Drug reference

Ceftriaxone

Cephalosporin · Antibiotic

Also known as Ceftriaxone Sodium, Rocephin

START

1 g IV/IM once daily

TYPICAL MAX

2 g IV q12h (meningitis)

STOP IF

Cephalosporin allergy · neonate with hyperbilirubinemia · Ca²⁺-containing IV with neonate

WATCH

Biliary sludge · C. difficile · hemolytic anemia

CDSCO approvedSchedule HJan AushadhiATC J01DD04

Dose laddermg/d

Renal dose adjustmenteGFR mL/min/1.73m²

KDIGO 2024 + manufacturer label

Pharmacokineticsplasma · t hours

ONSET: 30min · IV peak rapid
PEAK: 2h · IM Cmax
t½: 8h · plasma t½
DURATION: 1d · once-daily dosing window

EXCRETION

50% renal · 50% biliary unchanged

route + CYP

INTERACTIONS

11 major

incl. contraindicated

PREGNANCY

Category B — safe in pregnancy

FDA category + note

Top interactionssee all 12 →

Calcium Containing Iv SolutionsContraindicatedTextbookHarrison 22e · p1172
Calcium Containing Solutions (iv)ContraindicatedDatabase
WarfarinSevereTextbook-citedKDT 7e · p948
BilirubinSevereTextbookG&G 14e · p1158

Available in India

2,957 branded formulations and 3,116 fixed-dose combinations. Look up specific brands in the Drugs workspace.

Jan Aushadhi — generic available at GoI pharmacies

Mechanism

Ceftriaxone is a bactericidal antibiotic that inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins (PBPs). This binding prevents the cross-linking of peptidoglycan chains, which are essential components of bacterial cell walls, leading to cell lysis and death. Its broad spectrum covers many Gram-positive and Gram-negative bacteria.

Indications

MeningitisPneumonia (community-acquired and nosocomial)SepsisUrinary Tract Infections (complicated)Skin and Soft Tissue InfectionsBone and Joint InfectionsIntra-abdominal InfectionsGonorrheaLyme DiseaseSurgical ProphylaxisFebrile Neutropenia (off-label)Salmonellosis/Typhoid Fever (off-label)Community-acquired pneumoniaUrinary tract infectionsStreptococcal endocarditisSevere Lyme diseaseUrethral, cervical, rectal, or pharyngeal gonorrheaProphylaxis for meningococcal meningitis (during an epidemic)Prophylaxis for gonorrhoea/syphilisBacterial meningitis (especially in children)Multiresistant typhoid feverComplicated urinary tract infectionsAbdominal sepsis and septicaemiasGonorrhoea (including PPNG) (single dose)Chancroid (single dose)penicillinase producing gonorrhoeaearly syphilis (alternative)late syphilis (alternative)chancroid (first line)bacterial meningitis (i.v., usually combined with i.v. vancomycin for empirical therapy)Penicillin-susceptible streptococcal IERelatively penicillin-resistant streptococcal IEModerately penicillin-resistant streptococcal IEEnterococcus faecalis IE (in combination with ampicillin)HACEK group IECulture-negative subacute NVE (with vancomycin)Pneumococcal NVE/PVE (if penicillin MIC ≥2 µg/mL or meningitis suspected)Endocarditis prophylaxis for penicillin allergy (inability to take oral medication)Gonococcal urethritisEpididymitis (due to N. gonorrhoeae or C. trachomatis)Pelvic Inflammatory Disease (PID)Proctitis (gonococcal)ChancroidShigellosis (second-line)Focal neurologic disease due to Brucella species (supplementation of standard regimen for 3-6 months)Brucella endocarditis (as an optional add-on)Early syphilis (limited studies, 1 g/d, IM or IV for 8–10 days)Ocular syphilis (reports of success with 2 g/d)Neurosyphilis (possible alternative, 1-2 g/d IV for 10-14 days)Moderate/severe leptospirosis

Dosing

Adult: 1-2 g IV or IM once daily, or in two divided doses for severe infections. Max 4 g/day. For uncomplicated gonorrhea, 500 mg IM single dose. For surgical prophylaxis, 1 g IV 30-90 minutes before surgery.
Pediatric: 50-75 mg/kg/day IV or IM once daily or in two divided doses, not to exceed 2 g/day. For serious infections like meningitis, 80-100 mg/kg/day IV or IM in 1-2 divided doses, max 4 g/day. Neonates (>28 days): 50-75 mg/kg/day once daily.
Renal adjustment: No dosage adjustment is generally required for mild to moderate renal impairment (CrCl >10 mL/min). For severe renal impairment (CrCl <10 mL/min) or hemodialysis, the dose may be reduced to 0.5-1 g once daily, with careful monitoring.
Hepatic adjustment: No dosage adjustment is generally required for mild to moderate hepatic impairment. In severe hepatic impairment or concomitant severe renal and hepatic dysfunction, monitoring of ceftriaxone plasma concentrations is advised, and dose reduction might be necessary.
Geriatric: No specific dosage adjustment is necessary unless there is severe renal or hepatic impairment; dose at the lower end of the adult range.
Max dose: 4 g/day

Pharmacokinetics

Onset

Rapid (IV: immediate; IM: 1-2 hours)

Peak effect

End of infusion (IV); 2-3 hours (IM)

Duration

Up to 24 hours

Half-life

6-9 hours

Bioavailability

100% (after IV or IM administration)

Protein binding

85-95%

Metabolism

Primarily non-hepatic, metabolized in the gut by microbial flora to inactive metabolites; about 33-67% excreted unchanged.

Excretion

Dual excretion: approximately 35-65% via kidneys (glomerular filtration and tubular secretion) and 35-65% via bile/feces.

Contraindications

Hypersensitivity to ceftriaxone, any other cephalosporin, or beta-lactam antibiotics.
Neonates (<=28 days) with hyperbilirubinemia, especially premature neonates.
Concomitant intravenous calcium-containing solutions in neonates (<=28 days) due to risk of precipitation.
Previous severe hypersensitivity reaction to penicillin.

Side effects

Common

DiarrheaRashEosinophiliaThrombocytosisLeukopeniaElevated liver enzymes (AST, ALT, ALP)Injection site pain/indurationPhlebitis at IV siteGastrointestinal side effects (e.g., diarrhea)

Serious

Clostridioides difficile-associated diarrhea (CDAD)
Anaphylaxis
Hemolytic anemia
Pseudolithiasis (biliary sludge/gallstones)
Renal stones (rare)
Interstitial nephritis
Severe cutaneous adverse reactions (e.g., SJS, TEN)
Add "Hypoprothrombinemia (risk of bleeding, especially with co-administration of anticoagulants)"
Hypoprothrombinaemia
Bleeding
Haemolysis
Hypersensitivity reactions (rash to anaphylaxis)
Serum sickness
Stevens-Johnson syndrome
Nephropathy
Hematologic reactions (neutropenia, prolonged use)
Neurotoxicity (seizure, high doses, renal impairment)

Pregnancy & lactation

Pregnancy

Category B — safe in pregnancy

Lactation

Excreted in low concentrations in breast milk. Generally considered safe, but monitor infant for potential adverse effects (e.g., diarrhea, candidiasis, allergic reaction). Use with caution, especially in premature infants or those with compromised renal/hepatic function.

Drug interactions

Calcium Containing Iv Solutions

Contraindicated

Textbook

Precipitation of ceftriaxone-calcium particulate.

Concomitant use is contraindicated in neonates (<28 days). For infants >28 days, can be given sequentially and lines thoroughly flushed or infused via separate lines.

Source: Harrison 22e · p1172

Calcium Containing Solutions (iv)

Contraindicated

Database

Fatal ceftriaxone-calcium precipitates in lungs and kidneys, especially in neonates. Can occur even with separate infusion lines if administered sequentially without adequate flush.

Ceftriaxone is contraindicated in neonates (≤28 days) if they require or are expected to require IV calcium-containing solutions. In patients older than 28 days, ceftriaxone and calcium-containing solutions should not be co-administered simultaneously or within 48 hours of each other, even via different infusion lines. If sequential administration is unavoidable, flush the line thoroughly with a compatible fluid between administrations.

Warfarin

Severe

Textbook-cited

Increased bleeding risk.

Monitor INR and reduce anticoagulant dose

Source: KDT 7e · p948

Bilirubin

Severe

Textbook

Potential for causing jaundice in neonates.

Cefotaxime is the preferred agent in this patient population.

Source: G&G 14e · p1158