International Journal of Clinical Pharmacy

, Volume 33, Issue 3, pp 537–542 | Cite as

Impact of the FDA warning of potential ceftriaxone and calcium interactions on drug use policy in clinical practice

  • John S. Esterly
  • Emily Steadman
  • Marc H. ScheetzEmail author
Research Article


Objective In September 2007, the FDA issued an alert recommending that ceftriaxone and calcium-containing solutions should not be administered to any patient within 48 h of each other. Due to the widespread use of ceftriaxone, significant concern was expressed by the greater healthcare community about the warning, which the FDA eventually retracted in April of 2009. We sought to quantify the impact of the warning on healthcare institutions. Setting A survey was administered to the membership of the Society of Infectious Diseases Pharmacists to quantify perceived changes in ceftriaxone use among healthcare institutions across the United States. Method A survey of Infectious Diseases experts was conducted. Participants were queried for hospital policies/drug use statistics during two times: immediately after the FDA warning and approximately 13 months post warning (preceding the FDA retraction). Main Outcome Measure Related changes in formulary, drug-use policy, and the number of employee hours that were devoted to addressing the FDA warning were assessed. Results Ninety-four surveys representing 94 hospital systems were included in the analysis. Approximately half (n = 49, 52%) of respondent institutions enacted at least one drug-use policy change based on the warning; one institution removed ceftriaxone from a clinical protocol. Institutions’ final interpretations of the warning differed slightly from initial understanding of the warning, and there was an overall minor decrease in the perceived use of ceftriaxone. The majority of those surveyed (n = 70, 74%) estimated that their respective institutions devoted between 1 and 49 employee hours to address the warning. Conclusion Hospitals with ID pharmacists had minimal changes to ceftriaxone use after the 2007 FDA warning. Specialized pharmacists may be uniquely situated to help hospitals interpret global recommendations locally.


Ceftriaxone Calcium Incompatible Interaction Neonate Precipitation Pulmonary embolism Renal failure Survey 



We would like to thank Melinda Neuhauser for her input on the design of this study, and her help coordinating SIDP membership participation. We also thank Debbie Guagliardo for her assistance in survey design.


This study was funded in part by the Society of Infectious Diseases Pharmacists: Infectious Diseases Pharmacotherapy Residency Award Program and by a Chicago College of Pharmacy, Student Leadership and Research Award, Midwestern University, Downers Grove, IL.

Conflicts of interest


Supplementary material

11096_2011_9503_MOESM1_ESM.doc (48 kb)
Supplementary material 1 (DOC 48 kb)


  1. 1.
  2. 2.
    Tunkel AR, Hartman BJ, Kaplan SL, Kaufman BA, Roos KL, Scheld WM, et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis. 2004;39:1267–84.PubMedCrossRefGoogle Scholar
  3. 3.
    Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(Suppl 2):S27–72.PubMedCrossRefGoogle Scholar
  4. 4.
  5. 5.
  6. 6.
    Gin AS, Wheaton H, Dalton B. Clinical pharmaceutics and calcium-ceftriaxone. Ann Pharmacother. 2008;42:450–1.PubMedCrossRefGoogle Scholar
  7. 7.
    Puzovic M, Hardy G. Comment: clinical pharmaceutics and calcium ceftriaxone. Ann Pharmacother. 2008;42:1914.PubMedGoogle Scholar
  8. 8.
  9. 9.
    The American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys. 5th ed. Lenexa, Kansas: AAPOR; 2008.Google Scholar
  10. 10.
    Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines. MMWR Recomm Rep. 2010;59:1–110.PubMedGoogle Scholar
  11. 11.
    World Health Organization. Management of a child with serious infection or severe malnutrition. Guidelines for care at first referral level in developing countries. 2000. Accessed 18 Jan 2011.
  12. 12.
    Steadman E, Raisch DW, Bennett CL, Esterly JS, Becker T, Postelnick M, et al. Evaluation of a potential clinical interaction between ceftriaxone and calcium. Antimicrob Agents Chemother. 2010;54:1534–40.Google Scholar
  13. 13.
    Rapp RP, Kuhn R. Clinical pharmaceutics and calcium ceftriaxone. Ann Pharmacother. 2007;41:2072.PubMedCrossRefGoogle Scholar
  14. 14.
    Monte SV, Prescott WA, Johnson KK, Kuhman L, Paladino JA. Safety of ceftriaxone sodium at extremes of age. Expert Opin Drug Saf. 2008;7:515–23.PubMedCrossRefGoogle Scholar
  15. 15.
    Morrell M, Cannella C, Simpson S. 2008. Abstract 48th annual meeting of ICAAC/IDSA. Abstr. A-1876. Retrospective analysis of concomitant ceftriaxone and intravenous calcium administration at a University Hospital.Google Scholar
  16. 16.
    Pope SD, Dellit TH, Owens RC, Hooton TM. Results of survey on implementation of Infectious Diseases Society of America and Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Infect Control Hosp Epidemiol. 2009;30:97–8.PubMedCrossRefGoogle Scholar
  17. 17.
    World Health Organization. Overcoming antimicrobial resistance. Geneva: WHO; 2000.Google Scholar
  18. 18.
    Conclusions of the European Union Conference on ‘The microbial threat’, 9–10 Sept 1998. The Copenhagen recommendation. Ministry of Health Ministry of Food, Agriculture and Fisheries. Vet Res. 1999;30:119–22.Google Scholar
  19. 19.
    Marr JJ, Moffet HL, Kunin CM. Guidelines for improving the use of antimicrobial agents in hospitals: a statement by the Infectious Diseases Society of America. J Infect Dis. 1988;157:869–76.PubMedCrossRefGoogle Scholar
  20. 20.
    MacKenzie FM, Struelens MJ, Towner KJ, Gould IM. Report of the consensus conference on antibiotic Resistance; prevention and control (ARPAC). Clin Microbiol Infect. 2005;11:938–54.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • John S. Esterly
    • 1
    • 2
  • Emily Steadman
    • 3
  • Marc H. Scheetz
    • 2
    • 4
    Email author
  1. 1.Department of Pharmacy PracticeChicago State University College of PharmacyChicagoUSA
  2. 2.Department of PharmacyNorthwestern Memorial HospitalChicagoUSA
  3. 3.Midwestern University Chicago College of PharmacyDowners GroveUSA
  4. 4.Department of Pharmacy PracticeMidwestern University Chicago College of PharmacyDowners GroveUSA

Personalised recommendations