Editors:Elham Reshid and Hailemariam Shimelis
The Food and Drug Administration (FDA) after it received case reports of neonatal deaths attributable to a drug interaction between calcium-containing infusion products (such as Ringer’s solution, lactated Ringer’s solution, and parenteral nutrition containing calcium) and ceftriaxone (Rocephin and generics) has alerted health care professionals for the warning labels of ceftriaxone.
Depending on the concentrations used calcium containing solutions may be incompatible with ceftriaxone. Some of the calcium containing IV compounds that have been reported to interact include calcium acetate, calcium chloride, Ringers [lactated] solution, calcum gluceptate. This incompatibility arises when these compounds are mixed or used concomitantly, even when administered via different infusion lines at different sites they might bind together in the blood and to form precipitates. Several neonatal deaths have been attributed to formation of these precipitates in the kidneys or lungs.
Two in vitro studies which evaluated the compatibility of ceftriaxone and calcium containing solutions in neonatal and adult plasma found the ceftriaxone-calcium precipitation was suspected in neonatal plasma at calcium concentrations above 16 mg/dL (4 mM) and in adult plasma at calcium concentrations above 24 mg/dL (6 mM). Based on these studies, the FDA recommends:
- Use of ceftriaxone and calcium products is contraindi-cated only in neonates up to 28 days old, and is not con-traindicated in patients older than 28 days.
- Ceftriaxone shouldn’t be given to neonates (infants 28 days old or younger) if they are receiving or are expected to receive IV products containing calcium.
- Infants older than 28 days may receive ceftriaxone and a calcium-containing IV solution in sequence if the IV line is flushed thoroughly between the two infusions with a fluid compatible with both.
- No patient of any age should receive simultaneous ad-ministration of ceftriaxone and any IV solution containing calcium via an IV tubing Y site.
- Ceftriaxone shouldn’t be reconstituted, diluted or mixed with any calcium-containing product including Lactated Ringer’s, Ringer’s, Hartmann’s solution, or parenteral nutri-tion.
- The interaction occurs only when both products are administered intravenously—no drug interactions have been noted between IV ceftriaxone and oral calcium-containing products, or between intramuscular ceftriaxone and either IV or oral calcium-containing products.
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Diane S. Aschenbrenner. .American Journal of Nursing.Vol. 109(8)August 2009. p27.
John S. Bradley et al. Intravenous Ceftriaxone and Calcium in the Neonate: Assessing the Risk for Cardiopulmonary Adverse Events. PEDIATRICS Vol. 123(4) April 2009. pe610, e611.
Ceftriaxone Injection (Rocephin) – Interaction with Calcium Products and New Contraindication in Hyperbilirubinemic Neonates – Updated. http://pharmacyservices.utah.edu/alerts/243.html
Drug Interactions from Online databases.Micromedex Drug Interaction Checker.