What to Know About Ceftriaxone

Ceftriaxone is a type of antibiotic drug used to treat bacterial infections. It belongs to a class of drugs called cephalosporin antibiotics. These third-generation cephalosporins are used to treat bacterial strains that are commonly resistant to other types of antibiotics.

Ceftriaxone is administered either by intramuscular injection (into a large muscle) or intravenously (into a vein). Although it is generally well-tolerated, ceftriaxone may cause rash, diarrhea, and adverse changes in the white blood cell count.

Uses

Ceftriaxone is a broad-spectrum antibiotic, meaning that it can treat many different types of bacteria. Ceftriaxone works by breaking apart amino acids that make up the cell wall, irreparably damaging the bacteria and leading to rapid cell death.

Ceftriaxone is mainly used to treat skin, respiratory, soft tissue, urinary tract, and ear/nose/throat infections caused by bacteria such as:

• Citrobacter species
• Escherichia coli (E. coli)
• Haemophilus species
• Klebsiella pneumoniae
• Neisseria gonorrhoeae
• Proteus mirabilis
• Salmonella typhi
• Serratia marcescens
• Staphylococcus species
• Streptococcus pneumonaie
• Streptococcus pyogenes
• Treponema pallidum

These are the bacterial types that tend to be resistant to earlier-generation antibiotics.

There are some bacteria types that ceftriaxone cannot treat. These include Enterobacter species, Listeria monocytogenes, Pseudomonas aeruginosa, and Methicillin-resistant Staphylococcus aureus (MRSA). For these infections, fourth-generation cephalosporin antibiotics like cefepime may be used.

Types of Infections Treated

Although ceftriaxone and other third-generation cephalosporins are effective in treating a wide variety of bacterial infections, they tend to be reserved for harder-to-treat cases. Doing so prevents the overuse of the drug and can slow the development of ceftriaxone resistance.

Among the infections for which ceftriaxone is commonly used:

• Bacterial brain abscess
• Bacterial endocarditis (an infection of the heart)
• Bacterial meningitis (inflammation of tissues surrounding the brain and spinal cord)
• Bacterial otitis media (middle ear infection)
• Bacterial sepsis (a severe immune overreaction to infection)
• Bacterial skin infection
• Bacterial urinary tract infections
• Bone and joint infections
• Community-acquired pneumonia
• Epididymitis (inflammation of a vessel inside the testicle)
• Epiglottitis (inflammation of the windpipe)
• Gonorrhea (a bacterial sexually transmitted infection)
• Hospital-acquired bacterial infection
• Intra-abdominal infections
• Lower respiratory tract infections
• Lyme neuroborreliosis (a neurologic complication of Lyme disease)
• Pelvic inflammatory disease
• Typhoid fever

Off-Label Uses

In some cases, ceftriaxone may be used "off-label" to treat other conditions caused by a suspected bacterial infection, such as septic shock or toxic shock syndrome.

While ceftriaxone, like other antibiotics, cannot treat viral, fungal, or parasitic infections, early studies suggest it may have other therapeutic benefits. However, more data is needed to confirm its efficacy. These include:

Early studies suggest ceftriaxone might have neuroprotective properties that may aid in the treatment of neurodegenerative disorders like Alzheimer's disease, Parkinson's disease, Huntington's disease, and amyotrophic lateral sclerosis (ALS). Other studies are exploring whether ceftriaxone can aid in the treatment of alcohol and opioid addiction or help relieve chronic pain.

It is unclear if ceftriaxone can aid in the treatment of any of these conditions. Until further evidence can be found, ceftriaxone should only be used as indicated under the direction of a healthcare provider.

Before Taking

Before prescribing ceftriaxone, the practitioner will perform tests to identify which bacterium is causing the infection. These may involve a blood or urine test (such as those used to diagnose gonorrhea) or a bacteria culture (including those used to diagnose strep throat).

Other more severe infections, like sepsis or bacterial meningitis, may require antimicrobial susceptibility testing (AST) to determine how resistant a bacteria is to available antibiotic drugs.

There are different methods a lab can use, including blood, urine, sputum, stool, and spinal fluid tests that help identify the genotype (genetic makeup) of the bacterium and culture-based tests that identify the phenotype (physical makeup) of the bacterium.

These insights can help the pathologist predict with a high level of accuracy whether the bacterium is susceptible to ceftriaxone or if different antibiotics are better suited for treatment.

Precautions and Contraindications

The only absolute contraindication for ceftriaxone use is a known allergy to the antibiotic itself and any inactive ingredient in the formulation.

Having an allergy to other third-generation cephalosporins does not mean that you will be allergic to ceftriaxone. Nevertheless, ceftriaxone should be used with caution if you are. These include cephalosporin antibiotics like:

• Cefazolin
• Cefaclor
• Cefdinir
• Cefuroxime
• Cephalexin
• Cefadroxil
• cefepime
• Suprax (cefixime)
• Teflaro (ceftaroline fosamil)

Ceftriaxone should not be used in newborns with hyperbilirubinemia (high bilirubin). Doing so can cause bilirubin encephalitis, an inflammatory brain condition that can lead to hearing loss, brain damage, or death.

Ceftriaxone should never be used with intravenous calcium preparations (including Ringer's solution) in newborns younger than 28 days. Doing so can cause potentially fatal injury to the lungs and kidneys.

Ceftriaxone is generally considered safe for use during pregnancy. Even so, speak with your healthcare provider to understand the benefits and risks of treatment if you are pregnant, planning to get pregnant, or breastfeeding.

Dosage

Ceftriaxone comes either as a sterile powder that is reconstituted with a liquid or a frozen premixed solution that is thawed before use. The drug can then be injected into a large muscle or delivered intravenously into a vein. Of the two formulations:

• Ceftriaxone intramuscular injections come two strengths: 250 milligrams per milliliter (mg/mL) or 350 mg/mL.
• Ceftriaxone intravenous solution is prepared at a concentration of 100 mg/mL.

The recommended dose can vary by age and the type of infection being treated.

Adults

If your healthcare provider feels it is needed, ceftriaxone is used to treat both complicated and uncomplicated bacterial infections in adults. The recommended ceftriaxone dose for adults is between 250 mg and 2 grams per day, delivered as either a single dose or two equally divided doses given 12 hours apart. If needed, up to 4 grams can be used daily.

The dosage and duration of treatment can vary by the infection being treated. Some like gonorrhea only required a single 250-mg intramuscular injection. Others may require prolonged intravenous therapy.

Children

Ceftriaxone is generally indicated for the treatment of severe bacterial infections in babies, toddlers, and younger children.

• For serious infections other than meningitis, the recommended daily dose is calculated at 50 to 75 mg per kilogram (mg/kg) and given in two equally divided doses 12 hours apart. The total daily dose should not exceed 2 grams per day.
• For bacterial meningitis, the recommended daily dose is calculated at 100 mg/kg and given in two equally divided doses 12 hours apart. No more than 4 grams should be used daily.
• For bacterial otitis media, a single intramuscular injection calculated at 50 mg/kg should be given.

Teenagers with certain bacterial infections, such as gonorrhea or syphilis, may be treated in the same way as adults.

Modifications

Ceftriaxone is cleared from the body both by the kidneys and liver. Dosage adjustments should not be necessary in patients with impaired liver function or kidney function alone. However, in patients with both liver problems and significant renal disease, it's recommended that the ceftriaxone injection dosage not exceed 2 g daily.

Also, ceftriaxone is not removed by peritoneal dialysis or hemodialysis. In patients undergoing dialysis, no additional supplementary dosing is required following the dialysis treatment. Close clinical monitoring, however, is recommended for patients with both severe kidney and liver impairment.

How to Take and Store

Ceftriaxone treatment is delivered by a qualified health professional in a healthcare provider's office, clinic, or hospital. Intramuscular injections can also be self-administered at home after receiving instructions.

Intramuscular injections can be delivered into the buttocks, thigh, or other large muscles. Intravenous injections can either be injected directly into a vein or be infused through an intravenous (IV) line over 30 minutes or more.

Side Effects

Like all drugs, ceftriaxone may cause side effects. The common side effects of ceftriaxone are similar to those of other injected or intravenous antibiotics.

Common

Ceftriaxone will not cause symptoms in everyone but is more likely to do so at higher doses. The side effects affecting at least 1% of users include:

• Pain and redness at the injection site
• Warmth, tightness, and hardening of skin following intravenous use
• Diarrhea, ranging from mild to severe
• Rash (typically widespread with flat, red areas of skin covered with tiny bumps)
• Abnormal white blood cell counts, most commonly eosinophilia (high eosinophils) and leukopenia (low leukocytes)
• Abnormal red blood cells counts, primarily thrombocytosis (excessive platelets)

Less common side effects include headaches, dizziness, itching, fever, nausea, vomiting, vaginal inflammation (vaginitis), and thrush (candidiasis). Children can sometimes develop gallstones due to an overproduction of bile. Neurological adverse reactions include encephalopathy and seizures.

Severe

On rare occasions, ceftriaxone may cause a severe and potentially life-threatening drug reaction known as Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). Both are characterized by the rapid and widespread blistering and delamination (peeling) of skin.

SJS and TEN typically start with flu-like symptoms, including high fever, sore throat, difficulty swallowing, cough, body aches, and red, swollen eyes. Over the course of hours or days, a tender or painful rash may develop starting from the trunk and moving outward to the face and limbs. Blistering will soon occur, followed by the widespread peeling of skin in sheets.

If not treated as a medical emergency, SJS and TEN can cause massive dehydration, sepsis, shock, pneumonia, multiple organ failure, and death.

Cephalosporin antibiotics and penicillin are two of the more common drugs causes of SJS and TEN.

Warnings and Interactions

Severe cases of hemolytic anemia have been reported in people on ceftriaxone therapy. This is a form of anemia in which red blood cells are destroyed faster than they can be made. Treatment should be stopped immediately for anyone who develops anemia while on ceftriaxone and discontinued until the underlying cause is identified.

Clostridioides difficile-associated diarrhea has been reported with almost every antibacterial agent, caused when the drug alters the natural flora of the gut and allows C. difficile to proliferate. This condition can affect anyone, though you may be at higher risk if you are 65 and older, had a recent stay at a nursing home or hospital, have a weakened immune system, or were recently infected with C. difficile or had a known exposure. If diarrhea develops during ceftriaxone therapy, treatment should be stopped.

If needed, antibiotics like Flagyl (metronidazole), Dificid (fidaxomicin), and Vancomycin (oral vancomycin) can be used to resolve the C. difficile infection. On rare occasions, C. difficile-associated diarrhea can lead to pseudomembranous colitis, the potentially fatal inflammation of the large intestine.

Drug Interactions

Due to the risk of calcium–ceftriaxone precipitation in the gallbladder, ceftriaxone should not be used with any the following calcium-containing solutions in persons of any age (and avoided without exception in newborns):

• Calcium acetate
• Calcium chloride
• Calcium gluceptate
• Calcium gluconate
• Lactated Ringer's solution

There are instances when these calcium-containing solutions may be necessary, such as during pregnancy or surgery. If so, the dose of ceftriaxone can be separated from that of the calcium-containing product to minimize the risk.

Other drugs that can interact with ceftriaxone include:

• Amsacrine, a chemotherapy drug used to treat some types of lymphoma
• Aminoglycoside antibiotics, including Gentak (gentamicin) and Tobrex (tobramycin)
• Diflucan (fluconazole), an antifungal drug
• Vancocin (vancomycin), a glycopeptide antibiotic

A Word From Verywell

Ceftriaxone is an important and effective antibiotic, but one that has its limitations. It used inappropriately, it can cause more harm than good.

To reduce your risk of harm, let your healthcare provider know about any allergic reaction you have had to an antibiotic, and be sure that it is notated your electronic medical records (EMR). If you've ever had a severe reaction to ceftriaxone, penicillin, or any antibiotic drug, including SJS, TEN, or anaphylaxis, consider getting a medical ID bracelet so that medical staff are aware of this in the event of an emergency.