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ceftriaxone (Rx)Brand and Other Names:Rocephin

 
 
 

Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

injectable solution

  • 1g/50mL
  • 2g/50mL

powder for injection

  • 250mg
  • 500mg
  • 1g
  • 2g
  • 10g
  • 100g
more...

Intra-abdominal Infections

Complicated, mild-to-moderate, community acquired: 1-2 g/day IV in single daily dose or divided q12hr for 4-7 days, in combination with metronidazole

Acute Bacterial Otitis Media

50 mg/kg IM once

Persistent or treatment failures: 50 mg/kg IV/IM for 3 days

Pelvic Inflammatory Disease

250 mg IM as single dose with doxycycline, with or without metonidazole for 14 days

Septic/toxic Shock (Off-label)

2 g IV once daily; with clindamycin for toxic shock

Skin and Soft Necrotizing Infection (Off-label)

Due to Aeromonas hydrophilia: 1-2 g IV qDay in combination with doxycycline

Due to Vibrio vulnificus; 1 g IV qDay in combination with doxycycline

Continue treatment until further debridement not necessary, clinical improvement observed, and patient is afebrile for 48-72 hr

Severe Acute Bacterial Rhinosinusitis (Off-label)

Infection requiring hospitalization: 1-2 g IV q12-24hr for 5-7 days

Prosthetic Joint Infection

2 g IV q24hr for 2-6 weeks; continue treatment until clinical improvement observed and patient is afebrile for 48-72 hr

Meningitis

2 g IV q12hr for 7-14 days

Acute Uncomplicated Pyelonephritis

1-2 g IV qDay

Surgical Prophylaxis

Prophylaxis of surgical infection

1 g IV 0.5-2 hours before procedure

Uncomplicated Gonococcal Infections

Uncomplicated gonococcal infection of pharynx, cervix, urethra, or rectum: ceftriaxone 250 mg IM once plus azithromycin 1 g PO once (preferred) or alternatively, doxycycline 100 mg PO q12hr for 7 days

CDC STD guidelines: MMWR Recomm Rep. June 5, 2015:64(RR3);1-137

Sexual assault

  • Prophylaxis of sexually transmitted diseases (STDs) such as gonorrhea after sexual assault per CDC guidelines includes the following 3-drug regimen:
  • Ceftriaxone 250 mg IM once, PLUS
  • Azithromycin 1 g PO once, PLUS
  • Metronidazole or tinidazole 2 g PO once
  • If alcohol has been recently ingested or emergency contraception is provided, metronidazole or tinidazole can be taken by the victim at home rather than as directly observed therapy to avoid drug interactions

Other Gonococcal Infections (Off-label)

Gonococcal conjunctivitis: 1 g IM once

Disseminated gonococcal infection: 1 g/day IV/IM; continued for at least 24-48 hours after improvement is observed, then continued with cefixime 400 mg PO q12hr to complete at least 1 week of therapy

Gonococcal endocarditis:1-2 g IV q12hr for 4 weeks

Gonococcal meningitis: 1-2 g IV q12hr for 10-14 days

Acute epdidymitis: 250 mg IM once with doxycycline

Dosing Considerations

Susceptible organisms

  • Anaerobic cocci, Bacteroides fragilis, Borrelia burgdorferi, Clostridium spp, Enterobacter spp, Escherichia coli, Haemophilus influenzae, Klebsiella spp, Morganella morganii, Neisseria gonorrhoeae, Neisseria meningitidis, Proteus mirabilis, Providencia rettgeri, Pseudomonas spp, Serratia spp, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus pyogenes

Dosage Forms & Strengths

injectable solution

  • 1g/50mL
  • 2g/50mL

powder for injection

  • 250mg
  • 500mg
  • 1g
  • 2g
more...

Acute Bacterial Otitis Media

50 mg/kg IM in single dose; not to exceed 1 g 

Epiglottis (Off-label)

100 mg/kg/day IV on first day; follow with 50 mg/kg on day 2 or 75 mg/kg qDay for 10-14 days

Meningitis

100 mg/kg/day IV/IM in single daily dose or divided q12hr for 7-14 days; not to exceed 4 g/day 

Serious Infections Other Than Meningitis

50-75 mg/kg/day IV/IM divided q12hr for 7-14 days 

Acute Epdidymitis (Off-label)

>8 years and >45 kg: 250 mg IM once with concomitant doxycycline regimen

Skin/Skin Structure Infections

>12 years: 1-2 g/day IV/IM in single daily dose or divided q12hr for 7-14 days, depending on type and severity of infection

Gonococcal Infections

Neonates

  • Ophthalmia neonatorum: 25-50 mg/kg IV/IM once; not to exceed 125 mg 
  • Disseminated gonococcal infections and gonococcal scalp abscesses: 25-50 mg/kg/day IV/IM in single daily dose for 7 days; if meningitis is documented, treat for 10-14 days
  • Prophylaxis for infants of mothers with gonococcal infection: 25-50 mg/kg IV/IM once; not to exceed 125 mg

Children

  • <45 kg with uncomplicated gonococcal vulvovaginitis, cervicitis, urethritis, pharyngitis, or proctitis: 125 mg IM once
  • <45 kg with bacteremia or arthritis: 50 mg/kg/day IM/IV in single daily dose for 7 days; daily dose not to exceed 1 g
  • >45 kg with bacteremia or arthritis: 50 mg/kg/day IM/IV in single daily dose for 7 days
  • >45 kg: 1-2 g IV q12hr
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Interactions

Interaction Checker

ceftriaxone and

No Results

     
     activity indicator 
    No Interactions Found
    Interactions Found

    Contraindicated

      Serious - Use Alternative

        Significant - Monitor Closely

          Minor

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            Adverse Effects

            >10%

            Induration after IM injection (5-17%)

            1-10%

            Eosinophilia (6%)

            Thrombocytosis (5%)

            Diarrhea (3%)

            Elevated hepatic transaminases (3%)

            Leukopenia (2%)

            Rash (2%)

            Increased blood urea nitrogen (BUN) (1%)

            Induration at IV site (1%)

            Pain (1%)

            <1%

            Agranulocytosis

            Anaphylaxis

            Anemia

            Basophilia

            Bronchospasm

            Candidiasis

            Chills

            Diaphoresis

            Dizziness

            Dysgeusia

            Flushing

            Gallstones

            Glycosuria

            Headache

            Hematuria

            Hemolytic anemia

            Increased alkaline phosphatase or bilirubin

            Increased creatinine

            Jaundice

            Leukocytosis

            Lymphocytosis

            Lymphopenia

            Monocytosis

            Nausea

            Neutropenia

            Phlebitis

            Prolonged or decreased prothrombin time (PT)

            Pruritus

            Renal stones

            Serum sickness

            Thrombocytopenia

            Urinary casts

            Vaginitis

            Vomiting

            Postmarketing reports

            Pancreatitis, stomatitis and glossitis

            Oliguria, ureteric obstruction, post-renal acute renal failure

            Exanthema, allergic dermatitis, urticaria, edema; acute generalized exanthematous pustulosis (AGEP) and isolated cases of severe cutaneous adverse reactions (erythema multiforme, Stevens-Johnson syndrome or Lyell’s syndrome/toxic epidermal necrolysis)

            Convulsion

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            Warnings

            Contraindications

            Documented hypersensitivity; hyperbilirubinemic neonates, particularly those who are premature; neonates <28 days if they receive calcium-containing IV products

            Intravenous administration of ceftriaxone solutions containing lidocaine

            Lidocaine contraindications if lidocaine solution used as solvent with ceftriaxone for intramuscular injection

            Concomitant calcium-ceftriaxone administration

            • Risk of fatal calcium-ceftriaxone precipitant formation in lungs and kidneys of term and preterm neonates
            • <28 days: Do not give any calcium-containing IV drugs or products within 48 hours of ceftriaxone (within 5 days if neonate is <10 days, per Health Canada)
            • >28 days: Calcium may be given in sequence after ceftriaxone once infusion line has been flushed, but not simultaneously in same bag or line (chemically incompatible)

            Cautions

            10-g pharmacy bulk package should not be used for direct infusion

            Immune-mediated hemolytic anemia reported; if patient develops anemia while on ceftriaxone, stop antibiotic until etiology determined; severe hemolytic anemia, including fatalities, reported in both adults and children

            May increase INR, especially in nutritionally deficient patients, hepatic or renal disease or prolonged treatment

            Dosage must be adjusted in severe renal insufficiency (high dosages may cause CNS toxicity)

            Superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

            Use with caution in patients with history of penicillin allergy

            Use with caution in patients with history of GI disease, especially colitis

            Use with caution in breast-feeding women; drug may displace bilirubin from albumin-binding sites, increasing risk of kernicterus

            Abnormal gallbladder sonograms reported, possibly the result of ceftriaxone-calcium precipitates; discontinue if signs or symptoms of gallbladder diseease occur

            Ceftriaxone-calcium precipitates in urinary tract observed in patients receiving ceftriaxone; may be detected as sonographic abnormalities; patients may be asymptomatic or may develop symptoms of urolithiasis, and ureteral obstruction and post-renal acute renal failure; appears to be reversible upon discontinuation of therapy and institution of appropriate management; ensure adequate hydration; discontinue therapy in patients who develop signs and symptoms suggestive of urolithiasis, oliguria or renal failure and/or the sonographic findings

            Clostridium difficile-associated diarrhea (CDAD reported with use of nearly all antibacterial agents, including ceftriaxone; If CDAD suspected or confirmed, may consider discontinuing ongoing antibacterial use not directed against C. difficile; institute appropriate fluid and electrolyte management, protein supplementation, antibacterial treatment of C. difficile, and surgical evaluation

            Pancreatitis secondary to biliary obstruction reported rarely; use with caution in patients with gallbladder, biliary tract, liver, or pancreatic disease and patients with history of penicillin hypersensitivity

            Use with caution in patients with history of GI disease (eg, colitis)

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            Pregnancy & Lactation

            Pregnancy category: B

            Lactation: Drug enters breast milk in low concentrations; use with caution

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

            more...
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            Pharmacology

            Mechanism of Action

            Third-generation cephalosporin with broad-spectrum gram-negative activity; has lower efficacy against gram-positive organisms but higher efficacy against resistant organisms; highly stable in presence of beta-lactamases (penicillinase and cephalosporinase) of gram-negative and gram-positive bacteria; bactericidal activity results from inhibiting cell-wall synthesis by binding to 1 or more penicillin-binding proteins; exerts antimicrobial effect by interfering with synthesis of peptidoglycan (major structural component of bacterial cell wall); bacteria eventually lyse because activity of cell-wall autolytic enzymes continues while cell-wall assembly is arrested

            Absorption

            IM preparation well absorbed

            Peak plasma time: 2-3 hr (IM)

            Distribution

            Distributed throughout body, including gallbladder, lungs, bone, bile, and CSF (higher concentrations achieved when meninges are inflamed); crosses placenta; enters amniotic fluid and breast milk

            Protein bound: 85-95%

            Vd: 6-14 L

            Metabolism

            Metabolized in liver

            Elimination

            Half-life: 5-9 hr (normal hepatic and renal function); 12-16 hr (mild-to-severe renal impairment)

            Excretion: Urine (33-67% as unchanged drug), feces

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            Administration

            IV Incompatibilities

            Solution: LR (at drug concentrations >10 mg/mL; compatible at 1 mg/mL)

            Additive: Aminophylline, clindamycin, linezolid, theophylline, metronidazole (at metronidazole 15 g/L with ceftriaxone 20 g/L; compatible at metronidazole 7.5 g/L with ceftriaxone 10 g/L)

            Syringe: Lidocaine (variable)

            Y-site: Alatrofloxacin, amphotericin B cholesteryl sulfate, amsacrine, filgrastim, fluconazole, labetalol, pentamidine, vinorelbine, vancomycin

            General: Calcium-containing drugs

            IV/IM Preparation

            Dilutions are stable for 24 hours at room temperature

            IV

            • Reconstitute to ~100 mg/mL, then dilute further to 10-40 mg/mL
            • 10 g bulk package: not for direct IV infusion; reconstitute in 95 mL, then use appropriate portions for further dilution
            • 10-g bulk package not for direct IV injection; reconstitute in 95 mL, then use appropriate portions for further dilution

            IM

            • Dilute with compatible fluid (eg, SWI, NS, D5W) to 250-350 mg/mL

            IV/IM Administration

            IV: Infuse intermittently over 30 minutes

            IM: Inject deep into large muscle mass

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            Images

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            Formulary

            FormularyPatient Discounts

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

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            • View the formulary and any restrictions for each plan.
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            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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