Ceftriaxone Sodium

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
Brands: Rocephin

Introduction

Antibacterial; β-lactam antibiotic; third generation cephalosporin.^{1 16 104 105 106 165 171}

Uses for Ceftriaxone Sodium

Acute Otitis Media (AOM)

Treatment of AOM caused by S. pneumoniae, H. influenzae (including β-lactamase-producing strains), or Moraxella catarrhalis (including β-lactamase-producing strains).^{1 310 311 312 313 427 428 429 458 494} The single-dose IM ceftriaxone regimen has some practical advantages (ensures compliance, can be used in patients with nausea and vomiting),^{311 312 430 494} but manufacturer cautions that clinical cure rate with the single-dose regimen may be lower than that reported with multiple-dose regimens of oral anti-infectives usually used for AOM.¹

Treatment of persistent or recurrent AOM† in pediatric patients ≥3 months of age with infections that failed to respond to other anti-infectives (e.g., amoxicillin, amoxicillin and clavulanate potassium, cefaclor, cefuroxime).^{486 487}

Bone and Joint Infections

Treatment of bone and joint infections (e.g., osteomyelitis, septic arthritis) caused by susceptible Staphylococcus aureus, Streptococcus pneumoniae, Enterobacter, Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis.^{1 87 104 121 124 127 131 132 150 246}

Endocarditis

Treatment of native valve or prosthetic valve endocarditis caused by viridans streptococci (e.g., S. oralis, S. milleri group, S. mitis, S. mutans, S. salivarius, S. sanguis) or S. bovis (nonenterococcal group D streptococcus)†.^{413 414 415 416 417 491 500} Used for endocarditis caused by viridans streptococci or S. bovis highly susceptible to penicillin (penicillin MIC ≤0.12 mcg/mL) or relatively resistant to penicillin (penicillin MIC >0.12 mcg/mL but ≤0.5 mcg/mL).⁴¹³ Should not be used for endocarditis caused by viridans streptococci or S. bovis highly resistant to penicillin (penicillin MIC >0.5 mcg/mL) or caused by Abiotrophia defectiva, Granulicatella, or Gamella.⁴¹³

Treatment of native valve or prosthetic valve endocarditis caused by slow-growing fastidious gram-negative bacilli termed the HACEK group† (i.e., Haemophilus parainfluenzae, H. aphrophilus, H. paraphrophilus, H. influenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae, K. denitrificans).⁴¹³

Not usually recommended for treatment of endocarditis caused by Enterococcus (e.g., E. faecalis, E. faecium).⁴¹³ May be used in conjunction with ampicillin and sulbactam for treatment of native or prosthetic valve endocarditis caused by E. faecalis resistant to penicillin, aminoglycosides, and vancomycin when there are few therapeutic options.⁴¹³ Since treatment of enterococcal endocarditis caused by vancomycin-resistant or multidrug-resistant enterococci is complex, consult specialists in infectious disease, cardiology, cardiac surgery, and microbiology.⁴¹³

Not indicated for treatment of staphylococcal endocarditis.⁴¹³

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 endocarditis.⁵⁰⁹ Oral amoxicillin is usual drug of choice for such prophylaxis;⁵⁰⁹ ceftriaxone (or cefazolin) is an alternative in penicillin-allergic individuals or when an oral anti-infective cannot be used.⁵⁰⁹ Should not be used in those with immediate-type penicillin hypersensitivity (see Cross-hypersensitivity under Cautions).⁵⁰⁹ Consult most recent AHA recommendations for specific information on which cardiac conditions are associated with highest risk of endocarditis and which procedures require prophylaxis.⁵⁰⁹

Intra-abdominal Infections

Treatment of intra-abdominal infections caused by susceptible E. coli, K. pneumoniae, Bacteroides fragilis, Clostridium (not C. difficile), or Peptostreptococcus.^{1 104 105 129 132 149}

Treatment of mixed aerobic-anaerobic intra-abdominal infections;^{149 434} should not be used alone when B. fragilis may be present.^{119 128 434}

Meningitis and Other CNS Infections

Treatment of meningitis caused by susceptible H. influenzae, N. meningitidis, or S. pneumoniae in neonates,^{1 104 140 142 144 243 249 250} children,^{80 87 104 130 139 140 141 142 143 144 187 197 243 245 246 249 250 257 258 259 270 272} or adults.^{80 87 104 138 197 270 271} A drug of choice for meningitis caused by penicillin-resistant S. pneumoniae,^{292 324 329 331 332 334 346 347 349} but consider that S. pneumoniae with reduced susceptibility to cephalosporins have been reported with increasing frequency^{109 111 470 471} and susceptibility can no longer be assumed.^{243 292 323 330 324 344}

Treatment of meningitis and other CNS infections caused by susceptible Enterobacteriaceae† (e.g., E. coli, Klebsiella).^{1 104 133 156}

Should not be used alone for empiric treatment of meningitis when Listeria monocytogenes, enterococci, staphylococci, or Pseudomonas aeruginosa may be involved.^{9 87 137 197 292 400 468}

Empiric treatment of bacterial brain abscesses and other CNS infections (e.g., subdural empyema, intracranial epidural abscesses) caused by gram-positive aerobic cocci, Enterobacteriaceae (e.g., E. coli, Klebsiella), and/or anaerobic bacteria (e.g., Bacteroides, Fusobacterium).^{468 478}

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.^{1 87 88 104 105 119 120 121 124 125 127 128 129 131 197 246 313 423 493}

Treatment of community-acquired pneumonia (CAP).⁵¹² 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 has been demonstrated.⁵¹² Also recommended in certain combination regimens used for empiric treatment of CAP.⁵¹² 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).⁵¹²

For empiric outpatient treatment of CAP when risk factors for drug-resistant S. pneumoniae are present (e.g., comorbidities such as chronic heart, lung, liver, or renal disease, diabetes, alcoholism, malignancies, asplenia, immunosuppression, use of anti-infectives within the last 3 months), ATS and IDSA recommend monotherapy with a fluoroquinolone active against S. pneumoniae (moxifloxacin, gemifloxacin, levofloxacin) or, alternatively, a combination regimen that includes a β-lactam active against S. pneumoniae (high-dose amoxicillin or fixed combination of amoxicillin and clavulanic acid or, alternatively, ceftriaxone, cefpodoxime, or cefuroxime) given in conjunction with a macrolide (azithromycin, clarithromycin, erythromycin) or doxycycline.⁵¹²

For empiric inpatient treatment of CAP in patients not requiring treatment in an intensive care unit (non-ICU patients), IDSA and ATS recommend monotherapy with a fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) or, alternatively, a combination regimen that includes a β-lactam (usually cefotaxime, ceftriaxone, or ampicillin) given in conjunction with a macrolide (azithromycin, clarithromycin, erythromycin).⁵¹² For empiric inpatient treatment of CAP in ICU patients when Pseudomonas and methicillin-resistant S. aureus (MRSA; also known as oxacillin-resistant S. aureus or ORSA) are not suspected, IDSA and ATS recommend a combination regimen that includes a β-lactam (cefotaxime, ceftriaxone, fixed combination of ampicillin and sulbactam) given in conjunction with either azithromycin or a fluoroquinolone (gemifloxacin, levofloxacin, moxifloxacin).⁵¹²

Septicemia

Treatment of septicemia caused by S. aureus, S. pneumoniae, E. coli, H. influenzae, or K. pneumoniae.^{1 87 104 105 120 121 124 125 131 246}

Select anti-infective for treatment of sepsis syndrome based on probable source of infection, gram-stained smears of appropriate clinical specimens, immune status of the patient, and current patterns of bacterial resistance within the hospital and local community.¹⁹⁷ Some clinicians suggest that certain parenteral cephalosporins (i.e., cefepime, cefotaxime, ceftriaxone, ceftazidime) are good choices for treatment of gram-negative sepsis.¹⁹⁷

For initial treatment of life-threatening sepsis in adults, some clinicians suggest that a third or fourth generation cephalosporin (i.e., cefepime, cefotaxime, ceftriaxone, ceftazidime), fixed combination of piperacillin and tazobactam, or a carbapenem (imipenem or meropenem) be used in conjunction with vancomycin with or without an aminoglycoside (amikacin, gentamicin, tobramycin).¹⁹⁷

Skin and Skin Structure Infections

Treatment of skin and skin structure infections caused by susceptible S. aureus, S. epidermidis, S. pyogenes (group A β-hemolytic streptococci), viridans streptococci, E. coli, E. cloacae, K. oxytoca, K. pneumoniae, P. mirabilis, Morganella morganii, Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, B. fragilis, or Peptostreptococcus.^{1 87 89 104 105 120 121 124 128 129 131 132}

Urinary Tract Infections (UTIs)

Treatment of complicated and uncomplicated UTIs caused by E. coli, K. pneumoniae, M. morganii, P. mirabilis, or P. vulgaris.^{1 82 91 104 119 120 121 124 125 127 128 129 131 246 455}

Considered a drug of choice for treatment of 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.¹⁹⁷

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.^{105 106 128 179 446}

Actinomycosis

Has been used for treatment of infections caused by Actinomyces†.^{380 381} Not considered a drug of choice; penicillin G generally preferred for initial treatment of all forms of actinomycosis, including thoracic, abdominal, CNS, and cervicofacial infections.^{197 292 382}

Bartonella Infections

Treatment of bacteremia caused by Bartonella quintana† (in conjunction with oral erythromycin or oral azithromycin).³⁹⁶

The possible role of ceftriaxone in the treatment of infections caused by Bartonella henselae† (e.g., cat scratch disease, bacillary angiomatosis, peliosis hepatitis) has not been determined.⁴⁴³ 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.^{292 443 444 445} Anti-infectives also are indicated in patients with B. henselae infections who develop bacillary angiomatosis, neuroretinitis, or Parinaud’s oculoglandular syndrome.^{292 443 444 445}

Optimum regimens for treatment of infections caused by B. quintana or for treatment of cat scratch disease or other B. henselae infections have not been identified.^{197 292 396 442 464 465}

Capnocytophaga Infections

Treatment of infections caused by Capnocytophaga.¹⁹⁷

Optimum regimens for treatment of infections caused by Capnocytophaga have not been identified; some clinicians recommend use of penicillin G^{197 463} or, alternatively, a third generation cephalosporin (cefotaxime, ceftizoxime, ceftriaxone), a carbapenem (imipenem and cilastatin sodium, meropenem), vancomycin, a fluoroquinolone, or clindamycin.¹⁹⁷

Chancroid

Treatment of chancroid† (genital ulcers caused by H. ducreyi).^{167 210 211 229 241 274}

CDC¹⁶⁷ and others²⁴² 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.^{167 202 241 242} CDC recommends that the single-dose ceftriaxone regimen be used in HIV patients only if follow-up can be ensured.¹⁶⁷

Gonorrhea and Associated Infections

Treatment of uncomplicated cervical, urethral, or rectal infections caused by susceptible N. gonorrhoeae.^{1 167 242 273 274 292 336 508} Recommended by CDC, AAP, and others as a drug of choice for uncomplicated gonorrhea in adults, adolescents, and children.^{167 242 273 292 508}

Treatment of pharyngeal infections caused by N. gonorrhoeae.^{115 118 167 242 273 292 508} Recommended by CDC, AAP, and others as the regimen of choice for pharyngeal gonorrhea in adults, adolescents, and children.^{167 179 242 292 508}

Initial treatment of disseminated gonococcal infections†.^{167 221 292 508} Recommended by CDC, AAP, and others as the regimen of choice for initial parenteral treatment in adults, adolescents, and children, especially when meningitis, endocarditis, or conjunctivitis is involved.^{167 242 292 508}

Treatment of epididymitis† (in conjunction with doxycycline) in patients most likely to have infections caused by N. gonorrhoeae and/or C. trachomatis (e.g., in those <35 years of age).^{167 242 292} Drug of choice for empiric treatment.⁵⁰⁸

Treatment of proctitis† (in conjunction with doxycycline) in patients most likely to have infections caused by N. gonorrhoeae and/or C. trachomatis.¹⁶⁷

Parenteral prophylaxis† in neonates born to mothers with documented peripartum gonococcal infection.^{167 292} Considered drug of choice by CDC and AAP.^{167 292}

Treatment of ophthalmia neonatorum† caused by N. gonorrhoeae.^{167 292} The single-dose ceftriaxone regimen is adequate therapy for gonococcal conjunctivitis, but infants with ophthalmia neonatorum should be hospitalized and evaluated for signs of disseminated infection (e.g., sepsis, arthritis, meningitis).^{167 292}

Treatment of disseminated gonococcal infections (e.g., sepsis, arthritis, meningitis) in neonates.^{167 292} Should not be used in neonates who are hyperbilirubinemic (especially those born prematurely) (see Pediatric Use under Cautions);^{1 167 292} AAP suggests cefotaxime is preferred in these neonates.²⁹²

Leptospirosis

Treatment of severe leptospirosis† caused by Leptospira.^{197 292 513 516 518 519}

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).^{292 515 516 517}

Penicillin G generally has been considered the drug of choice for treatment of moderate to severe leptospirosis,^{197 292 513 515 516 519} and doxycycline has been used in less severe infections.^{197 292 516} Cephalosporins (ceftriaxone, cefotaxime), aminopenicillins (ampicillin, amoxicillin), tetracyclines (doxycycline, tetracycline), or macrolides (azithromycin) also have been recommended for severe infections.^{197 292 515 516 517 518 519}

Lyme Disease

Treatment of early neurologic Lyme disease† with acute neurologic manifestations such as meningitis or radiculopathy.^{197 262 277 279 292 353 356 357 358 359 360 361 362 363 365 366 367 477 481} IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.^{277 292 497 498} 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,^{197 262 277 279 292 353 356 357 358 359 360 361 362 363 365 366 367 477 481} a parenteral regimen usually is recommended when there are acute neurologic manifestations.^{197 262 277 279 292 353 356 357 358 359 360 361 362 363 365 366 367 477 481}

Treatment of Lyme carditis† when a parenteral regimen is indicated.^{262 277 292 497} IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.^{262 277 292 497} Although a parenteral regimen usually is recommended for initial treatment of hospitalized patients, an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) can be used to complete therapy and for the treatment of outpatients.^{262 277 292 497}

Treatment of Lyme arthritis† when a parenteral regimen is indicated.^{262 292 277 497 498} IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.^{262 292 277 497 498} Although the comparative safety and efficacy of oral versus IV anti-infectives for treatment of Lyme arthritis has not been fully evaluated,²⁷⁷ those with concomitant neurologic disease generally should receive a parenteral regimen.^{262 277 292 497 498}

Treatment of late neurologic Lyme disease† affecting the CNS or peripheral nervous system (e.g., encephalopathy, neuropathy).^{277 292} IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.^{277 292}

Neisseria meningitidis Infections

Treatment of invasive infections caused by N. meningitidis.¹ (See Meningitis and Other CNS Infections under Uses.)

Elimination of nasopharyngeal carriage of N. meningitidis†.^{292 374 376} CDC and AAP consider rifampin, ceftriaxone, or ciprofloxacin the drugs of choice for such carriers.^{292 374 376}

Postexposure prophylaxis to prevent meningococcal disease in household or other close contacts of patients with invasive meningococcal disease†.^{1 197 292 374 376}

Outbreak control of meningococcal disease when outbreaks involve small populations (e.g., a small organization such as a single school).³⁷⁷

Nocardiosis

Treatment of nocardiosis† caused by Nocardia.^{197 292 521 522 523 524 525 528}

Co-trimoxazole (fixed combination of sulfamethoxazole and trimethoprim) generally is the drug of choice for treatment of nocardiosis.^{197 292} 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 (minocycline), cephalosporins (ceftriaxone, cefotaxime, cefuroxime), cefoxitin, carbapenems (imipenem or meropenem), fixed combination of amoxicillin and clavulanate, clarithromycin, cycloserine, or linezolid.^{197 292 521 522 524 525 528}

For treatment of invasive nocardiosis or when sulfonamides cannot be tolerated, select anti-infectives based on results of in vitro susceptibility tests.²⁹² If nocardiosis involves the CNS or if the infection is disseminated or overwhelming, some clinicians suggest that amikacin and ceftriaxone be included in the treatment regimen during the first 4–12 weeks of therapy or until there is clinical improvement.²⁹² A regimen of amikacin and ceftriaxone has been effective for the treatment of disseminated N. asteroides infection complicated by cerebral abscess.⁵²²

Pelvic Inflammatory Disease (PID)

Treatment of PID caused by N. gonorrhoeae.^{1 167 242 292 397 398 460 508}

Not considered a drug of choice for parenteral regimens used for treatment of PID.^{167 508} CDC states ceftriaxone may be effective for PID, but is less active than cefotetan or cefoxitin against anaerobic bacteria.¹⁶⁷

When an oral regimen is 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, ceftizoxime) given in conjunction with oral doxycycline (with or without oral metronidazole).^{167 508}

Because ceftriaxone (like other cephalosporins) is not active against Chlamydia, concomitant use of a drug active against Chlamydia (e.g., doxycycline) is necessary when these organisms are suspected pathogens.^{1 167}

Pseudomonas aeruginosa Infections

May be effective for treatment of some infections caused by Ps. aeruginosa (see Skin and Skin Structure Infections under Uses).¹

Because many strains of Ps. aeruginosa are only susceptible to high concentrations of ceftriaxone in vitro and because resistant strains of the organism have developed during therapy with the drug,^{120 121 124 127 132 150} ceftriaxone generally should not be used alone in the treatment of any infection where Ps. aeruginosa may be present.^{104 105 106 124 125 128 170 250}

Relapsing Fever

Treatment of relapsing fever† caused by Borrelia recurrentis;²⁶⁴ other drugs (e.g., tetracyclines, penicillin G) usually considered drugs of choice.^{197 292}

Shigella Infections

Treatment of shigellosis† in children caused by susceptible Shigella sonnei or S. flexneri.^{401 402}

Anti-infectives generally indicated in addition to fluid and electrolyte replacement for severe shigellosis.^{292 403} Ceftriaxone is considered a drug of choice for shigellosis when the susceptibility of the isolate is unknown, especially in areas where ampicillin-resistant Shigella have been reported.^{217 292 403}

Syphilis

Alternative for treatment of early syphilis† in patients hypersensitive to penicillin; CDC cautions that optimal dosage and duration of ceftriaxone for this use have not been defined.¹⁶⁷

Alternative for treatment of neurosyphilis† in patients hypersensitive to penicillin.¹⁶⁷

CDC states that IM or IV ceftriaxone may be considered for treatment of infants with clinical evidence of congenital syphilis if there is a penicillin shortage and penicillin G sodium and penicillin G procaine are unavailable.¹⁶⁷ However, the drug should be used in consultation with a specialist in treatment of infants with congenital syphilis and with careful clinical and serologic follow-up.¹⁶⁷

CDC states that data are insufficient to recommend use of ceftriaxone for treatment of early syphilis in pregnant women or pediatric patients hypersensitive to penicillin or for prevention of congenital syphilis and the only acceptable alternatives to penicillin G for patients with late latent syphilis, syphilis of unknown duration, or tertiary syphilis are doxycycline or tetracycline.¹⁶⁷ Use of ceftriaxone in HIV-infected individuals with syphilis has not been adequately studied and such therapy should be undertaken with caution.¹⁶⁷

Because of limited experience with penicillin alternatives, close follow-up is essential if ceftriaxone is used in the treatment of syphilis.¹⁶⁷ If compliance with an alternative regimen cannot be ensured in patients hypersensitive to penicillin, the CDC recommends desensitization and treatment with penicillin G.¹⁶⁷

Typhoid Fever and Other Salmonella Infections

Treatment of typhoid fever (enteric fever) or septicemia caused by Salmonella typhi or S. paratyphi†, including multidrug-resistant strains.^{188 267 406 407 408 409 410 419}

Treatment of infections caused by nontyphi Salmonella, including bacteremia or osteomyelitis caused by S. typhimurium.^{410 418}

Treatment of gastroenteritis caused by Salmonella (e.g., S. enteritidis, S. typhimurium) in individuals with severe Salmonella gastroenteritis and in those who are at increased risk of invasive disease.^{197 217 292 412}

Whipple's Disease

Treatment of Whipple’s disease†, a progressive systemic infection caused by Tropheryma whippelii.^{383 384 385 386}

Empiric Therapy in Febrile Neutropenic Patients

Empiric anti-infective therapy of presumed bacterial infections in febrile neutropenic adults or pediatric patients†; used in conjunction with an aminoglycoside.^{387 388 390 437}

Ceftriaxone monotherapy may not provide adequate coverage against some potential pathogens (e.g., Ps. aeruginosa) and such monotherapy generally is not recommended for empiric anti-infective therapy in febrile neutropenic patients.^{390 435 436}

Perioperative Prophylaxis

Perioperative prophylaxis to reduce the incidence of infection in patients undergoing contaminated or potentially contaminated surgical procedures,¹ including cholecystectomy,^{1 147 152 294 295 296 297 298 449} intra-abdominal surgery,^{152 450} or vaginal or abdominal hysterectomy,^{1 154} and in those undergoing clean surgical procedures in which the development of infection at the surgical site would represent a serious risk,¹ including coronary artery bypass,¹ open heart surgery,^{67 105 151} thoracic surgery,⁴⁵² or orthopedic surgery.^{105 153} The drug also has been used perioperatively in patients undergoing transurethral resection of the prostate†.^{148 155 451}

Other cephalosporins or cephamycins (cefazolin, cefuroxime, cefotetan, cefoxitin) are the preferred drugs for perioperative prophylaxis.^{104 106 164 168 175 236 306} Ceftriaxone and other third generation cephalosporins usually not used for perioperative prophylaxis since they are expensive, some are less active against staphylococci than cefazolin, they have a spectrum of activity wider than necessary for organisms encountered in elective surgery, and their use for prophylaxis promotes emergence of resistant organisms.³⁰⁶

Prophylaxis in Sexual Assault Victims

Empiric anti-infective prophylaxis in sexual assault victims†; used in conjunction with oral metronidazole and oral azithromycin or doxycycline.^{167 292}

Prophylaxis Following Bite Wounds

Prophylaxis following a bite wound† (human or animal).²⁹²

Ceftriaxone Sodium Dosage and Administration

Administration

Administer by IV infusion or deep IM injection.^{1 180 307 501 502}

The commercially available premixed ceftriaxone injection (frozen) should be used only for IV infusion.³⁰⁷

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.^{1 180 507 511 529}

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).^{1 507 510 511 529} (See Interaction with Calcium-containing Products under Cautions.)

Ceftriaxone is 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.^{1 529} In adults and pediatric patients older than 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.^{1 5}