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Statement Regarding Ceftriaxone Prescribing
Administration of Ceftriaxone 80mk/kg over 10 minutes
In order to facilitate ambulating children on IV ceftriaxone, 80mg/kg ceftriaxone (generic) is safe to give over 10 minutes by slow intravenous injection.

Although most hospitals currently use 30 minute infusions, there is lack of clarity from the manufacturers regarding speed of administration (1). Common practice in other countries, including America and Australia, is to give it more quickly and the European-wide medicines authorisation states that giving it over 10 minutes is acceptable.

Ceftriaxone 80mg/kg administration over 10 minutes was evaluated at Southampton Children’s Hospital). Of the 213 doses (159 children) administered, 193 (90.6%) were successfully administered over 10 minutes. 22 (12.2%) doses were associated with side effects, all of which might be expected according to the summary of product characteristics.1 Twenty-two (10.3%) were associated with pain at the infusion site and 4 (1.7%) with nausea and vomiting. Of the 22 children experiencing pain at the infusion site, 19 patients (median, 5 years; IQR, 2.5–6 years) had their infusion slowed to between 15 and 30 minutes, with resolution of their pain. No clinically significant abnormal observations (temperature/heart rate/respiratory rate/blood pressure) were observed beyond those present at the start of infusions and no drug side effects required any other clinical intervention apart from slowing of the infusion. Administration over 10 minutes was preferred by the majority of parents and young people because it meant that they spend less time having their medications (2). 

Furthermore, in a five-and-a-half-year period between 1st October 2018 and 24th April 2024, ceftriaxone (>50mg/kg) administration over 10 minutes continued to be evaluated at Southampton Children’s Hospital. Of the 1056 doses started as a 10-minute infusion, 1002 (94.9%) were successfully administered over 10 minutes.
Of those who completed the rapid infusion (n=1002), 25 (2.5%) doses had associated with manageable side effects. Eighteen (1.8%) were associated with mild pain at the infusion site, five (0.5%) with nausea and/or vomiting (although 3 of these patients had symptoms pre infusion), one (0.1%) had an episode of diarrhea post infusion and one (0.1%) had dizziness which escalated from mild pre infusion to moderate during the infusion. All side effects which might be expected according to the summary of product characteristics.
A further 54 doses (5.1%) were started as a 10-minute infusion but were discontinued due to unmanageable side effects. Fifty (4.7%) experienced pain at the infusion site that was not tolerated, two (0.2%) had pain at the infusion site plus nausea/vomiting, one (0.1%) had pain at the infusion site and developed mild abdominal discomfort, and one (0.1%) developed a mild headache followed by a vomit. All side effects which might be expected according to the summary of product characteristics. All 54 had their infusion slowed to between 15 and 30 minutes, with complete resolution of symptoms in 51 of the fifty-four children.
No clinically significant abnormal observations (temperature/heart rate/respiratory rate/blood pressure) were observed beyond those present at the start of infusion and no drug side effects required any other clinical intervention apart from slowing of the infusion in any patient
The administration of ceftriaxone as a 10 minute infusion has been approved by both the Southampton Children’s Hospital Governance group and the University Hospital Southampton (UHS) Medicines committees.

Children receiving intravenous antibiotics as part of the UHS paediatric intravenous antibiotic service, including 10-minute infusions of ceftriaxone, will routinely have clinical observations and any side effects recorded on a proforma. Any adverse events will be reported back to the Wessex paediatric infectious diseases network.
Timing of Second Dose of Ceftriaxone
The EU FP7 funded GriP Neonatal and Paediatric Prescribing Book was published in 2019. It is a handbook on Neonatal and Paediatric Prescribing that complements the BNFc, which facilitates translation of essential pharmacological principles into good prescribing practice. Chapters were peer reviewed, and the book has been endorsed by GriP, RCPCH, NPPH and BNFc.

The Prescribing in infection (i) antibacterials chapter states:
  • If a first dose of ceftriaxone has been given overnight it can be moved to day time by giving the second dose early, any time from 12 hours following the initial dose
  • A regimen of 80mg/kg with the first two doses being given at a 12 hourly interval was previously widely and effectively used for paediatric meningococcal sepsis without adverse effects
 
In addition:
  • In patients of any age ceftriaxone must not be mixed or administered simultaneously with any calcium-containing IV solutions (such as TPN or Hartmann’s), even via different infusion lines or at different infusion sites
  • In patients older than 28 days of age ceftriaxone and calcium-containing solutions may be administered sequentially one after another through a different IV site or through the same IV site if thoroughly flushed with normal saline.
Dose Banding
​Dose banding can facilitate the use of pre-filled syringes. In addition, dose-banding can reduce the risk of administration errors.3 If a ceftriaxone dose of 80mg/kg is being prescribed, the following dose bands can be used:
 
  • 3 - 4kg = 300mg
  • > 4 - 5kg = 400mg
  • > 5 - 6kg = 500mg
  • > 6 - 8kg = 600mg
  • > 8 - 10kg = 800mg
  • >10 - 13kg = 1000mg
  • >13 - 17kg = 1300mg
  • >17 - 20kg = 1500mg
  • >20 - 25kg = 2000mg
  • >25 - 30kg = 2500mg
  • >30 - 40kg = 3000mg
  • >40kg = 4000mg
References​
1. Summary of product characteristics. http://mri.cts- mrp.eu/download/NL_H_1622_003_FinalSPC.pdf (accessed 23/11/2017)
2. Patel S, Green H, Gray J, Rutter M, Bevan A, Hand K, Jones CE, Faust SN. Evaluating Ceftriaxone 80 mg/kg Administration by Rapid Intravenous Infusion-A Clinical Service Evaluation. Pediatr Infect Dis J. 2021 Feb 1;40(2):128-129. doi: 10.1097/INF.0000000000002923. PMID: 33165272.
3. Al-Turkait A, Khan F. Can dose-banding help to reduce prescribing errors in a paediatric 
Document Version: 
2.0

Lead Authors: 
Sanjay Patel
​Saul Faust
Approving Network:
Wessex Infectious Disease Network

Date of Approval: 
June 2021
Review Due:
June 2027