Authors
Harleen Chohan, BSc, PharmD (biography, no disclosures), Jenny Hong, PharmD (biography, no disclosures), SungEun Michelle Kim (biography, no disclosures), Victor Leung, MD, FRCPC (biography and disclosures) and Colin Lee, BSc (Pharm), PharmD, MSc (Pharm) (biography and disclosures)
Victor Leung’s disclosures: Has received financial payments from Pfizer, GSK, Merck, Paladin, bioMerieux and Moderna. There is no relationship to the contents of this article. Mitigating potential bias: Only published trial data is presented. Recommendations are consistent with published guidelines. Recommendations are consistent with current practice patterns. Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements.
Colin Lee’s disclosures: I have received an award from the Providence Health Care research challenge competition. This funding did not influence the content of the article.
What we did before
Cephalosporins are a group of broad-spectrum, semi-synthetic beta-lactam antibiotics that are commonly used in practice. Parenteral cephalosporin antibiotics, such as ceftriaxone, are frequently used to treat a variety of infections, including pneumonia, urinary tract infections (UTIs) and skin and soft tissue infections (SSTIs) in hospitals. The usual recommended dosing regimen for ceftriaxone (CTX) for most infections is 1-2 g IV every 24 hours, but clinicians tend to opt for the 2 g dose.
What changed our practice
To evaluate the differences between the 1 g and 2 g IV every-24-hour dosing regimens of CTX, we reviewed the existing literature to assess their safety and efficacy. We also conducted a retrospective chart review of CTX prescribing patterns at St. Paul’s Hospital, focusing on its use in community-acquired pneumonia, UTIs and SSTIs.
Current evidence shows no difference in the efficacy or safety between the two CTX dosing regimens.¹⁻³ Hasegawa et al.¹ conducted a prospective, propensity-matched study involving 350 patients with non-invasive or community-acquired pneumonia. They reported no statistically significant difference in clinical cure rates between patients receiving CTX 1 g IV every 24 hours (94.6%) and those receiving 2 g IV every 24 hours (93.1%). In a randomized controlled trial, Segev et al.² evaluated clinical outcomes in 222 patients with moderate to severe community-acquired infections—including pneumonia, UTIs, and SSTIs—treated with either CTX 1 g or 2 g IV every 24 hours. The study found no significant differences in clinical cure (91% versus 86%), clinical failure (3% versus 8%) or relapse rates (3% versus 3%).
To further elucidate the safety, efficacy and cost-effectiveness of CTX 1 g IV every 24 hours versus 2 g IV every 24 hours for the treatment of non-invasive, community-acquired infections, we reviewed 532 charts from 15 November 2019 to 30 April 2023. Our inclusion criteria were: patients older than 18 years old and admitted for pneumonia, UTIs or non-abscess SSTIs. We excluded patients with complex or invasive infections, hospital-acquired infections, critical care admissions, or infections in transplant recipients. The primary outcome was a composite measure that included clinical failure, readmission due to reinfection within 30 days, documented therapy failure, switching of antibiotics due to failure and 30-day mortality.
We evaluated 47 patients who received CTX 1 g IV every 24 hours and 100 patients who received CTX 2 g IV every 24 hours. There was no statistically significant difference in the primary outcome between the two groups (31.9% versus 32%, P = 1.00). Regarding adverse events, we found no significant differences in the incidence of Clostridioides difficile infections (2.1% versus 3%, P = 1.00) or elevations in cholestatic liver enzymes (2.1% versus 3%, P = 1.00).
In terms of cost, each batched bag of CTX 2 g costs $3.16, while CTX 1 g costs $1.58. At our study site, switching 30% of the CTX 2 g batched bags to CTX 1 g would yield estimated cost savings of $14,295.84. If 80% of the bags were switched, the projected savings would increase to $38,123.82.
Our study has several limitations. First, it was conducted at a single center, and because our site had not yet widely adopted the CTX 1 g IV every-24-hours dosing regimen, the sample size for that group was relatively small. Additionally, the retrospective design required reliance on clinician documentation to assess outcomes. To address this, we applied objective assessment criteria and implemented rigorous, conservative thresholds, which likely underestimated the efficacy differences between the two groups. Despite these limitations, our findings align with those of previous studies by Hasegawa et al.¹ and Segev et al.²
What we do now
In alignment with the recommendations from the BC Provincial Antimicrobial Clinical Expert Committee (PACE),⁴ we now recommend using CTX 1 g IV every 24 hours as the initial dosing regimen for treating mild to moderate community-acquired pneumonia, urinary tract infections and skin and soft tissue infections in non-critically ill patients.⁵
Table 1. Suggested ceftriaxone dosing for community acquired infections
| Non-critically ill patients | Critically ill patients | |
| Community-acquired pneumonia | Ceftriaxone 1 g IV every 24 hours* (mild-moderate CAP, CRB-65 score 1-2) | Ceftriaxone 2 g IV every 24 hours and Azithromycin or Doxycycline (for severe CAP, score CRB-65 3-4) |
| Community-acquired urinary tract infections | Ceftriaxone 1 g IV every 24 hours* | Ceftriaxone 2 g IV every 24 hours |
| Skin and soft tissue infections | Ceftriaxone 1 g IV every 24 hours* | Ceftriaxone 2 g IV every 24 hours |
*Consider Ceftriaxone 2 g IV daily for patients with obesity (greater than 100 kg) per PACE Committee recommendations.4
Resources
- ASPIRES Smart Prescribing. Pneumonia (CAP, HAP, Aspiration) Treatment Recommendations
- BC Provincial Antimicrobial Clinical Expert (PACE) Committee. Ceftriaxone – Adult Dosing Recommendations
References
- Hasegawa S, Sada R, Yaegashi M, Morimoto K, Mori T; Adult Pneumonia Study Group-Japan. 1g versus 2g daily intravenous ceftriaxone in the treatment of community onset pneumonia – a propensity score analysis of data from a Japanese multicenter registry. BMC Infect Dis. 2019;19(1):1079. doi:10.1186/s12879-019-4552-8 (View)
- Segev S, Raz R, Rubinstein E, et al. Double-blind randomized study of 1g versus 2g intravenous ceftriaxone daily in the therapy of community acquired infections. Eur J Clin Microbiol Infect Dis. 1995;14(10):851–855. doi:10.1007/BF01691490 (View with UBC)
- Telles JP, Cieslinski J, Gasparetto J, Tuon FF. Efficacy of ceftriaxone 1g daily versus 2g daily for the treatment of community-acquired pneumonia: a systematic review with meta-analysis. Expert Rev Anti Infec Ther. 2019;17(7):501–510. doi:10.1080/14787210.2019.1627872 (View with UBC)
- Provincial Antimicrobial Clinical Expert group. Ceftriaxone – adult dosing recommendations. BC Centre for Disease Control. Updated July 9, 2025. Accessed July 30, 2025. (View PDF)
- ASPIRES Smart Prescribing. Pneumonia (CAP, HAP, aspiration) treatment recommendations. Vancouver Coastal Health. Updated November 13, 2024. Accessed July 30, 2025. (View PDF)
Vote
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Is there a recommended time frame for each of these infections?
I attended the TI lecture on length of tx using oral abx which dispelled some myths regarding longer lengths of tx being better than shorter ones.
Response to Maryanne Roy:
Thank you for your comment and for sharing an excellent resource with us. The dose reduction for ceftriaxone does not impact duration of therapy. For CAP, typical therapy is 5 days but discontinuation of antibiotics after 3 days can be considered if rapid resolution of symptoms (there is a specific criteria), following the RCT evidence presented by Dinh et al. (Discontinuing β-lactam treatment after 3 days for patients with community-acquired pneumonia in non-critical care wards (PTC): a double-blind, randomised, placebo-controlled, non-inferiority trial – PubMed). For more information on the criteria for rapid resolution of symptoms and clinical stability, please refer to our Providence Health Care First line App that provides clinicians guidance with duration of therapies. For uncomplicated UTIs, 3-5 days is usually recommended and for cellulitis, 5-7 days. The Therapeutics Initiative webinar – Antimicrobial Durations in Practice – by Dr. Davie Wong (Therapeutics Initiative | Antimicrobial Durations in Practice – A Product of Magical Thinking in Medicine) delves into the literature through which these recommendations were crafted and we would invite other interested readers to engage with this material.
I think this is where antibiotic stewardship starts eating its tail here. The financial benefits are absolutely miniscule (if you take into account the cost of the stewardship teams’ intervention – this is a money losing intervention), whereas there are so many more bigger fish to fry of antibiotic use that needs to be addressed (overly broad therapy, shorter duration, PO abx use) which are way more financially cost effective and beneficial in terms of patient outcomes. – this type of intervention seems like “rearranging deck chairs on the titanic” in terms of scale.
Your study is way too small to draw any meaningful conclusions, and doesn’t address key concerns about why 2g has historically been used. Given that many patients live with obesity, concerns around patient weight need to be taken into account (https://pmc.ncbi.nlm.nih.gov/articles/PMC7563366/) and while not particularly an inpatient problem, 2g has been used for outpatient SSTI where there may be a contraindication with CFZ + probenecid for non-purulent SSTI for better MSSA activity (linkinghub.elsevier.com/retrieve/pii/S0924857922000279).
Agree for smaller, older patients treating a suspected urinary source infection 1 gram is certainly sufficient, but a blanket statement about 1 vs 2 g seems way too simplistic.
Response to Anonymous:
Thank you for your comments and this exciting opportunity for continued dialogue. We do agree that our retrospective chart review is limited in numbers, however, it is consistent with larger bodies of data available in this field which we have tried to highlight in our article. Our findings align with current PACE recommendations in this field and clinically align with eastern provinces who have been using 1g dosing historically. The main purpose of our study was to determine our current dosing practices in our hospitals. Your point regarding patient size particularly highlights the difficulty in teasing out the effect of dosing through retrospective studies given that obesity on its own can be a risk factor for infection and poor outcomes. The dose reduction by 50% may not be a high dollar amount, but if amplified, has an important role in health care sustainability. We recognize value based health care interventions and do not intend for this to be a resource intense antimicrobial stewardship intervention, but rather we hope to raise awareness of dosing as a concept for consideration to prescribers.