Rocephin

3rd Generation Cephalosporin Antibiotics

Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Ensure adequate hydration during treatment with ceftriaxone to prevent ceftriaxone-calcium precipitation in the urinary tract.[29920]

NOTE: Do NOT use diluents containing calcium to reconstitute ceftriaxone vials or for further dilution of the reconstituted vial for IV administration due to the potential for precipitation. This precipitation can also occur when ceftriaxone is mixed with calcium-containing solutions in the same IV line; do not administer ceftriaxone simultaneously with calcium-containing IV solutions, including continuous calcium-containing infusions (i.e. parenteral nutrition) via a Y-site. In patients other than neonates, ceftriaxone and calcium-containing solutions may be administered sequentially if the infusion lines are flushed with a compatible solution. Ceftriaxone is contraindicated in neonates that require any calcium-containing IV solutions. There have been no reports of an interaction between ceftriaxone and oral calcium-containing products.[29920]
NOTE: The IV administration of ceftriaxone solutions containing lidocaine is contraindicated.[29920]
 
Intravenous (IV) Infusion
Powder Vials for Injection
Reconstitution
Do NOT use solutions containing calcium (i.e., Lactated Ringer's Injection or Hartmann's solution).[29920]
Reconstitute 250 mg, 500 mg, 1 g, and 2 g vials with 2.4, 4.8, 9.6, or 19.2 mL, respectively, with a compatible IV solution to give solutions containing 100 mg/mL of ceftriaxone.[29920] [51458]
Compatible IV solutions include Sterile Water for Injection, Bacteriostatic Water for Injection, 5% Dextrose Injection, 0.9% Sodium Chloride Injection, and 10% Dextrose Injection.[29920] [51458] Bacteriostatic Water for Injection should NOT be used for the preparation of neonatal doses.[56836]
Storage: Reconstituted solutions may be stored for 2 days at room temperature (25 degrees C) or for 10 days in the refrigerator (4 degrees C).[29920] [51458]
 
Dilution
Do NOT use diluents containing calcium (i.e., Lactated Ringer's Injection or Hartmann's solution).
Dilute the appropriate dose of reconstituted ceftriaxone with a compatible IV solution to a usual final concentration of 10 to 40 mg/mL (usually 50 or 100 mL for older children and adults).[29920] [51458]
Compatible IV solutions include Sterile Water for Injection, Bacteriostatic Water for Injection, 5% Dextrose Injection, 0.9% Sodium Chloride Injection, and 10% Dextrose Injection.[29920] [51458] Bacteriostatic Water for Injection should NOT be used for the preparation of neonatal doses.[56836]
Storage: Diluted solutions may be stored for 2 days at room temperature or for 10 days in the refrigerator. Ceftriaxone reconstituted and diluted with 5% Dextrose Injection or 0.9% Sodium Chloride Injection at concentrations of 10 to 40 mg/mL are stable frozen (-20 degrees C) in PVC or polyolefin contains for 26 weeks. Frozen solutions should be thawed at room temperature before use. Do not refreeze.[29920] [51458]
 
Bulk Vials for Injection
Reconstitution
Do NOT use diluents containing calcium (i.e., Lactated Ringer's Injection or Hartmann's solution)
Reconstitute 10 g vial with 95 mL of a compatible IV solution to result in a 100 mg/mL solution.
For pharmacy bulk packages, the closure may be penetrated only one time after reconstitution; use a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents. Withdrawal of the contents should be completed within 4 hours from initial closure entry.
Compatible IV solutions include Sterile Water for Injection, Bacteriostatic Water for Injection, 5% Dextrose Injection, 0.9% Sodium Chloride Injection, and 10% Dextrose Injection.
Further dilution is required.
Storage: Reconstituted bulk vials should be used within 4 hours.[51460]
 
Dilution
Do NOT use diluents containing calcium (i.e., Lactated Ringer's Injection or Hartmann's solution)
Dilute the appropriate dose of reconstituted ceftriaxone with a compatible IV solution to a usual final concentration of 10 to 40 mg/mL (usually 50 or 100 mL for older children and adults).
Compatible IV solutions include Sterile Water for Injection, Bacteriostatic Water for Injection, 5% Dextrose Injection, 0.9% Sodium Chloride Injection, and 10% Dextrose Injection.
For pharmacy bulk packages, the closure may be penetrated only one time after reconstitution; use a suitable sterile transfer device or dispensing set that allows measured dispensing of the contents.
Storage: Diluted solutions may be stored for 2 days at room temperature (25 degrees C) or for 10 days in the refrigerator (4 degrees C). Ceftriaxone reconstituted and diluted with 5% Dextrose Injection or 0.9% Sodium Chloride Injection at concentrations of 10 to 40 mg/mL are stable frozen (-20 degrees C) in PVC or polyolefin contains for 26 weeks. Frozen solutions should be thawed at room temperature before use. Do not refreeze.[51460]
 
ADD-Vantage vials
Reconstitution
Reconstitute 1 or 2 g vial with 0.9% Sodium Chloride Injection or 5% Dextrose Injection in the appropriate 50 or 100 mL flexible diluent container.
Storage: Reconstituted solutions may be stored for 2 days at room temperature or for 10 days in the refrigerator.[51459]
 
Frozen Pre-mixed Bags
Preparation
Thaw at room temperature; do not force thaw. No reconstitution is necessary.
Storage: Thawed solution is stable for 48 hours at room temperature or 21 days in the refrigerator. Do not refreeze thawed antibiotics.[51461]
 
DUPLEX Drug Delivery System
Preparation
Use only if container and seals are intact. To inspect the drug powder for foreign matter or discoloration, peel the foil strip from the drug chamber.
Protect from light after removal of foil strip. If the foil strip is removed and the container will not be used immediately, refold container and latch the side tab until ready to activate and use within 7 days.
Once ready for activation, allow the product to reach room temperature before patient use.
Unfold Duplex container and point the set port downward. Starting at the hanger tab end, fold the Duplex container just below the diluent meniscus trapping all air above the fold.
To activate, squeeze the folded diluent chamber until the seal between the diluent and powder opens, releasing diluent into the drug powder chamber.
Agitate the liquid-powder mixture until the drug powder completely dissolves.
Do not use plastic containers in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete
Storage: After reconstitution (activation), use within 24 hours if stored at room temperature or within 7 days if stored under refrigeration.[54265]
 
Intermittent IV Infusion
Infuse IV over 30 minutes.[29920] [51459] In neonates, infuse IV over 60 minutes to decrease the risk of bilirubin encephalopathy (kernicterus).[29920]
 
Intravenous (IV) Push†
NOTE: Ceftriaxone is not approved by the FDA for IV push administration.[29920]
Powder Vials for Injection
Reconstitution
A study included 544 adult hospitalized patients who received ceftriaxone IV push (median 3 doses).[65354]
Doses of 1 g were reconstituted with 10 mL of 0.9% Sodium Chloride Injection and doses of 2 g were reconstituted with 20 mL of 0.9% Sodium Chloride Injection.
A study included 1,110 adult patients who received cephalosporins, including ceftriaxone, by IV push in the emergency department.[65288]
Doses of 1 and 2 g were reconstituted with 10 mL of Sterile Water for Injection.
A study included 63 adult and pediatric patients who received ceftriaxone by IV push at home.[51462]
Doses of 1 g were reconstituted in 10 mL of Sterile Water for Injection.
A study included 9 adult patients who received ceftriaxone by IV push.[60227]
Doses of 1 g were reconstituted in 10 mL of Sterile Water for Injection.
Stability:
Solutions reconstituted to a concentration of 100 mg/mL with a compatible solution are stable for 2 days at room temperature (25 degrees C) or for 10 days in the refrigerator (4 degrees C).[29920] [51458]
In a study, ceftriaxone reconstituted in Sterile Water for Injection and stored in polypropylene syringes, was stable for 5 days at 20 degrees C, for 40 days at 4 degrees C, and for 180 days at -20 degrees C. Concentrations were at least 90% the initial concentration.[65291]
 
Intermittent IV Push
Doses have been administered IVP at a rate of 1 to 5 minutes for adults, 2 to 4 minutes for patients 11 years and older, and 5 minutes in patients as young as 5 months.[51462] [51463] [60218] [60219] [60227] [65288] [65354]
Although data are limited, there may be a higher risk of certain adverse events with IV push administration compared to intermittent IV infusion.
In one report, an adult experienced tachycardia, restlessness, diaphoresis, and palpitations after receiving a 2 g dose via IV push over 5 minutes. Subsequent doses were administered over 30 minutes without any complications.[60217]
Limited data suggest that in young infants, IV push administration may have contributed to the risk of cardiopulmonary adverse events associated with the interaction between ceftriaxone and IV calcium.[60220]
A small study showed a higher rate of cholelithiasis when ceftriaxone was administered to children as IV push as compared to a 30 minute IV infusion.[60221]

Reconstitution
Vials may be reconstituted with Sterile Water for Injection, 0.9% Sodium Chloride Injection, 5% Dextrose Injection, Bacteriostatic Water for Injection containing 0.9% benzyl alcohol, or 1% lidocaine HCl (without epinephrine). Do NOT use diluents containing calcium (e.g., Lactated Ringer's Injection or Hartmann's solution), as particulate formation can result.[51458] Bacteriostatic Water for Injection should NOT be used for preparation of neonatal doses.[56836]
For a solution concentration of 250 mg/mL, reconstitute the 250 mg vial with 0.9 mL, the 500 mg vial with 1.8 mL, the 1 g vial with 3.6 mL, and the 2 g vial with 7.2 mL of diluent.
For a solution concentration of 350 mg/mL, reconstitute the 500 mg vial with 1 mL, the 1 g vial with 2.1 mL, and the 2 g vial with 4.2 mL of diluent; do not use the 250 mg vial to reconstitute a 350 mg/mL solution.
Storage: Reconstituted solution may be stored for 24 hours at room temperature or for 3 days in the refrigerator.[51458]
 
Intramuscular Injection
Inject deeply into a large muscle (e.g., anterolateral thigh or deltoid).[51458]
In general, the American Academy of Pediatrics suggests the following volume limits for intramuscular administration of medications [60486]:
0.5 mL per injection for small infants
1 mL per injection for larger infants
2 mL per injection for school-aged children
3 mL per injection for adolescents

azotemia / Delayed / 1.2-1.2
hemolytic anemia / Delayed / 0-1.0
coagulopathy / Delayed / 0.4-0.4
agranulocytosis / Delayed / 0-0.1
serum sickness / Delayed / 0-0.1
bronchospasm / Rapid / 0-0.1
aplastic anemia / Delayed / Incidence not known
seizures / Delayed / Incidence not known
biliary obstruction / Delayed / Incidence not known
pancreatitis / Delayed / Incidence not known
C. difficile-associated diarrhea / Delayed / Incidence not known
erythema multiforme / Delayed / Incidence not known
angioedema / Rapid / Incidence not known
toxic epidermal necrolysis / Delayed / Incidence not known
acute generalized exanthematous pustulosis (AGEP) / Delayed / Incidence not known
anaphylactoid reactions / Rapid / Incidence not known
Stevens-Johnson syndrome / Delayed / Incidence not known
renal failure / Delayed / Incidence not known
oliguria / Early / Incidence not known

eosinophilia / Delayed / 6.0-6.0
thrombocytosis / Delayed / 5.1-5.1
elevated hepatic enzymes / Delayed / 0-3.3
leukopenia / Delayed / 2.1-2.1
phlebitis / Rapid / 0-1.0
thrombocytopenia / Delayed / 0-1.0
anemia / Delayed / 0-1.0
lymphopenia / Delayed / 0-1.0
neutropenia / Delayed / 0-1.0
hyperbilirubinemia / Delayed / 0-1.0
vaginitis / Delayed / 0-1.0
candidiasis / Delayed / 0-1.0
colitis / Delayed / 0-0.1
hypoprothrombinemia / Delayed / 0-0.1
lymphocytosis / Delayed / 0-0.1
jaundice / Delayed / 0-0.1
cholelithiasis / Delayed / 0-0.1
palpitations / Early / 0-0.1
nephrolithiasis / Delayed / 0-0.1
glycosuria / Early / 0-0.1
hematuria / Delayed / 0-0.1
glossitis / Early / Incidence not known
stomatitis / Delayed / Incidence not known
bleeding / Early / Incidence not known
hypertonia / Delayed / Incidence not known
encephalopathy / Delayed / Incidence not known
myoclonia / Delayed / Incidence not known
confusion / Early / Incidence not known
cholestasis / Delayed / Incidence not known
pseudomembranous colitis / Delayed / Incidence not known
superinfection / Delayed / Incidence not known
pneumonitis / Delayed / Incidence not known
edema / Delayed / Incidence not known
urinary tract obstruction / Delayed / Incidence not known

injection site reaction / Rapid / 1.0-17.0
diarrhea / Early / 2.7-2.7
rash / Early / 1.7-1.7
nausea / Early / 0-1.0
dysgeusia / Early / 0-1.0
vomiting / Early / 0-1.0
dizziness / Early / 0-1.0
headache / Early / 0-1.0
pruritus / Rapid / 0-1.0
diaphoresis / Early / 0-1.0
flushing / Rapid / 0-1.0
chills / Rapid / 0-1.0
fever / Early / 0-1.0
dyspepsia / Early / 0-0.1
flatulence / Early / 0-0.1
abdominal pain / Early / 0-0.1
leukocytosis / Delayed / 0-0.1
epistaxis / Delayed / 0-0.1
drowsiness / Early / Incidence not known
hyperactivity / Early / Incidence not known
lethargy / Early / Incidence not known
urticaria / Rapid / Incidence not known
Jarisch-Herxheimer reaction / Early / Incidence not known

Ceftrisol Plus, Rocephin

Rx

Parenteral third-generation cephalosporin antibiotic
Used to treat infections such as gonorrhea, respiratory tract infections, and meningitis
Has longest half-life of all cephalosporins, allowing for once-daily dosing and for outpatient therapy

1 to 2 g IV every 12 to 24 hours. Start within 1 hour for septic shock or within 3 hours for possible sepsis without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours. The FDA-approved dosage is 50 to 75 mg/kg/day (Max: 2 g/day) IV divided every 12 hours; however, higher doses have been shown to be necessary to attain pharmacodynamic targets (100% free T above the MIC) in critically ill children. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for de-escalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.

50 mg/kg/dose IV every 24 hours.[29920] Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for de-escalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from the scope of the Surviving Sepsis Campaign guidelines.[64985]

1 to 2 g IV or IM every 24 hours for 7 to 14 days with or without an aminoglycoside for pyelonephritis. A single dose prior to oral therapy may be used in patients not requiring hospitalization.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours. Treat for 48 to 72 hours or until patient is clinically stable and afebrile, followed by oral antibiotics for a total duration of 7 to 14 days.

50 to 75 mg/kg/day IV or IM divided every 12 to 24 hours. Infants younger than 2 to 3 months are at risk for systemic infection and rapid change in their clinical condition. Treat UTIs as presumed pyelonephritis in these patients.

50 mg/kg/dose IV or IM every 24 hours. Neonates are at risk for systemic infection and rapid change in their clinical condition. Treat UTIs as presumed pyelonephritis in these patients.

1 to 2 g IV or IM every 24 hours for 7 to 14 days. A single dose prior to oral therapy may be used in patients not requiring hospitalization.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours for 7 to 14 days.

50 to 75 mg/kg/day IV or IM divided every 12 to 24 hours for 7 to 14 days.

50 mg/kg/dose (Max: 1 g/dose) IV/IM every 24 hours for 1 or 3 days as initial treatment for patients who cannot tolerate oral therapy and for 3 days in patients who have failed initial oral antibiotic therapy.

1 to 2 g IV every 24 hours for 7 to 14 days for moderate or severe infections in patients with recent antibiotic exposure or infections with no complicating features or with ischemic limb/necrosis/gas forming plus clindamycin or metronidazole. Continue treatment for up to 28 days if infection is improving but is extensive and resolving slower than expected or if patient has severe peripheral artery disease.

1 g IV every 24 hours plus metronidazole for incisional surgical site infections of the intestinal or genitourinary tract or axilla or perineum.

1 g IV every 12 hours plus an anaerobic agent. In setting of a cat or dog bite, preemptive early antimicrobial therapy for 3 to 5 days is recommended for patients who are immunocompromised, asplenic, have advanced liver disease, have edema of the bite area, have moderate to severe injuries, particularly of the hand or face, or have penetrating injuries to the periosteum or joint capsule.

1 to 2 g IV every 24 hours plus doxycycline for Aeromonas hydrophila infections or 1 g IV every 24 hours for Vibrio vulnificus infections until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours. Ceftriaxone may also be considered for mixed infections plus metronidazole and an agent active against methicillin-resistant S. aureus.

1 to 2 g IV or IM divided every 12 to 24 hours.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours.

50 mg/kg/dose IV or IM every 24 hours.

1 to 2 g IV every 24 hours for 7 days with or without metronidazole.

1 to 2 g IV every 24 hours for 5 to 14 days.

50 to 75 mg/kg/day (Max: 2 g/day) IV divided every 12 to 24 hours for 5 to 14 days.

2 g IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary. The duration of prophylaxis should not exceed 24 hours. The FDA-approved dosage is 1 g IV or IM 30 to 120 minutes prior to the procedure.

50 to 75 mg/kg/dose (Max: 2 g/dose) IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary. The duration of prophylaxis should not exceed 24 hours.

50 to 75 mg/kg/dose IV as a single dose within 60 minutes prior to the surgical incision; no intraoperative redosing is necessary. The duration of prophylaxis should not exceed 24 hours.

1 to 2 g IV or IM every 12 to 24 hours.[29920]

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours.[29920] Consider 100 mg/kg/day (Max: 4 g/day) IV or IM divided every 12 hours for serious infections.

50 mg/kg/dose IV or IM every 24 hours.[29920]

1 to 2 g IV every 24 hours for at least 5 days as part of combination therapy for hospitalized patients.[34362] [64669]

50 mg/kg/dose (Max: 2 g/day) IV every 12 hours for 5 to 7 days. [46963] [66745] Guidelines recommend empiric therapy with ceftriaxone for hospitalized patients who are not fully immunized, in regions where local epidemiology of invasive pneumococcal strains documents high-level penicillin resistance, and for life-threatening infection. Consider combination therapy with a macrolide for suspected atypical pneumonia or with clindamycin or vancomycin for suspected infection due to S. aureus.[46963]

1 to 2 g IV every 12 to 24 hours.[29920] Use in combination with metronidazole for at least 2 weeks after drainage and defervescence.[61949]

50 mg/kg/dose (Max: 2 g/day) IV every 12 hours. Use in combination with metronidazole for at least 2 weeks after drainage and defervescence.[61949]

2 g IV or IM every 24 hours for 4 weeks as monotherapy or for 2 weeks plus gentamicin.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 weeks.

50 mg/kg/dose IV or IM every 24 hours for 4 weeks.

2 g IV or IM every 24 hours for 4 weeks plus gentamicin for 2 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 weeks plus gentamicin for 2 weeks.

50 mg/kg/dose IV or IM every 24 hours for 4 weeks plus gentamicin for 2 weeks.

2 g IV or IM every 24 hours for 4 to 6 weeks plus gentamicin for at least 2 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 weeks plus gentamicin for 2 weeks for relatively resistant strains.

50 mg/kg/dose IV or IM every 24 hours for 4 weeks plus gentamicin for 2 weeks for relatively resistant strains.

2 g IV or IM every 24 hours for 4 weeks.

2 g IV or IM every 24 hours for 4 to 6 weeks.

2 g IV or IM every 24 hours for 6 weeks with or without gentamicin for 2 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 6 weeks plus gentamicin for 2 weeks.

50 mg/kg/dose IV or IM every 24 hours for 6 weeks plus gentamicin for 2 weeks.

2 g IV or IM every 12 hours for 6 weeks plus ampicillin as an alternative for patients who have or develop creatinine clearance less than 50 mL/minute during therapy with gentamicin-containing regimen.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 to 6 weeks plus ampicillin for aminoglycoside-resistant enterococci or aminoglycoside-intolerant patients.

50 mg/kg/dose IV or IM every 24 hours for 4 to 6 weeks plus ampicillin for aminoglycoside-resistant enterococci or aminoglycoside-intolerant patients.

2 g IV or IM every 24 hours for 4 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 weeks.

50 mg/kg/dose IV or IM every 24 hours for 4 weeks.

2 g IV or IM every 24 hours for 6 weeks plus an aminoglycoside or fluoroquinolone.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for at least 6 weeks plus an aminoglycoside.

50 mg/kg/dose IV or IM for at least 6 weeks plus an aminoglycoside.

2 g IV or IM every 24 hours plus vancomycin for at least 4 to 6 weeks.

2 g IV or IM every 24 hours for 4 weeks; consider adding vancomycin and rifampin for strains resistant to ceftriaxone.

2 g IV or IM every 24 hours for 6 weeks plus gentamicin.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 6 weeks plus gentamicin.

50 mg/kg/dose IV or IM every 24 hours for 6 weeks plus gentamicin.

2 g IV or IM every 24 hours for 6 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 4 weeks.

50 mg/kg/dose IV or IM every 24 hours for 4 weeks.

2 g IV or IM every 24 hours for 6 weeks plus gentamicin for 2 weeks with or without doxycycline for 6 weeks.

50 mg/kg/dose (Max: 2 g/dose) IV or IM every 12 hours for 6 weeks plus gentamicin for 2 weeks with or without doxycycline for 6 weeks.

50 mg/kg/dose IV or IM every 12 hours for 6 weeks plus gentamicin for 2 weeks.

50 mg/kg/dose IV or IM every 24 hours for 6 weeks plus gentamicin for 2 weeks.

1 g IV or IM as a single dose given 30 to 60 minutes before procedure as an alternative for patients allergic to penicillin and/or unable to take oral medications. Prophylaxis is recommended for at-risk cardiac patients who are undergoing dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa.

50 mg/kg/dose (Max: 1 g/dose) IV or IM as a single dose given 30 to 60 minutes before procedure as an alternative for patients allergic to penicillin and/or unable to take oral medications. Prophylaxis is recommended for at-risk cardiac patients who are undergoing dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa.

2 g IV every 12 hours for 10 to 14 days; consider the addition of rifampin if dexamethasone is also given or ceftriaxone MIC is more than 2 mcg/mL.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for 10 to 14 days; consider the addition of rifampin if dexamethasone is also given or ceftriaxone MIC is more than 2 mcg/mL.

50 mg/kg/dose IV every 24 hours for 10 to 14 days; consider the addition of rifampin if dexamethasone is also given or ceftriaxone MIC is more than 2 mcg/mL. Guidelines recommend cefotaxime as the third-generation cephalosporin of choice for meningitis in neonates.

2 g IV every 12 hours for 14 to 21 days.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for 14 to 21 days.

50 mg/kg/dose IV every 24 hours for 14 to 21 days. Guidelines recommend cefotaxime as the third-generation cephalosporin of choice for meningitis in neonates.

2 g IV every 12 hours for 7 days.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for 7 days.

50 mg/kg/dose IV every 24 hours for 7 days. Guidelines recommend cefotaxime as the third-generation cephalosporin of choice for meningitis in neonates.

2 g IV every 12 hours for 10 to 21 days.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for 10 to 21 days.

50 mg/kg/dose IV every 24 hours for 2 weeks beyond the first sterile CSF culture or at least 21 days, whichever is longer. Guidelines recommend cefotaxime as the third-generation cephalosporin of choice for meningitis in neonates.

2 g IV every 12 hours for 10 to 14 days.

50 mg/kg/dose (Max: 2 g/dose) IV every 12 hours for 10 to 14 days.

250 mg IM as a single dose. A longer course of therapy may be required in HIV-infected patients and uncircumcised males. Data for efficacy of single-dose ceftriaxone regimen are limited in patients with HIV; an erythromycin 7-day regimen or ciprofloxacin 3-day regimen may be preferred.

250 mg IM as a single dose. A longer course of therapy may be required in HIV-infected patients and uncircumcised males. Data for efficacy of single-dose ceftriaxone regimen are limited in patients with HIV; an erythromycin 7-day regimen or ciprofloxacin 3-day regimen may be preferred.

50 mg/kg/dose (Max: 250 mg/dose) IM as a single dose. A longer course of therapy may be required in HIV-infected patients and uncircumcised males.

1 g IM as a single dose. The FDA-approved dosage is 250 mg IM as a single dose.

500 mg IM as a single dose. The FDA-approved dosage is 250 mg IM as a single dose.

1 g IM as a single dose.

500 mg IM as a single dose.

500 mg IM as a single dose.

25 to 50 mg/kg/dose (Max: 250 mg/dose) IV or IM as a single dose.

1 g IV or IM every 24 hours for 7 days. If treating for arthritis-dermatitis syndrome, may switch to an oral agent 24 to 48 hours after clinical improvement for a total of at least 7 days.

1 g IV or IM every 24 hours for 7 days. If treating for arthritis-dermatitis syndrome, may switch to an oral agent 24 to 48 hours after clinical improvement for a total of at least 7 days.

50 mg/kg/dose (Max: 1 g/dose) IV or IM every 24 hours for 7 days.

1 to 2 g IV every 24 hours for 10 to 14 days.

1 to 2 g IV every 24 hours for 10 to 14 days.

50 mg/kg/dose (Max: 2 g/dose) IV every 24 hours for 10 to 14 days.

25 to 50 mg/kg/dose IV every 24 hours for 10 to 14 days.

1 to 2 g IV every 24 hours for at least 4 weeks.

1 to 2 g IV every 24 hours for at least 4 weeks.

1 g IM as a single dose. Lavage the infected eye(s) with saline solution to remove accumulated secretions.

1 g IM as a single dose. Lavage the infected eye(s) with saline solution to remove accumulated secretions.

25 to 50 mg/kg/dose (Max: 250 mg/dose) IV or IM as a single dose.

25 to 50 mg/kg/dose IV or IM every 24 hours for 7 days.

50 mg/kg/dose (Max: 1 g/dose) IV or IM every 24 hours for 7 days.

1 g IM as a single dose in combination oral doxycycline when most likely due gonorrhea or chlamydia or with oral levofloxacin when most likely due to gonorrhea, chlamydia, or enteric organisms.

500 mg IM as a single dose in combination oral doxycycline when most likely due gonorrhea or chlamydia or with oral levofloxacin when most likely due to gonorrhea, chlamydia, or enteric organisms.

1 g IM as a single dose in combination oral doxycycline when most likely due gonorrhea or chlamydia or with oral levofloxacin when most likely due to gonorrhea, chlamydia, or enteric organisms.

500 mg IM as a single dose in combination oral doxycycline when most likely due gonorrhea or chlamydia or with oral levofloxacin when most likely due to gonorrhea, chlamydia, or enteric organisms.

500 mg IM as a single dose in combination oral doxycycline when most likely due gonorrhea or chlamydia or with oral levofloxacin when most likely due to gonorrhea, chlamydia, or enteric organisms.

25 to 50 mg/kg/dose (Max: 250 mg/dose) IV or IM as a single dose may be used if erythromycin ointment is not available and infant is at high risk for exposure (i.e., infants born to mothers at risk for gonococcal infection or with no prenatal care).

1 g IM as a single dose.

500 mg IM as a single dose.

1 g IM as a single dose.

500 mg IM as a single dose.

25 to 50 mg/kg/dose (Max: 250 mg/dose) IV or IM as a single dose for infants at high risk for exposure (i.e., infants born to mothers at risk for gonococcal infection or with no prenatal care).

2 g IV once daily for 14 to 28 days in patients with no or minimal response (moderate to severe joint swelling with minimal reduction of the joint effusion) to the initial course of oral antibiotics.

50 to 75 mg/kg/dose (Max: 2 g/dose) IV once daily for 14 to 28 days in patients with no or minimal response (moderate to severe joint swelling with minimal reduction of the joint effusion) to the initial course of oral antibiotics.

2 g IV once daily in hospitalized patients with severe disease (i.e., symptomatic, first degree AV block with PR interval 300 milliseconds or greater, second or third degree AV block) until clinical improvement, then switch to oral stepdown therapy for a total of 14 to 21 days.

50 to 75 mg/kg/dose (Max: 2 g/dose) IV once daily in hospitalized patients with severe disease (i.e., symptomatic, first degree AV block with PR interval 300 milliseconds or greater, second or third degree AV block) until clinical improvement, then switch to oral stepdown therapy for a total of 14 to 21 days.

2 g IV once daily until clinical improvement, then switch to oral stepdown therapy for a total of 14 to 21 days. For acutely ill patients or prior to confirmation of Lyme neuroborreliosis, IV therapy is preferred with appropriate stepdown to oral treatment.

50 to 75 mg/kg/dose (Max: 2 g/dose) IV once daily until clinical improvement, then switch to oral stepdown therapy for a total of 14 to 21 days. For acutely ill patients or prior to confirmation of Lyme neuroborreliosis, IV therapy is preferred with appropriate stepdown to oral treatment.

2 g IV once daily for 14 to 28 days. IV therapy is preferred.

50 to 75 mg/kg/dose (Max: 2 g/dose) IV once daily for 14 to 28 days. IV therapy is preferred.

1 to 2 g IV or IM every 12 to 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess. Ceftriaxone plus metronidazole is standard of care for appendicitis.

50 mg/kg/dose IV or IM every 24 hours as part of combination therapy for 7 to 10 days. Ceftriaxone plus metronidazole is standard of care for appendicitis.

1 to 2 g IV or IM every 12 to 24 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours as part of combination therapy. Antibiotics should be discontinued within 24 hours. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel. Ceftriaxone plus metronidazole is standard of care for appendicitis.

1 g IV every 12 hours for at least 5 to 7 days.

1 g intraperitoneally every 24 hours for 21 days.

1 to 2 g IV or IM every 12 to 24 hours for at least 48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel.

50 to 75 mg/kg/day (Max: 2 g/day) IV or IM divided every 12 to 24 hours for at least 48 hours, followed by oral step-down therapy for a total treatment duration of 5 to 10 days as part of combination therapy. Uncomplicated infections include acute appendicitis without perforation, abscess, or local peritonitis; traumatic bowel perforations repaired within 12 hours; acute cholecystitis without perforation; and ischemic, non-perforated bowel. Ceftriaxone plus metronidazole is standard of care for appendicitis.

250 mg IM as a single dose. Initiate prophylaxis as soon as possible after exposure (ideally less than 24 hours after identification of index patient); prophylaxis initiated more than 14 days after onset of illness in the index patient has very limited or no value.

250 mg IM as a single dose. Initiate prophylaxis as soon as possible after exposure (ideally less than 24 hours after identification of index patient); prophylaxis initiated more than 14 days after onset of illness in the index patient has very limited or no value.

125 mg IM as a single dose. Initiate prophylaxis as soon as possible after exposure (ideally less than 24 hours after identification of index patient); prophylaxis initiated more than 14 days after onset of illness in the index patient has very limited or no value.

1 g IV every 24 hours for 5 days. Routine use is not recommended.

1 g IV every 24 hours for 5 days. Routine use is not recommended.

1 g IV every 24 hours for 48 to 72 hours or until the patient becomes afebrile; treat for 7 to 14 days if concurrent bacteremia. Routine use is not recommended; reserve for patients at high risk for invasive infection.

50 to 100 mg/kg/dose (Max: 1 g/dose) IV every 24 hours for 48 to 72 hours or until the patient becomes afebrile; treat for 7 to 14 days if concurrent bacteremia. Routine use is not recommended; reserve for patients at high risk for invasive infection.

1 g IV every 24 hours for 7 to 14 days as alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if recurrent bacteremia or gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.

1 g IV every 24 hours for 7 to 14 days as alternative; treat for at least 14 days if concurrent bacteremia in persons with a CD4 count more than 200 cells/mm3. Treat for 2 to 6 weeks in persons with a CD4 count less than 200 cells/mm3. Follow with long-term suppressive therapy if recurrent bacteremia or gastroenteritis with a CD4 count less than 200 cells/mm3 and severe diarrhea.

1 g IV every 24 hours for 3 to 5 days.

50 to 100 mg/kg/dose (Max: 1 g/dose) IV every 24 hours for 2 to 5 days.

1 g IV every 12 hours or 2 g IV every 24 hours for 7 to 14 days; treat for 14 days if concurrent bacteremia.

50 mg/kg/dose (Max: 2 g/dose) IV every 24 hours for 5 to 14 days; treat for 14 days if concurrent bacteremia.

50 to 75 mg/kg/day IV divided every 12 to 24 hours for 7 to 14 days; treat for at least 7 days after defervescence. Usual dose: 1 to 4 g/day.

50 to 100 mg/kg/day (Max: 4 g/day) IV divided every 12 to 24 hours for 5 to 14 days; treat for at least 7 days after defervescence.

1 g IV or IM once daily for 10 days may be effec

1 g IV or IM once daily for 10 days may be effective for primary or secondary syphilis. Ceftriaxone may also be effective for treating latent syphilis; however, the optimal dose and duration have not been established.

1 to 2 g IV or IM once daily for 10 to 14 days if penicillin desensitization is not possible.

1 to 2 g IV or IM once daily for 10 to 14 days if penicillin desensitization is not possible.

100 mg/kg/dose (Max: 2 g/dose) IV or IM every 24 hours for 10 to 14 days may be considered with careful clinical and serologic follow-up during a shortage of aqueous penicillin G and penicillin G procaine.

75 mg/kg/dose IV or IM every 24 hours for 10 to 14 days may be considered with careful clinical and serologic follow-up during a shortage of aqueous penicillin G and penicillin G procaine.

50 to 75 mg/kg/dose IV or IM every 24 hours for 10 to 14 days may be considered with careful clinical and serologic follow-up during a shortage of aqueous penicillin G and penicillin G procaine.

1 or 2 g IV every 24 hours for 7 days as first-line therapy for severe disease.

80 to 100 mg/kg/dose (Max: 2 g/dose) IV every 24 hours for 7 days as first-line therapy for severe disease.

1 g IM as a single dose in combination with oral doxycycline and metronidazole for 14 days. Patients who fail to respond within 72 hours should be reevaluated to confirm diagnosis and switched to IV therapy.

500 mg IM as a single dose in combination with oral doxycycline and metronidazole for 14 days. Patients who fail to respond within 72 hours should be reevaluated to confirm diagnosis and switched to IV therapy.

1 g IM as a single dose in combination with oral doxycycline and metronidazole for 14 days. Patients who fail to respond within 72 hours should be reevaluated to confirm diagnosis and switched to IV therapy.

500 mg IM as a single dose in combination with oral doxycycline and metronidazole for 14 days. Patients who fail to respond within 72 hours should be reevaluated to confirm diagnosis and switched to IV therapy.

1 g IV every 24 hours in combination with doxycycline and metronidazole. Ceftriaxone should be continued for at least 24 to 48 hours after clinical improvement, and then stepdown to oral doxycycline and metronidazole for a total of 14 days of therapy.

1 g IV every 24 hours in combination with doxycycline and metronidazole. Ceftriaxone should be continued for at least 24 to 48 hours after clinical improvement, and then stepdown to oral doxycycline and metronidazole for a total of 14 days of therapy.

1 to 2 g IV every 12 to 24 hours for 5 to 10 days.

50 to 75 mg/kg/dose (Max: 1 g/dose) IV every 24 hours for 10 to 14 days.

50 mg/kg/dose (Max: 2 g/dose) IV or IM as a single dose, followed by an oral antibiotic 24 hours later.

1 g IV every 24 hours for 7 days. Consider discontinuing therapy when hemorrhage has resolved and vasoactive drugs are discontinued.

1 to 2 g IV every 24 hours for 4 to 6 weeks.

50 to 100 mg/kg/day (Max: 2 g/day) IV divided every 12 to 24 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.

50 to 100 mg/kg/day IV divided every 12 to 24 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.

50 mg/kg/dose IV every 24 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.

1 to 2 g IV every 24 hours. Treat for 1 to 2 weeks or until clinically improved, followed by oral step-down therapy for 2 to 4 weeks.

50 to 100 mg/kg/day (Max: 2 g/day) IV divided every 12 to 24 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.

50 to 100 mg/kg/day IV divided every 12 to 24 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.

50 mg/kg/dose IV every 24 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.

1 to 2 g IV every 24 hours in combination with rifampin for 2 to 6 weeks, followed by oral step-down therapy, which may be followed by chronic oral suppressive therapy.

2 g IV every 24 hours for 6 weeks.

2 g IV every 24 hours for 6 to 8 weeks.

2 g IV every 24 hours for 4 to 6 weeks.

2 g IV every 24 hours for 7 to 14 days plus ciprofloxacin as first-line therapy.

1 g IV every 12 hours for 10 to 14 days plus chloramphenicol as first-line therapy or amikacin as second-line therapy.

70 mg/kg/dose (Max: 2 g/dose) IV every 24 hours for 7 to 14 days plus ciprofloxacin as first-line therapy.

1 g IM as a single dose in combination with doxycyline.

500 mg IM as a single dose in combination with doxycyline.

2 g IM every 24 hours for 2 to 6 weeks, followed by oral therapy for 6 to 12 months. Shorter courses may be appropriate for less extensive infections.

1 g IV every 24 hours in combination with doxycycline for 7 to 14 days.

50 to 75 mg/kg/dose (Max: 1 g/dose) IV every 24 hours in combination with doxycycline for 7 to 14 days.

2 g IV every 24 hours for 5 days or until CSF leak is closed, whichever is longer as an alternative. Add metronidazole for penetrating spinal cord injury if abdominal cavity is involved and consider adding metronidazole for penetrating brain injury if gross contamination with organic debris.

2 g IV every 24 hours for 14 days.

50 to 75 mg/kg/day (Max: 2 g/day) IV divided every 12 to 24 hours for 14 days.

†Indicates off-label use

Use ceftriaxone with caution and do not exceed 2 g/day in persons with hepatic impairment and significant renal impairment. Ceftriaxone dosage adjustments are not normally required in persons with hepatic dysfunction alone. Consider a 50% reduction in dosage for patients with Child-Pugh class C cirrhosis.

Use ceftriaxone with caution and do not exceed 2 g/day in persons with significant renal impairment and hepatic impairment. Ceftriaxone dosage adjustments are not normally required in persons with renal failure alone.
 
Pediatric patients†
GFR 10 mL/minute/1.73 m2 or more: No dosage adjustment needed.
GFR less than 10 mL/minute/1.73 m2: Administer usual dose every 24 hours.
 
Intermittent hemodialysis
Ceftriaxone is not removed by hemodialysis. Therefore, no supplementary doses are necessary after dialysis.
 
Adults†
1 to 2 g IV or IM every 24 hours.
 
Pediatric patients†
50 mg/kg/dose (Max: 2 g/dose) IV or IM every 24 hours.
 
Peritoneal dialysis
Ceftriaxone is not removed by peritoneal dialysis. Therefore, no supplementary doses are necessary after dialysis.
 
Adults†
1 g IV or IM every 12 hours.
 
Pediatric patients†
50 mg/kg/dose (Max: 2 g/dose) IV or IM every 24 hours.
 
Continuous renal replacement therapy (CRRT)†
NOTE: Various CRRT modalities include continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), continuous venovenous hemodiafiltration (CVVHDF), continuous venovenous high-flux hemodialysis (CVVHFD), continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), and continuous arteriovenous hemodiafiltration (CAVHDF). Dosing should take into consideration patient-specific factors (e.g., intrinsic renal function), type of infection, the duration of renal replacement therapy, the effluent flow rate, and the replacement solution administered.[42303]
 
Adults
No dosage adjustment needed.
 
Pediatric patients
50 mg/kg/dose (Max: 2 g/dose) IV or IM every 24 hours.
 
Plasmapheresis†
Administer usual dose after plasmapheresis or at least 15 hours before plasmapheresis.

Calcium Acetate: (Major) Ceftriaxone is contraindicated in neonates who are receiving or are expected to receive IV calcium-containing solutions, including calcium-containing parenteral nutrition. Cases of fatal pulmonary and renal precipitate embolism in neonates have been described. There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or between intramuscular ceftriaxone and calcium-containing products. Precipitation of ceftriaxone and calcium can occur when mixed. In patients other than neonates, the risk for precipitate embolism may be adequately addressed by separating administrations or administering each medication sequentially if IV infusion lines are thoroughly flushed between infusions with a compatible fluid.
Calcium Chloride: (Major) Ceftriaxone is contraindicated in neonates who are receiving or are expected to receive IV calcium-containing solutions, including calcium-containing parenteral nutrition. Cases of fatal pulmonary and renal precipitate embolism in neonates have been described. There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or between intramuscular ceftriaxone and calcium-containing products. Precipitation of ceftriaxone and calcium can occur when mixed. In patients other than neonates, the risk for precipitate embolism may be adequately addressed by separating administrations or administering each medication sequentially if IV infusion lines are thoroughly flushed between infusions with a compatible fluid.
Calcium Gluconate: (Major) Ceftriaxone is contraindicated in neonates who are receiving or are expected to receive IV calcium-containing solutions, including calcium-containing parenteral nutrition. Cases of fatal pulmonary and renal precipitate embolism in neonates have been described. There have been no reports of an interaction between ceftriaxone and oral calcium-containing products or between intramuscular ceftriaxone and calcium-containing products. Precipitation of ceftriaxone and calcium can occur when mixed. In patients other than neonates, the risk for precipitate embolism may be adequately addressed by separating administrations or administering each medication sequentially if IV infusion lines are thoroughly flushed between infusions with a compatible fluid.
Cyclosporine: (Moderate) Cyclosporine serum concentrations may be increased if ceftriaxone is added. Although data are limited, ceftriaxone should be used cautiously in patients currently stabilized on cyclosporine. Vigilant serum cyclosporine serum concentration monitoring is warranted. Two case reports suggest that cyclosporine serum concentrations may rise if ceftriaxone is added. No changes in renal or hepatic function were observed in the 2 renal transplant patients. The mechanism of the potential interaction is unknown.
Loop diuretics: (Minor) Nephrotoxicity associated with cephalosporins may be potentiated by concomitant therapy with loop diuretics. Clinicians should be aware that this may occur even in patients with minor or transient renal impairment.
Oral Contraceptives: (Moderate) It would be prudent to recommend alternative or additional contraception when oral contraceptives (OCs) are used in conjunction with antibiotics. It was previously thought that antibiotics may decrease the effectiveness of OCs containing estrogens due to stimulation of metabolism or a reduction in enterohepatic circulation via changes in GI flora. One retrospective study reviewed the literature to determine the effects of oral antibiotics on the pharmacokinetics of contraceptive estrogens and progestins, and also examined clinical studies in which the incidence of pregnancy with OCs and antibiotics was reported. It was concluded that the antibiotics ampicillin, ciprofloxacin, clarithromycin, doxycycline, metronidazole, ofloxacin, roxithromycin, temafloxacin, and tetracycline did not alter plasma concentrations of OCs. Antituberculous drugs (e.g., rifampin) were the only agents associated with OC failure and pregnancy. Based on the study results, these authors recommended that back-up contraception may not be necessary if OCs are used reliably during oral antibiotic use. Another review concurred with these data, but noted that individual patients have been identified who experienced significant decreases in plasma concentrations of combined OC components and who appeared to ovulate; the agents most often associated with these changes were rifampin, tetracyclines, and penicillin derivatives. These authors concluded that because females most at risk for OC failure or noncompliance may not be easily identified and the true incidence of such events may be under-reported, and given the serious consequence of unwanted pregnancy, that recommending an additional method of contraception during short-term antibiotic use may be justified. During long-term antibiotic administration, the risk for drug interaction with OCs is less clear, but alternative or additional contraception may be advisable in selected circumstances. Data regarding progestin-only contraceptives or for newer combined contraceptive deliveries (e.g., patches, rings) are not available.
Sodium picosulfate; Magnesium oxide; Anhydrous citric acid: (Major) Prior or concomitant use of antibiotics with sodium picosulfate; magnesium oxide; anhydrous citric acid may reduce efficacy of the bowel preparation as conversion of sodium picosulfate to its active metabolite bis-(p-hydroxy-phenyl)-pyridyl-2-methane (BHPM) is mediated by colonic bacteria. If possible, avoid coadministration. Certain antibiotics (i.e., tetracyclines and quinolones) may chelate with the magnesium in sodium picosulfate; magnesium oxide; anhydrous citric acid solution. Therefore, these antibiotics should be taken at least 2 hours before and not less than 6 hours after the administration of sodium picosulfate; magnesium oxide; anhydrous citric acid solution.
Warfarin: (Moderate) The concomitant use of warfarin with many classes of antibiotics, including cephalosporins, may increase the INR thereby potentiating the risk for bleeding. Inhibition of vitamin K synthesis due to alterations in the intestinal flora may be a mechanism; however, concurrent infection is also a potential risk factor for elevated INR. Additionally, certain cephalosporins (cefotetan, cefoperazone, cefamandole) are associated with prolongation of the prothrombin time due to the methylthiotetrazole (MTT) side chain at the R2 position, which disturbs the synthesis of vitamin K-dependent clotting factors in the liver. Monitor patients for signs and symptoms of bleeding. Additionally, increased monitoring of the INR, especially during initiation and upon discontinuation of the antibiotic, may be necessary.

Ceftriaxone/Ceftriaxone Sodium Intravenous Inj Pwd: 100g
Ceftriaxone/Ceftriaxone Sodium Intravenous Inj Sol: 1g, 2g, 50mL
Ceftriaxone/Ceftriaxone Sodium/Ceftrisol Plus/Rocephin Intramuscular Inj Pwd F/Sol: 1g, 2g, 10g, 250mg, 500mg
Ceftriaxone/Ceftriaxone Sodium/Ceftrisol Plus/Rocephin Intravenous Inj Pwd F/Sol: 1g, 2g, 10g, 250mg, 500mg

4 g/day IV/IM.

4 g/day IV/IM.

100 mg/kg/day IV/IM (Max: 4 g/day).

100 mg/kg/day IV/IM (Max: 4 g/day).

100 mg/kg/day IV/IM.

50 mg/kg/day IV/IM.

Ceftriaxone, a beta-lactam antibiotic, is mainly bactericidal. It inhibits the third and final stage of bacterial cell wall synthesis by preferentially binding to specific penicillin-binding proteins (PBPs) that are located inside the bacterial cell wall. PBPs are responsible for several steps in cell wall synthesis and are found in quantities of several hundred to several thousand molecules per bacterial cell. PBPs vary among different bacterial species. Thus, the intrinsic activity of ceftriaxone and other beta-lactams against a particular organism depends on their ability to gain access to and bind with the necessary PBP. Like all beta-lactam antibiotics, ceftriaxone's ability to interfere with PBP-mediated cell wall synthesis ultimately leads to cell lysis. Lysis is mediated by bacterial cell wall autolytic enzymes (i.e., autolysins). The relationship between PBPs and autolysins is unclear, but it is possible that the beta-lactam antibiotic interferes with an autolysin inhibitor.[51464] [51465] Prevention of the autolysin response to beta-lactam antibiotic exposure through loss of autolytic activity (mutation) or inactivation of autolysin (low-medium pH) by the microorganism can lead to tolerance to the beta-lactam antibiotic resulting in bacteriostatic activity.[51465]
 
Beta-lactams, including ceftriaxone, exhibit concentration-independent or time-dependent killing. In vitro and in vivo animal studies have demonstrated that the major pharmacodynamic parameter that determines efficacy for beta-lactams is the amount of time free (non-protein bound) drug concentrations exceed the minimum inhibitory concentration (MIC) of the organism (free T more than MIC).[34145] [34143] [35436] [35437] [35438] [35439] This microbiological killing pattern is due to the mechanism of action, which is acylation of PBPs. There is a maximum proportion of PBPs that can be acylated; therefore, once maximum acylation has occurred, killing rates cannot increase.[35439] Free beta-lactam concentrations do not have to remain above the MIC for the entire dosing interval. The percentage of time required for both bacteriostatic and maximal bactericidal activity is different for the various classes of beta-lactams. Cephalosporins require free drug concentrations to be above the MIC for 35% to 40% of the dosing interval for bacteriostatic activity and 60% to 70% of the dosing interval for bactericidal activity.[35436] [35437] [35438]
 
The susceptibility interpretive criteria for ceftriaxone are delineated by pathogen. The MICs are defined for Enterobacterales and Viridans group Streptococcus sp. as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more based on a dosage of 1 g 1 IV every 24 hours for Enterobacterales. The MICs are defined for H. influenzae and H. parainfluenzae as susceptible at 2 mcg/mL or less. The MICs are defined for N. gonorrhoeae as susceptible at 0.25 mcg/mL or less. The MICs are defined for N. meningitidis as susceptible at 0.12 mcg/mL or less. The MICs are defined for beta-hemolytic Streptococcus sp. as susceptible at 0.5 mcg/mL or less. The MICs are defined for Acinetobacter sp. as susceptible at 8 mcg/mL or less, intermediate at 16 to 32 mcg/mL, and resistant at 64 mcg/mL or more. For S. pneumoniae, MICs are based on the site of infection. For non-meningitis infections, the MICs are defined for S. pneumoniae as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more. For meningitis, the MICs are defined for S. pneumoniae as susceptible at 0.5 mcg/mL or less, intermediate at 1 mcg/mL, and resistant at 2 mcg/mL or more (requires therapy with maximum doses). The Clinical and Laboratory Standards Institute (CLSI) and the FDA differ on MIC interpretation for anaerobes. The MICs are defined for anaerobes by the FDA as susceptible at 1 mcg/mL or less, intermediate at 2 mcg/mL, and resistant at 4 mcg/mL or more; however, the MICs are defined for anaerobes by CLSI as susceptible at 16 mcg/mL or less, intermediate at 32 mcg/mL, and resistant at 64 mcg/mL or more. Oxacillin-susceptible staphylococci may be considered susceptible to ceftriaxone.[63320] [63321]

Ceftriaxone is administered intravenously and intramuscularly. Protein-binding ranges from 85 to 95%. It is distributed into most body tissues including the gallbladder, liver, kidney, bone, uterus, ovary, sputum, and fluids including urine, biliary, peritoneal, pleural, middle ear, and synovial fluids. Ceftriaxone penetrates inflamed meninges and reaches therapeutic levels within the CSF. The drug does cross the placenta. Approximately 33 to 67% of ceftriaxone is excreted into the urine, primarily via glomerular filtration, and into feces via bile. Following biliary excretion, a small amount of the drug is metabolized in the intestines to an inactive metabolite prior to fecal excretion. A small percentage is excreted in breast milk. In patients with normal renal function, the elimination half-life is 6 to 9 hours. The elimination half-life increases as renal function declines.[29920]
 
Affected cytochrome P450 isoenzymes: none

Ceftriaxone is not absorbed from the GI tract.

Peak ceftriaxone serum concentrations occur within 30 minutes of an IV dose. In pediatric patients with meningitis who received ceftriaxone 50 mg/kg IV or 75 mg/kg IV, the mean maximum serum concentrations were 216 mcg/mL and 275 mcg/mL, respectively; the mean maximum serum concentrations in healthy adults who received 1 g or 2 g IV were 151 mcg/ml and 257 mcg/mL, respectively. After a 1 g IV dose in adults, average concentrations of ceftriaxone, determined from 1 to 3 hours after dosing, were 581 mcg/mL in the gallbladder bile, 788 mcg/mL in the common duct bile, 898 mcg/mL in the cystic duct bile, 78.2 mcg/g in the gallbladder wall and 62.1 mcg/mL in the concurrent plasma.

Peak ceftriaxone serum concentrations occur within 1.5 to 4 hours following an IM dose. Concentrations in the middle ear reach a peak of 35 mcg/mL approximately 24 hours after a single IM dose of 50 mg/kg; concentrations of 19 mcg/mL persist for up to 48 hours. In pediatric patients, concentrations in the middle ear reach a peak of 35 mcg/ml approximately 24 hours after a single IM dose of 50 mg/kg; concentrations of 19 mcg/mL persist for up to 48 hours.

Available data over several decades with cephalosporin use, including ceftriaxone, in pregnant women have not established a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes with use during pregnancy. Ceftriaxone crosses the placenta. In animal studies, no adverse developmental effects were observed when ceftriaxone was administered at doses up to approximately 2.8 times the clinical dose of 2 g/day.[29920]

Ceftriaxone is present in human breast milk. There are no data on the effects of ceftriaxone on the breast-fed child or on milk production. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for ceftriaxone and any potential adverse effects on the breast-fed child from ceftriaxone or the underlying maternal condition.[29920] Rare potential complications in the nursing infant include alterations of gut flora that might result in diarrhea or other related complications (e.g., dehydration). Previous American Academy of Pediatrics (AAP) recommendations generally considered ceftriaxone as compatible for use in lactating women.[27500]