Ceftriaxone

ROCEPHIN

What it isThird-generation PBP-inhibiting cephalosporin; pneumonia, meningitis, pyelonephritis, and gonorrhea.

Why this oneExcellent CSF penetration, once-daily use, and substantial biliary clearance distinguish it from most cephalosporins.

What limits itCalcium coadministration can form fatal precipitates in neonates; biliary sludging occurs, and it lacks pseudomonal coverage.

FDA-approved for

FDA dosing	Population	Start	Target	Max
General infections	Adults	1–2 g/day QD or divided BID	1–2 g/day QD or BID	4 g/day
Uncomplicated gonococcal infection	Adults	250 mg IM single dose	250 mg IM single dose
Surgical prophylaxis	Adults	1 g IV 0.5–2 h pre-op	1 g single dose
Skin/skin-structure infection	Children	50–75 mg/kg/day QD or divided BID	50–75 mg/kg/day	2 g/day
Acute bacterial otitis media	Children	50 mg/kg IM single dose	50 mg/kg IM single dose	1 g
Serious infections (non-meningitis)	Children	50–75 mg/kg/day divided q12h	50–75 mg/kg/day divided q12h	2 g/day
Meningitis	Children	100 mg/kg (max 4 g) initial, then 100 mg/kg/day QD or divided q12h	100 mg/kg/day	4 g/day

Renal No adjustment needed for renal or hepatic impairment alone (up to 2 g/day; monitor if both renal and hepatic impairment present)

Hepatic No adjustment needed

Ceftriaxone-calcium precipitation risk — separate from calcium-containing infusions (flush line between sequential use in non-neonates)

IV infusion over 30 min (neonates over 60 min to reduce bilirubin-encephalopathy risk)
Do not use calcium-containing diluents (Ringer's/Hartmann's); do not mix or co-administer with calcium-containing IV solutions (contraindicated in neonates)
S. pyogenes infection: treat ≥10 days; max 4 g/day

Premature neonates up to postmenstrual age 41 weeks
Hyperbilirubinemic neonates (risk of bilirubin encephalopathy from albumin displacement)
Neonates (≤28 days) requiring calcium-containing IV solutions (ceftriaxone-calcium precipitation)
IV administration of ceftriaxone solutions containing lidocaine

Hypersensitivity/anaphylaxis; cross-reactivity in penicillin/beta-lactam-allergic patients
Ceftriaxone-calcium precipitation (fatal lung/kidney crystalline deposits in neonates); biliary/renal precipitation, gallbladder sludge
Pseudomembranous colitis
Encephalopathy, seizures, myoclonus, nonconvulsive status epilepticus
Hemolytic anemia; positive Coombs; prolonged PT

Eosinophilia, thrombocytosis, leukopenia
Diarrhea/loose stools; elevated AST/ALT; rash
Local injection-site pain/induration; phlebitis
Rare: agranulocytosis, biliary lithiasis/sludge, nephrolithiasis, seizures, serum sickness

Pregnancy No animal embryotoxicity/fetotoxicity/teratogenicity (incl. primates); no adequate human studies — use only if clearly needed

Lactation Undefined

NO BOXED WARNINGS

Principal riskFatal calcium precipitates in neonates; biliary sludging

Cost, est. cash$20–$1,500/dose or month

Generic entry1985

Therapeutic safety burden1 / 4

Overdose danger1 / 4

Weight-gain liability0 / 4

Sedation liability0 / 4

QT / Torsades0 / 4

Direct muscarinic antagonism0 / 4

Embryofetal risk0 / 4

Legacy pregnancy categoryB

Defining liabilityAllergy, gastrointestinal effects and agent-specific renal, hepatic, hematologic or interaction risks.

OAT substrate