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Ceftriaxone - Ringer Lactate's Deadly Interaction



Administration of different Intravenous (IV) medications through the same IV cannula is a common act found among health professionals in most settings. This is usually done without a critical look at the effect the drugs may have on each other.

For example, simultaneous administration of IV Ciprofloxacin and IV Metronidazole is very common in the treatments of severe gastrointestinal infections whereas simultaneous administration of an intravenous infusions such as Ringers Lactate after other IV medications is more like a routine.

The Big Question is, " Could any of these combinations have any clinically fatal interactions?"

Today, we will look at one of such instances... Ceftriaxone -Calcium Interaction

Ceftriaxone for injection, a broad spectrum antibiotic, has been found to precipitate (form crystals) when combined with calcium containing products such as Ringer's Lactate. Such combination increases the risk of lethal precipitates forming in the lungs and kidneys, especially in Neonates, and eventually resulting in death. Roche, the manufacturer of ceftriaxone, said it had received reports of five neonatal deaths related to the interaction between ceftriaxone and calcium-containing products.

This literally suggests that, combining Ceftriaxone and Ringer's Lactate  or other intravenous calcium containing products can have a fatal consequences on your patients.

CLINICAL RECOMMENDATIONS

1. Do not mix or reconstitute Ceftriaxone with Calcium- Containing infusions such as Ringer's Lactate.

2. It's best to avoid sequential administration of Ceftriaxone and calcium containing infusions such as Ringer's Lactate. However in unlikely situations, the IV line must be thoroughly flushed in between infusions with compatible fluid before sequential administration can be done. One may also consider 5:4:1, an IV infusion with a similar composition as R/L with the exception of the absence of calcium.

3. Ceftriaxone must not be administered simultaneously with intravenous Calcium containing solutions through Y-site.

4. Ceftriaxone and Calcium Combination is CONTRAINDICATED in NEONATES (28days or below). Do NOT use or serve Ceftriaxone in NEONATES if they are receiving ( or are expected to receive) any calcium containing intravenous fluid.

REFERENCES
Fasipe OJ,  Akinwumi  AA,  Oluseyi  AA, Oluwole  BA,  Okaka  EI.  Prevalence  and  pattern  of  potential  drug-drug interactions  among  chronic  kidney  disease  patients  in  south-western  Nigeria. Niger Postgrad Med J 2017;24:88-92.

https://www.medpagetoday.com/pediatrics/generalpediatrics/6661

https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/ucm084263.htm

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