIAXone for Injection

500 mg (of ceftriaxone)*

cefTRIAXone for Injection

1 g (of ceftriaxone)*

cefTRIAXone for Injection

2 g (of ceftriaxone)*

cefTRIAXone for Injection

For injection, for IV infusion

1 g (of ceftriaxone)*

cefTRIAXone ADD-Vantage

Hospira

cefTRIAXone for Injection, for IV Infusion (available in dual-chambered Duplex drug delivery system with 3.74% dextrose injection)

B Braun

cefTRIAXone for Injection, for IV Infusion

2 g (of ceftriaxone)*

cefTRIAXone ADD-Vantage

Hospira

cefTRIAXone for Injection, for IV Infusion (available in dual-chambered Duplex drug delivery system with 2.22% dextrose injection)

B Braun

cefTRIAXone for Injection, for IV Infusion

10 g (of ceftriaxone) pharmacy bulk package*

cefTRIAXone for Injection, for IV Infusion

100 g (of ceftriaxone) pharmacy bulk package*

cefTRIAXone for Injection, for IV Infusion

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

cefTRIAXone Sodium in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection (frozen), for IV infusion

20 mg (of ceftriaxone) per mL (1 g) in 3.8% Dextrose*

cefTRIAXone Iso-osmotic in Dextrose Injection (Galaxy [Baxter])

40 mg (of ceftriaxone) per mL (2 g) in 2.4% Dextrose*

cefTRIAXone Iso-osmotic in Dextrose Injection (Galaxy [Baxter])

AHFS DI Essentials™. © Copyright 2021, Selected Revisions October 1, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

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