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Uses

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). The single-dose IM ceftriaxone regimen has some practical advantages (ensures compliance, can be used in patients with nausea and vomiting), 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.

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).

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.

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)†. 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). 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.

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).

Not usually recommended for treatment of endocarditis caused by Enterococcus (e.g., E. faecalis, E. faecium). 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. 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.

Not indicated for treatment of staphylococcal endocarditis.

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

Intra-abdominal Infections

Treatment of intra-abdominal infections caused by susceptible E. coli, K. pneumoniae, Bacteroides fragilis, Clostridium (not C. difficile), or Peptostreptococcus.

Treatment of mixed aerobic-anaerobic intra-abdominal infections; should not be used alone when B. fragilis may be present.

Meningitis and Other CNS Infections

Treatment of meningitis caused by susceptible H. influenzae, N. meningitidis, or S. pneumoniae in neonates, children, or adults. A drug of choice for meningitis caused by penicillin-resistant S. pneumoniae, but consider that S. pneumoniae with reduced susceptibility to cephalosporins have been reported with increasing frequency and susceptibility can no longer be assumed.

Treatment of meningitis and other CNS infections caused by susceptible Enterobacteriaceae† (e.g., E. coli, Klebsiella).

Should not be used alone for empiric treatment of meningitis when Listeria monocytogenes, enterococci, staphylococci, or Pseudomonas aeruginosa may be involved.

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).

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.

Septicemia

Treatment of septicemia caused by S. aureus, S. pneumoniae, E. coli, H. influenzae, or K. pneumoniae.

A parenteral cephalosporin (i.e., cefepime, cefotaxime, ceftriaxone) given in conjunction with an aminoglycoside (amikacin, gentamicin, tobramycin) is one of several preferred regimens for initial treatment of life-threatening sepsis in adults.

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.

Urinary Tract Infections (UTIs)

Treatment of complicated and uncomplicated UTIs caused by E. coli, K. pneumoniae, M. morganii, P. mirabilis, or P. vulgaris.

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.

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.

Actinomycosis

Has been used for treatment of infections caused by Actinomyces†. 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.

Bartonella Infections

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

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. 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. Anti-infectives also are indicated in patients with B. henselae infections who develop bacillary angiomatosis, neuroretinitis, or Parinaud’s oculoglandular syndrome.

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.

Capnocytophaga Infections

Treatment of infections caused by Capnocytophaga.

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

Chancroid

Treatment of chancroid† (genital ulcers caused by H. ducreyi).

CDC and others 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. CDC recommends that the single-dose ceftriaxone regimen be used in HIV patients only if follow-up can be ensured.

Gonorrhea and Associated Infections

Treatment of uncomplicated cervical, urethral, or rectal infections caused by susceptible N. gonorrhoeae. Recommended by CDC, AAP, and others as a drug of choice for uncomplicated gonorrhea in adults, adolescents, and children.

Treatment of pharyngeal infections caused by N. gonorrhoeae. Recommended by CDC, AAP, and others as the regimen of choice for pharyngeal gonorrhea in adults, adolescents, and children.

Initial treatment of disseminated gonococcal infections†. 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.

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). Drug of choice for empiric treatment.

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

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

Treatment of ophthalmia neonatorum† caused by N. gonorrhoeae. 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).

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

Lyme Disease

Treatment of early neurologic Lyme disease† with acute neurologic manifestations such as meningitis or radiculopathy. IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G. 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, a parenteral regimen usually is recommended when there are acute neurologic manifestations.

Treatment of Lyme carditis† when a parenteral regimen is indicated. IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G. 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.

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

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

Neisseria meningitidis Infections

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

Elimination of nasopharyngeal carriage of N. meningitidis†. CDC and AAP consider rifampin, ceftriaxone, or ciprofloxacin the drugs of choice for such carriers.

Postexposure prophylaxis to prevent meningococcal disease in household or other close contacts of patients with invasive meningococcal disease†.

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

Pelvic Inflammatory Disease (PID)

Treatment of PID caused by N. gonorrhoeae.

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

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).

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.

Pseudomonas aeruginosa Infections

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

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, ceftriaxone generally should not be used alone in the treatment of any infection where Ps. aeruginosa may be present.

Relapsing Fever

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

Shigella Infections

Treatment of shigellosis† in children caused by susceptible Shigella sonnei or S. flexneri.

Anti-infectives generally indicated in addition to fluid and electrolyte replacement for severe shigellosis. 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.

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.

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

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. 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.

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. Use of ceftriaxone in HIV-infected individuals with syphilis has not been adequately studied and such therapy should be undertaken with caution.

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

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.

Treatment of infections caused by nontyphi Salmonella, including bacteremia or osteomyelitis caused by S. typhimurium.

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.

Whipple's Disease

Treatment of Whipple’s disease†, a progressive systemic infection caused by Tropheryma whippelii.

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.

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.

Perioperative Prophylaxis

Perioperative prophylaxis to reduce the incidence of infection in patients undergoing contaminated or potentially contaminated surgical procedures, including cholecystectomy, intra-abdominal surgery, or vaginal or abdominal hysterectomy, and in those undergoing clean surgical procedures in which the development of infection at the surgical site would represent a serious risk, including coronary artery bypass, open heart surgery, thoracic surgery, or orthopedic surgery. The drug also has been used perioperatively in patients undergoing transurethral resection of the prostate†.

Other cephalosporins or cephamycins (cefazolin, cefuroxime, cefotetan, cefoxitin) are the preferred drugs for perioperative prophylaxis. 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.

Prophylaxis in Sexual Assault Victims

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

Prophylaxis Following Bite Wounds

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