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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Drugs>Antimicrobial Agents>
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Ceftriaxone

Paul A. Pham Pharm.D. and John G. Bartlett M.D.
09-24-2010

Zambia Specific Information

  • Available formulation in Zambia: Powder for injection: 250 mg, 1 g (as sodium salt) vial.
  • Good activity against S. pneumoniae, E.coli, Klebsiella, Enterobacter, Serratia and indole-positive Proteus spp.
  • Complicated UTI: ceftriaxone 1 gm IV once daily x 14 days in pts unable to tolerate aminoglycosides.
  • Community acquired pneumonia (CAP): ceftriaxone 1 gm IV once daily. If severe CAP, add erythromycin 500 mg PO q6h. .
  • Spontaneous bacterial peritonitis: ceftriaxone 1 gm IV once daily
  • GC arthritis: ceftriaxone 1 gm IV once daily
  • Empiric treatment of community acquired meningitis: ceftriaxone 2gm IV q12h x 10d (plus dexamethasone 10 mg IV 6h x 4 days.)
  • Meningococcal meningitis prophylaxis in children: 125 mg IM x1
  • Brain abscess: ceftriaxone 2gm IV q12h (plus metronidazole)
  • Complicated bacterial sinusitis: ceftriaxone 2gm IV q12h
  • Mastoiditis: ceftriaxone 2gm IV q12h
  • Spontaneous endophthalmitis: ceftriaxone 2gm IV once daily x 7 days
  • Typhoid fever (S. typhi or S. paratyphi): ceftriaxone 1gm q12h
  • STDs in pregnant women: ceftriaxone 125 mg IM x1 PLUS erythromycin 500 mg q6h x 7d PLUS metronidazole 400 mg twice daily x 7d.
Zambia Information Author: Paul A. Pham Pharm.D.

INDICATIONS

FDA

  • Lower respiratory tract infections
  • Acute otitis media
  • Skin and skin-structure infections
  • Urinary tract infections
  • Uncomplicated gonorrhea
  • Pelvic inflammatory disease
  • Septicemia
  • Bone and joint infections
  • Intra-abdominal infections
  • Meningitis and surgical prophylaxis
NON-FDA APPROVED USES

  • Brain abscess (with metronidazole)
  • Appendicitis (with metronidazole)
  • Peritonitis:spontaneous bacterial & secondary
  • Endocarditis
  • Diabetic foot infections (with metronidazole or clindamycin)
  • Lyme disease: and neuroborreliosis
  • Meningococcal meningitis prophylaxis: 125 mg x1 (<15 yrs); 250 mg x1 (>15 yrs). Due to reports of fluoroquinolone resistance, rifampin, ceftriaxone, and azithromycin is recommended in selected counties in North Dakota and Minnesota (MMWR 2008; 57:173-175).
  • Neurosyphilis
  • Disseminated GC

FORMS

brand 
name
 
generic 
Mfg 
brand 
forms
 
cost* 
RocephinCeftriaxone Roche and generic manufacturers IV
vial
250mg
$2.41
      IV
vial
500mg
$5.28
      IV
vial
1g
$7.68
      IV
vial
2g
$17.07
      IV
vial
10g
$42.58
      IV
bag
1g/50mL
$6.995
      IV
bag
2g/50mL
$14.24

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

Use for meningitis treatment.

  • Most infections: 1-2Gm IM or IV q24h (up to 4 gm max per day).
  • Meningitis: 2 gm IV q12h.
  • Uncomplicated GC: 250 mg IM x 1 .
  • Surgical prophylaxis: 1 gm IV within 1 hr before surgery .
  • Obese patients: consider 2 gm IV q12h.

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

Usual dose.

DOSING FOR GLOMERULAR FILTRATION OF 10-50

Usual dose.

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

Usual dose.

DOSING IN HEMODIALYSIS

1-2Gm IV q24h (No extra doses needed post dialysis).

DOSING IN PERITONEAL DIALYSIS

Usual regimen.

DOSING IN HEMOFILTRATION

Usual dose.

ADVERSE DRUG REACTIONS

GENERAL

  • Generally well tolerated
OCCASIONAL

  • Pseudocholelithiasis with sludge in gallbladder by ultrasound
  • Minimal phlebitis at infusion sites
  • Allergic reactions (eosinophilia):cross-allergy to PCN lower than 1st generation cephalosporins
  • Diarrhea and C.difficile colitis
  • Positive Coombs' test
RARE

  • CNS: convulsions (high dose with renal failure); confusion, disorientation, and hallucinations
  • Drug fever
  • Neutropenia and thrombocytopenia
  • Hepatitis
  • Anaphylaxis reaction
  • Hemolytic anemia
  • Cholecystitis
  • Interstitial nephritis
  • Calcium-ceftriaxone precipitates in the lungs and kidneys in both term and premature neonates (with calcium solution co-administration). Avoid co-administration in pts <28 days of age.

DRUG INTERACTIONS

  • Calcium containing solutions: ceftriaxone should not be mixed or administered simultaneously or within 48-hours with calcium-containing solutions or products, even via different infusion lines. Consider using cefotaxime with calcium-containing solution co-administration.
  • Probenecid: increase in cephalosporin serum concentration due to inhibition of tubular secretion by probenecid.
  • Warfarin: anticoagulation effect may be enhanced.

SPECTRUM

Detailed Spectrum of Activity

RESISTANCE

  • MIC breakpoint for Enterobacteriaceae : < 1 mcg/mL (sensitive); 2 mcg/mL (intermediate); > 4 mcg/mL (resistant).
  • MIC breakpoint for S. aureus: < 8 mcg/mL (sensitive); 16-32 mcg/mL (intermediate); > 64 mcg/mL (resistant).
  • MIC breakpoint for S. viridans: <1 mcg/mL (sensitive); 2 mcg/mL (intermediate); > 4 mcg/mL (resistant).
  • MIC breakpoint for S. pneumoniae:< 0.5 mcg/mL (meningitis) and < 1 mcg/mL (non-meningitis).
  • MIC breakpoint for beta-hemolytic Streptococcus spp.: < 0.5 mcg/mL.

PHARMACOLOGY

Pharmacology

COMMENTS

Parenteral 3rd generation cephalosporin w/ convenient once a day dosing often used for outpatient IV therapy. Cefotaxime is clinically equivalent, but given q6h. Excreted via biliary and urinary tracts. May cause biliary sludging and cholecystitis. Cefotaxime and ceftriaxone are the preferred cephalosporins for serious pneumococcal infections (meningitis and pneumonia), but 1.6 to 5+% of strains are resistant.

REFERENCES

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