Cefuroxime is a semisynthetic, second generation cephalosporin antibiotic.1, 3
Cefuroxime axetil is used orally for the treatment of mild to moderate respiratory tract infections (i.e., acute maxillary sinusitis, acute bacterial exacerbations of chronic bronchitis) caused by susceptible bacteria;79, 82, 92, 93, 101, 103, 145, 153, 164, 166 acute bacterial otitis media;79, 82, 88, 89, 102, 110, 143, 145, 184 mild to moderate pharyngitis and tonsillitis caused by Streptococcus pyogenes (group A β-hemolytic streptococci);79, 90, 91, 145, 175 uncomplicated skin and skin structure infections caused by Staphylococcus aureus (including β-lactamase-producing strains) or S. pyogenes ;79, 82, 94, 145 and uncomplicated urinary tract infections caused by Escherichia coli or Klebsiella pneumoniae .79, 82, 95, 96, 104, 145 Cefuroxime axetil also is used orally for the treatment of Lyme disease50, 62, 79, 143, 145, 147, 181, 183 and has been used for the treatment of uncomplicated gonorrhea.79, 125, 144, 145, 147
Cefuroxime sodium is used parenterally in the treatment of lower respiratory tract infections (including pneumonia), skin and skin structure infections, genitourinary tract infections, bone and joint infections, septicemia, and meningitis caused by susceptible organisms.1 Cefuroxime sodium also is used parenterally for perioperative prophylaxis.1, 3, 6, 48, 66, 71, 193, 194, 195, 196, 197
Because cefuroxime, like other second generation cephalosporins, generally is less active against susceptible gram-positive cocci than are first generation cephalosporins, most clinicians state that cefuroxime probably should not be used in the treatment of infections caused by gram-positive bacteria when a penicillin or a first generation cephalosporin could be used.3, 18, 45 In addition, because cefuroxime generally is less active in vitro against Enterobacteriaceae than third generation cephalosporins, some clinicians state that a third generation drug such as cefotaxime or ceftriaxone generally is preferred if a parenteral cephalosporin is indicated in the treatment of infections known or suspected to be caused by these gram-negative bacteria.18, 45
When available, consider culture and susceptibility information in selecting or modifying antibacterial therapy.1, 79 In the treatment of known or suspected sepsis or the treatment of other serious infections when the causative organism is unknown, concomitant therapy with an aminoglycoside may be indicated.1
Cefuroxime axetil is used orally in adults and pediatric patients ≥13 years of age for the treatment of acute otitis media (AOM) caused by Streptococcus pneumoniae , Haemophilus influenzae (including β-lactamase-producing strains), Moraxella catarrhalis (including β-lactamase-producing strains), or Streptococcus pyogenes .79, 82, 88, 89, 102, 110, 145, 198, 199, 200, 750, 751
Results of controlled clinical studies in children 3 months to 12 years of age with AOM indicate that a 10-day regimen of oral cefuroxime axetil is as effective as or more effective than a 10-day regimen of oral cefaclor,203, 204 oral amoxicillin,201 or oral amoxicillin and clavulanate potassium.199, 204 In published studies, the overall clinical response rate to a 10-day regimen of oral cefuroxime axetil in pediatric patients with AOM has ranged from 62-94%.199, 201, 202, 203, 204
Cefuroxime axetil also has been effective for the treatment of AOM in pediatric patients when administered in a 5-day regimen†.198, 200 In a randomized study in children 3 months to 12 years of age with AOM, a satisfactory bacteriologic response (cure or presumed cure) was obtained in 92% of those who received a 5-day regimen of cefuroxime axetil (30 mg/kg daily given in 2 divided doses), 84% of those who received a 10-day regimen of cefuroxime axetil (30 mg/kg daily given in 2 divided doses), or 95% of those who received a 10-day regimen of amoxicillin and clavulanate potassium (40 mg/kg daily given in 3 divided doses).198 There is evidence from a randomized study in children 6-36 months of age with AOM that a 5-day regimen of oral cefuroxime axetil is as effective as and may be better tolerated than an 8- or 10-day regimen of oral amoxicillin and clavulanate potassium.200 The American Academy of Pediatrics (AAP) states that oral anti-infective regimens of less than 10 days' duration are not recommended for the treatment of AOM in children younger than 2 years of age or in patients with severe symptoms.184
When anti-infective therapy is indicated for the treatment of AOM, AAP recommends high-dose amoxicillin or amoxicillin and clavulanate potassium as the drugs of first choice for initial treatment.184, 750, 751 These experts recommend certain cephalosporins (cefdinir, cefpodoxime, cefuroxime, ceftriaxone) as alternatives for initial treatment in penicillin-allergic patients who do not have a history of severe penicillin-allergic reactions.184, 750, 751
Parenteral cefuroxime is used for the treatment of bone and joint infections caused by susceptible Staphylococcus aureus (including penicillinase-producing strains).1
Gonorrhea and Associated Infections
IM cefuroxime sodium has been used in conjunction with oral probenecid for the treatment of uncomplicated gonorrhea caused by Neisseria gonorrhoeae , including penicillinase-producing strains (PPNG).1, 9, 20 Parenteral cefuroxime sodium also has been used for the treatment of disseminated gonococcal infections caused by N. gonorrhoeae , including PPNG.1 Cefuroxime axetil has been used orally for the treatment of uncomplicated urethral and endocervical gonorrhea caused by N. gonorrhoeae and for the treatment of uncomplicated rectal gonorrhea in females caused by nonpenicillinase-producing strains of the organism.79, 83, 84, 85, 86, 87, 125, 126, 127, 144, 145, 146 However, parenteral cefuroxime sodium and oral cefuroxime axetil are not included in current US Centers for Disease Control and Prevention (CDC) recommendations for the treatment of gonococcal infections.68, 143
Because of concerns related to reports of N. gonorrhoeae with reduced susceptibility to cephalosporins, the CDC states that oral cephalosporins are no longer recommended as first-line treatment for uncomplicated gonorrhea.36, 68 For the treatment of uncomplicated urogenital, anorectal, or pharyngeal gonorrhea, the CDC recommends a single dose of IM ceftriaxone.36
The CDC states that cefuroxime axetil is not recommended for the treatment of gonococcal infections due to inferior efficacy and less favorable pharmacodynamics compared with recommended treatments (i.e., IM ceftriaxone, oral cefixime).36
Lyme disease is a tick-borne spirochetal disease.134, 135, 143, 181, 182, 183, 744 In the US, Lyme disease is caused by the spirochete Borrelia burgdorferi (or, in rare cases, Borrelia mayonii ), which is transmitted by the bite of Ixodes scapularis or I. pacificus ticks.134, 135, 143, 181, 182, 183, 744
Oral cefuroxime axetil is used in adults and pediatric patients ≥13 years of age for the treatment of early Lyme disease manifested as erythema migrans.50, 58, 62, 79, 143, 145, 147, 181, 182, 183, 208, 209, 210, 744 When an oral regimen is indicated, oral cefuroxime axetil also has been used in the treatment of early neurologic Lyme disease† in patients with cranial nerve palsy alone without evidence of meningitis, Lyme carditis† , and uncomplicated Lyme arthritis† without clinical evidence of neurologic disease.143 182, 208, 209, 744
Efficacy of cefuroxime axetil for the treatment of early Lyme disease has been evaluated in studies that included adults and pediatric patients ≥12 years of age with physician-documented erythema migrans (with or without systemic manifestations of infection), and results of these studies indicate that the drug is as effective as oral doxycycline in producing resolution of erythema migrans and preventing the development of manifestations of late Lyme disease.50, 62, 79, 145, 147 The clinical diagnosis of early Lyme disease in study patients was validated objectively by a blinded expert who examined available photographs of skin lesions taken before therapy and/or by serologic evidence of antibodies specific to B. burgdorferi identified using enzyme-linked immunosorbent assay (ELISA) and Western immunoblot.79 Patients were randomized to receive oral cefuroxime axetil (500 mg of cefuroxime twice daily) or oral doxycycline (100 mg 3 times daily) for 20 days and evaluated during treatment (days 8-12) and posttreatment (days 1-5, 1 month, and then at 3-month intervals for up to 1 year).50, 62, 79, 147 In patients who were evaluated at 1 month posttreatment, a satisfactory clinical response consisting of either clinical success (defined as resolution of erythema migrans and other manifestations of infection within 5 days posttreatment and maintained through follow-up at 1 month posttreatment) or clinical improvement (defined as resolution of erythema migrans within 5 days posttreatment with incomplete resolution of other manifestations of infection at that time but further improvement or complete resolution of manifestations by follow-up at 1 month posttreatment) was attained in 91 or 93% of patients who received cefuroxime axetil or doxycycline, respectively.50, 62, 79 Clinical success was attained in 72 or 73% of patients receiving cefuroxime axetil or doxycycline, respectively; clinical improvement was attained in 19% of patients receiving either drug.50, 62, 79 In patients evaluated at 1 year, a satisfactory clinical outcome consisting of success (defined as the absence of signs or symptoms of late Lyme disease throughout the 1-year follow-up) or clinical improvement (defined as the presence of some signs or symptoms consistent with late Lyme disease but no objective evidence of active disease throughout the 1-year follow-up) was attained in 84 or 87% of patients who received cefuroxime axetil or doxycycline, respectively.50, 62, 79 Success at 1 year was attained in 73% of patients receiving either drug; clinical improvement was attained in 10% of patients receiving cefuroxime axetil and 13% of patients receiving doxycycline.50, 62, 79
Appropriate antibiotic treatment shortens the duration of erythema migrans and usually prevents the development of late sequelae of Lyme disease.182 The American Academy of Pediatrics (AAP) states that children with early Lyme disease treated with effective antimicrobial agents rarely develop late manifestations of Lyme disease.744 According to treatment guidelines from the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR), guidelines from AAP, and other clinicians, oral anti-infectives (doxycycline, amoxicillin, cefuroxime axetil) are the preferred treatment for Lyme disease associated with erythema migrans, in the absence of specific neurologic manifestations or advanced atrioventricular (AV) heart block.58, 143, 182, 208, 209, 210, 744 For patients unable to take either doxycycline or ß-lactam antibiotics, the preferred second-line treatment for erythema migrans is azithromycin.182, 208, 744 The recommended duration of treatment is 10 days for doxycycline, 14 days for amoxicillin or cefuroxime axetil, and 7 days for azithromycin.182, 208, 744 Although doxycycline generally is not recommended for pediatric patients <8 years of age, AAP states that the drug is considered safe when used for ≤21 days in pediatric patients of any age.744 AAP states that the choice of oral antibiotic for treatment of erythema migrans should be individualized based on the presence of neurologic disease (for which doxycycline is the drug of choice), drug allergy history, likelihood of coinfection with other bacteria (e.g., Anaplasma phagocytophilum or Ehrlichia muris -like agent, neither of which is sensitive to ß-lactam antibiotics), adverse effect profile, frequency of administration, ability to minimize sun exposure, and presence of symptoms difficult to distinguish from Staphylococcus aureus cellulitis (doxycycline is effective against most strains of S. aureus , including methicillin-resistant strains).744
According to treatment guidelines from IDSA/AAN/ACR, in patients with Lyme disease-associated meningitis, cranial neuropathy, radiculoneuropathy, or with other peripheral nervous system manifestations, the recommended treatment is parenteral therapy with ceftriaxone, cefotaxime, or penicillin G, or oral therapy with doxycycline.208 AAP states that a growing body of evidence suggests that oral doxycycline is effective for the treatment of Lyme disease-associated meningitis and may be used as an alternative to hospitalization and parenteral ceftriaxone or penicillin G therapy in pediatric patients who are well enough to be treated as outpatients.744 The choice of antibiotic, including route of administration, should be individualized based on drug allergy history, adverse effect profile, ease of administration, ability to tolerate oral medications, and compliance factors.208 The route of therapy may be changed from IV to oral during treatment in patients who have experienced clinical improvement.182, 208 The recommended duration of treatment is 14-21 days.182, 208, 744 In patients with acute neurologic Lyme disease with parenchymal involvement of the brain or spinal cord, IV antibiotic treatment is recommended for the entire 14-21 days.182, 208
Oral cefuroxime axetil has been used in the treatment of Lyme carditis†.208 In outpatients with Lyme carditis, IDSA/AAN/ACR recommend treatment with oral antibiotics (doxycycline, amoxicillin, cefuroxime axetil, or azithromycin) over treatment with IV antibiotics.182, 208 In patients with or at high risk of severe cardiac complications, including those with a PR interval >0.3 seconds, other arrhythmias, or clinical manifestations of myopericarditis, IDSA/AAN/ACR recommend hospitalization with continuous ECG monitoring and treatment with IV ceftriaxone over treatment with oral antibiotics; upon clinical improvement, patients may be switched to oral antibiotics to complete the recommended 14-21 days of treatment.182, 208 For patients with symptomatic bradycardia due to Lyme carditis that cannot be managed medically, IDSA/AAN/ACR recommend temporary pacing modalities rather than implanting a permanent pacemaker.208
744 In pediatric patients with Lyme disease associated with atrioventricular heart block or carditis†, AAP recommends oral treatment with doxycycline, amoxicillin, or cefuroxime axetil for 14 days (range: 14-21 days) or IV treatment with ceftriaxone for 14 days (range: 14-21 days for a hospitalized patient).182, 744 Oral antibiotics may be substituted for IV treatment when the patient is stabilized or discharged from the hospital to complete the recommended 14-21 days of treatment.182, 744 AAP states that azithromycin has not been sufficiently studied for manifestations of Lyme disease other than erythema migrans.744
In patients with Lyme disease-associated arthritis†, IDSA/AAN/ACR and AAP recommend initial treatment with a 28-day course of oral antibiotics (doxycycline, amoxicillin, or cefuroxime axetil).182, 208, 744 In patients who experience a partial response to an initial course of treatment, the choice of whether to observe the patient or initiate a second course of antibiotic treatment should be made based on consideration of other causes of joint swelling, medication adherence, duration of arthritis before initial treatment, degree of synovial proliferation versus joint swelling, patient preferences, and cost.208 A second course of oral antibiotics for up to 1 month may be a reasonable alternative for patients in whom synovial proliferation is modest compared with joint swelling and for those who prefer repeating a course of oral antibiotics before considering IV antibiotic therapy.208 In patients with minimal or no response (moderate to severe joint swelling with minimal reduction of the joint effusion) to an initial 28-day course of oral antibiotic, IDSA/AAN/ACR and AAP recommend a 2- to 4-week course of IV ceftriaxone over a second course of oral antibiotics.182, 208, 744 In patients who have failed one course of oral antibiotics and one course of IV antibiotics, referral to a rheumatologist or other trained specialist is advised.208 Antibiotic therapy for >8 weeks (including one course of IV antibiotics) is not expected to provide additional benefit to patients with persistent arthritis.208
Persistent Symptoms Following Lyme Disease Treatment
For patients who have persistent or recurring nonspecific symptoms such as fatigue, pain, or cognitive impairment following recommended treatment for Lyme disease, but who lack objective evidence of reinfection or treatment failure, IDSA/AAN/ACR and AAP recommend against additional antibiotic therapy.182, 208, 744 Several double-blind, randomized, placebo-controlled trials have found that retreatment with additional antimicrobial agents for patients with residual posttreatment subjective symptoms of Lyme disease may be associated with harm and does not offer benefit.744 However, retreatment is appropriate in patients who experience subsequent acute infections caused by B. burgdorferi .744
Parenteral cefuroxime has been used in neonates†, children1 , and adults1 for the treatment of meningitis caused by susceptible S. pneumoniae , H. influenzae (including ampicillin-resistant strains), N. meningitidis , or S. aureus (penicillinase- and nonpenicillinase-producing strains);7, 25, 26, 43, 44, 64, 159, 161 however, cefuroxime is not considered a drug of choice for these infections.58, 143, 165, 217 Treatment failures have been reported when cefuroxime was used in the treatment of meningitis, especially in meningitis caused by H. influenzae .160, 162 In addition, while results of some studies in pediatric patients with meningitis indicate that the clinical cure rate with IV cefuroxime is similar to that reported for IV ceftriaxone, the bacteriologic response to cefuroxime appears to be slower, which may increase the risk for hearing loss and neurologic sequelae.159, 161 In a study in children 44 days to 16 years of age with acute bacterial meningitis who were randomized to receive empiric therapy with IV ceftriaxone (100 mg/kg once daily) or IV cefuroxime (240 mg/kg daily in 4 doses), all patients in both groups were considered clinically cured; however, the rate of sterilization of CSF after the first 18-36 hours of therapy was higher in those who received ceftriaxone (98%) than in those who received cefuroxime (88%).159 When a cephalosporin is indicated for the treatment of bacterial meningitis, a parenteral third generation cephalosporin (usually ceftriaxone or cefotaxime) generally is recommended.58, 143, 157, 158, 165, 217, 750, 751, 754, 755, 756
IV cefuroxime sodium is used for perioperative prophylaxis in patients undergoing cardiac surgery1, 66, 193, 195, 196, 197, 213 and is considered a drug of choice for cardiac procedures (e.g., coronary artery bypass, pacemaker or other cardiac device insertion, ventricular assist devices).71, 213 IV cefuroxime also is considered a drug of choice when used alone for perioperative prophylaxis in patients undergoing clean head and neck surgery involving placement of prosthesis (excluding tympanostomy) and when used in conjunction with metronidazole for perioperative prophylaxis in patients undergoing clean-contaminated cancer surgery of the head and neck or other clean-contaminated head and neck procedures (excluding tonsillectomy and functional endoscopic sinus procedures).213
IV cefuroxime also has been used for perioperative prophylaxis in patients undergoing noncardiac thoracic surgery,213 GI or biliary tract surgery,3, 6, 213 gynecologic or obstetric surgery (e.g., vaginal hysterectomy),1, 3, 6, 213 orthopedic procedures,194, 213 or heart transplantation.213 However, other anti-infectives (e.g., cefazolin) usually are recommended for perioperative prophylaxis in patients undergoing these procedures.71, 213
Cefuroxime axetil is used orally in adults and pediatric patients ≥13 years of age for the treatment of mild to moderate pharyngitis and tonsillitis caused by Streptococcus pyogenes (group A β-hemolytic streptococci).79, 90, 91, 145, 175 Efficacy of the drug in the subsequent prevention of rheumatic fever remains to be established.79
A 10-day regimen of oral cefuroxime axetil is at least as effective as a 10-day regimen of oral penicillin V for the treatment of S. pyogenes pharyngitis and tonsillitis.90, 91, 145, 175 In addition, results of a prospective, randomized study in children 2-15 years of age indicate that a 4-day regimen of oral cefuroxime axetil (20 mg/kg of cefuroxime in 2 divided doses daily) is as effective as a 10-day regimen of oral penicillin V (45 mg/kg daily in 3 divided doses).169 The clinical response rate was 94.8% in those who received the 4-day cefuroxime regimen and 96.1% in those who received the 10-day penicillin regimen; 30 days after treatment, the bacteriologic relapse rate was 2.8 and 2.3%, respectively.169
Selection of an anti-infective for the treatment of S. pyogenes pharyngitis and tonsillitis should be based on the drug's spectrum of activity, bacteriologic and clinical efficacy, potential adverse effects, ease of administration, patient compliance, and cost.45, 170, 171, 173, 174 No regimen has been found to date that effectively eradicates group A β-hemolytic streptococci in 100% of patients.45
Because the drugs have a narrow spectrum of activity, are inexpensive, and generally are effective with a low frequency of adverse effects, the AAP,143, 750 Infectious Diseases Society of America (IDSA),171 American Heart Association (AHA),45 and others58, 173 recommend a penicillin regimen (i.e., 10 days of oral penicillin V or oral amoxicillin or a single dose of IM penicillin G benzathine) as the treatment of choice for S. pyogenes pharyngitis and tonsillitis and prevention of initial attacks (primary prevention) of rheumatic fever. Other anti-infectives (e.g., oral cephalosporins, oral macrolides, oral clindamycin) are recommended as alternatives in penicillin-allergic individuals.45, 143, 171, 750
If an oral cephalosporin is used for the treatment of S. pyogenes pharyngitis and tonsillitis, a 10-day regimen of a first generation cephalosporin (cefadroxil, cephalexin) is preferred instead of other cephalosporins with broader spectrums of activity (e.g., cefaclor, cefdinir, cefixime, cefpodoxime, cefuroxime).45, 143, 171
Although there is some evidence that a shorter duration of therapy with certain oral cephalosporins (e.g., a 5-day regimen of cefadroxil, cefdinir, cefixime, or cefpodoxime proxetil or a 4- or 5-day regimen of cefuroxime axetil) achieves bacteriologic and clinical cure rates equal to or greater than those achieved with the traditional 10-day oral penicillin V regimen,45, 169, 170, 173, 174, 175, 176, 177 the IDSA and AHA state that use of cephalosporin regimens administered for 5 days or less for the treatment of S. pyogenes pharyngitis and tonsillitis cannot be recommended at this time.45, 171
Cefuroxime axetil is used orally in adults and pediatric patients ≥13 years of age for the treatment of mild to moderate respiratory tract infections, including acute maxillary sinusitis caused by susceptible Streptococcus pneumoniae or Haemophilus influenzae (non-β-lactamase-producing strains only)58, 79, 145, 153, 164, 166 and acute exacerbations of chronic bronchitis caused by susceptible S. pneumoniae , H. influenzae (non-β-lactamase-producing strains only), or H. parainfluenzae (non-β-lactamase-producing strains only).79, 82, 92, 93, 103, 124, 163 Cefuroxime axetil also has been used orally for the treatment of secondary infections of acute bronchitis† caused by susceptible S. pneumoniae , H. influenzae (non-β-lactamase-producing strains only), or H. parainfluenzae (non-β-lactamase-producing strains only).82, 92, 93, 103, 124
Cefuroxime sodium is used parenterally for the treatment of lower respiratory tract infections, including pneumonia, caused by susceptible S. pneumoniae , Staphylococcus aureus (penicillinase- and nonpenicillinase-producing strains), S. pyogenes (group A β-hemolytic streptococci), H. influenzae (including ampicillin-resistant strains), Escherichia coli , and Klebsiella .1
Cefuroxime axetil is used orally in adults and pediatric patients ≥13 years of age for the treatment of acute maxillary sinusitis caused by susceptible S. pneumoniae or H. influenzae (non-β-lactamase-producing strains only).58, 79, 145, 153, 164, 166 The safety and effectiveness of cefuroxime axetil have been established for pediatric patients 3 months to 12 years of age for acute bacterial maxillary sinusitis based upon its approval in adults.79 The manufacturers state that insufficient data exist to establish efficacy of cefuroxime axetil in the treatment of acute bacterial maxillary sinusitis that is known or suspected to be caused by β-lactamase-producing strains of H. influenzae or M. catarrhalis .79
When anti-infective therapy is indicated for the treatment of acute bacterial sinusitis, the Infectious Diseases Society of America (IDSA) recommends amoxicillin and clavulanate potassium and the American Academy of Pediatrics (AAP) recommends either amoxicillin or amoxicillin and clavulanate potassium as the drug of choice for initial empiric treatment.219, 220, 750 Because of variable activity against S. pneumoniae and H. influenzae , IDSA no longer recommends second or third generation oral cephalosporins for empiric monotherapy of sinusitis in adults or children.219 If an oral cephalosporin is used as an alternative for empiric treatment of acute bacterial sinusitis in children (e.g., in penicillin-allergic individuals), the IDSA and AAP recommend a combination regimen that includes a third generation cephalosporin (cefixime or cefpodoxime) and clindamycin (or linezolid).219, 220
Oral cefuroxime axetil is used for the treatment of mild to moderate community-acquired pneumonia† (CAP).51 The American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) recommended cefuroxime as an alternative in certain combination regimens used for empiric treatment of CAP.51
Parenteral cefuroxime is used for the treatment of lower respiratory tract infections, including pneumonia, caused by susceptible S. pneumoniae , Staphylococcus aureus (including penicillinase-producing strains), S. pyogenes (group A β-hemolytic streptococci), H. influenzae (including ampicillin-resistant strains), Escherichia coli , and Klebsiella .1 A sequential regimen of parenteral cefuroxime sodium (given for 48-72 hours) followed by oral cefuroxime axetil (given for 7 days) has been used effectively for the treatment of CAP in adults.167
Initial treatment for CAP generally is empiric and is based on selecting drugs effective against the major bacterial causes of CAP.51 Traditionally, these bacterial pathogens include S. pneumoniae , H. influenzae , Mycoplasma pneumoniae , S. aureus , Legionella species, Chlamydia pneumoniae , and Moraxella catarrhalis .51, 751 The emergence of multidrug-resistant pathogens, including methicillin-resistant S. aureus (MRSA) and Pseudomonas aeruginosa , requires separate recommendations when the risk of each of these pathogens is elevated.51 In addition to H. influenzae and M. catarrhalis (both of which frequently produce ß-lactamase), S. aureus and gram-negative bacilli are more common causes of CAP in patients with comorbidities, such as chronic obstructive pulmonary disease (COPD).51 Observational data suggest that inpatient and outpatient CAP are generally due to the same pathogens, except for Legionella and gram-negative bacilli, which are rarely documented in outpatient settings.51
Pretreatment sputum cultures are not routinely recommended in outpatients being treated for CAP.51 Pretreatment sputum cultures are recommended in hospitalized patients being treated for CAP who have severe CAP (especially if intubated), who are being empirically treated for MRSA or P. aeruginosa , who previously were infected with MRSA or P. aeruginosa (especially those with prior respiratory tract infection), and who were hospitalized and received parenteral antibiotics (whether during the hospitalization event or not) in the last 90 days.51
IDSA/ATS recommend that the duration of antibiotic therapy for CAP should be guided by a validated measure of clinical stability (resolution of vital sign abnormalities [heart rate, respiratory rate, blood pressure, oxygen saturation, and temperature], ability to eat, and normal mentation), and that antibiotic therapy should be continued until the patient achieves stability and for no less than a total of 5 days.51 Most patients will achieve clinical stability within the first 48-72 hours of antibiotic treatment.51 If therapy is initiated with parenteral antibiotics and patients are to be switched to oral antibiotics, either the same drug or a drug from the same class should be used.51
For empiric outpatient treatment of CAP in otherwise healthy adults without risk factors for antibiotic-resistant pathogens, IDSA/ATS recommend amoxicillin or doxycycline; in areas with pneumococcal resistance to macrolides <25%, a macrolide (azithromycin, clarithromycin, or extended-release clarithromycin) also is an option.51
For empiric outpatient treatment of CAP in adults with comorbidities (e.g., chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancy; asplenia), IDSA/ATS recommend either combination therapy with a ß-lactam antibiotic (amoxicillin/clavulanate, cefpodoxime, or cefuroxime) and a macrolide (azithromycin, clarithromycin, or extended-release clarithromycin) or doxycycline; or, monotherapy with a respiratory fluoroquinolone (levofloxacin, moxifloxacin, or gemifloxacin).51 The choice between these options should be based on an individual risk-benefit assessment, weighing local epidemiological data against specific risk factors, such as documented ß-lactam or macrolide allergy, cardiac arrhythmia (a consideration for use of macrolides), vascular disease (a consideration for use of fluoroquinolones), and history of infection with Clostridioides difficile .51 In addition, patients with recent exposure to one class of antibiotics should receive treatment with antibiotics from a different class, given the increased risk for bacterial resistance to the previously used drug class.51
For empiric inpatient treatment of nonsevere CAP in adult patients without risk factors for MRSA or P. aeruginosa , IDSA and ATS recommend either combination therapy with a ß-lactam (ampicillin-sulbactam, cefotaxime, ceftriaxone, or ceftaroline) and a macrolide (azithromycin or clarithromycin) or monotherapy with a respiratory fluoroquinolone (levofloxacin or moxifloxacin).51 In patients who have contraindications to both macrolides and fluoroquinolones, an alternative option is combination therapy with a ß-lactam (ampicillin-sulbactam, cefotaxime, ceftaroline, or ceftriaxone) and doxycycline.51 In choosing between these options, clinicians should weigh the risks and benefits of the drugs, particularly in light of individual patient risk factors, including a history of C. difficile infection.51
For empiric inpatient treatment of severe CAP in adult patients without risk factors for MRSA or P. aeruginosa , IDSA/ATS recommend a ß-lactam plus a macrolide or a ß-lactam plus a respiratory fluoroquinolone.51 There is stronger evidence in favor of ß-lactam/macrolide combination therapy compared with ß-lactam/fluoroquinolone combination therapy.51
Coverage for P. aeruginosa should be added in hospitalized patients with nonsevere or severe CAP who have had prior respiratory isolation of P. aeruginosa within the past year and in hospitalized patients with severe CAP who have undergone recent hospitalization and parenteral antibiotic treatment and who have locally validated risk factors for P. aeruginosa .51 Empiric treatment options for P. aeruginosa include piperacillin-tazobactam, cefepime, ceftazidime, aztreonam, meropenem, or imipenem.51
Coverage for MRSA should be added in hospitalized patients with severe CAP who have had prior respiratory isolation of MRSA within the past year or who have undergone recent hospitalization and parenteral antibiotic treatment and have locally validated risk factors for MRSA.51 Empiric treatment options for MRSA include vancomycin or linezolid.51
In cases where empiric treatment for P. aeruginosa and/or MRSA is initiated, cultures should be obtained to allow deescalation or confirmation of a need for continued therapy.51
Anaerobic coverage for suspected aspiration pneumonia is not recommended unless lung abscess or empyema is suspected.51
For empiric treatment of CAP in fully immunized pediatric patients in regions without a high prevalence of penicillin-resistant pneumococcus, AAP recommends amoxicillin, ampicillin, or penicillin.750 In patients allergic to penicillin, suggested alternatives include clindamycin or levofloxacin.750
In pediatric inpatients in regions with high levels of penicillin-resistant pneumococcus, AAP recommends empiric treatment for CAP with ceftriaxone.750 If an atypical pathogen (e.g., Mycoplasma or Chlamydia species) is suspected, a macrolide should be added to the regimen.750 If MRSA is suspected, coverage with vancomycin, clindamycin, or linezolid should be added.750 In pediatric inpatients with CAP caused by pneumococci suspected or proven to be penicillin-nonsusceptible, in patients with serious infections including empyema, or in those not fully immunized with PCV13, PCV15, or PCV20, AAP recommends treatment with ceftriaxone or cefotaxime.751 Vancomycin should be added in patients with life-threatening infection.751 In patients with isolates nonsusceptible to penicillin (MICs of ≥4.0 mcg/mL) or serious allergy to ß-lactam antimicrobials, AAP states that treatment with clindamycin (if susceptible) or levofloxacin should be considered, assuming that concurrent meningitis has been excluded.751 AAP recommends a duration of antibiotic therapy of 5 days for uncomplicated CAP with resolution of fever, tachypnea, and supplemental oxygen requirement.750 When tolerated, an early switch from parenteral therapy to oral therapy is recommended.750 The duration of therapy may be extended when CAP is complicated by empyema, necrotizing pneumonia, or pulmonary abscess.750 AAP states that because respiratory viruses cause the majority of CAP, especially in young children, antibiotic therapy may not be indicated for all patients with CAP.750
Parenteral cefuroxime is used for the treatment of septicemia caused by susceptible Staphylococcus aureus (including penicillinase-producing strains), Streptococcus pneumoniae , Escherichia coli , Haemophilus influenzae (including ampicillin-resistant strains), or Klebsiella .1 In the treatment of known or suspected sepsis or the treatment of other serious infections when the causative organism is unknown, concomitant therapy with an aminoglycoside may be indicated.1
Skin and Skin Structure Infections
Oral cefuroxime axetil is used for the treatment of uncomplicated skin and skin structure infections caused by susceptible Staphylococcus aureus (including β-lactamase-producing strains) or Streptococcus pyogenes in adults and pediatric patients ≥13 years of age.79
Parenteral cefuroxime is used for the treatment of skin and skin structure infections caused by susceptible S. aureus (including penicillinase-producing strains), S. pyogenes , Escherichia coli , Klebsiella , or Enterobacter .1
Oral cefuroxime axetil is used for the treatment of uncomplicated UTIs caused by susceptible Escherichia coli or Klebsiella pneumoniae in adults and pediatric patients ≥13 years of age.79
Parenteral cefuroxime is used for the treatment of UTIs caused by susceptible E. coli or K. pneumoniae .1
Cefuroxime axetil is administered orally.79 Cefuroxime sodium is administered by IV injection or infusion or by deep IM injection.1 IV rather than IM administration may be preferred in patients with septicemia or other severe or life-threatening infections or in patients with lowered resistance, particularly if shock is present or impending.1
Although cefuroxime axetil film-coated tablets may be given orally without regard to meals,79 administration with food maximizes bioavailability of the drug.79, 81, 82, 97, 99 The manufacturer states that the tablets should be swallowed whole.79
Store cefuroxime axetil tablets in tight containers at 20-25°C.79 When cefuroxime axetil tablets are allowed to disintegrate in apple juice, the drug is stable for 24 hours at room temperature.116, 117
An oral suspension of cefuroxime axetil is no longer commercially available in the US. Although commercially available cefuroxime axetil tablets have been crushed and mixed with food (e.g., applesauce, ice cream),88, 110 the crushed tablets have a strong, persistent taste and the manufacturer states that the drug should not be administered in this manner.79 Cefuroxime axetil tablets also have been allowed to disintegrate in a small amount (60-90 mL) of beverage (e.g., apple juice or milk) and the beverage stirred and ingested immediately followed by additional amounts of bevera disintegration of the tablets is optimal when the beverage is at room temperature.116
Limited data from a study conducted by the manufacturer suggest that cefuroxime axetil is stable for 2 hours at room temperature when added as single 125- or 250-mg tablets to 40 mL of Tropicana® orange juice, Welch's® grape juice, or Nestle's® chocolate milk.123 However, extemporaneous preparation of an oral suspension of the drug intended for multiple dosing currently is not recommended since stability information for more prolonged periods currently is not available.116
For direct intermittent IV injection, vials labeled as containing 750 mg or 1.5 g of cefuroxime should be reconstituted with 8.3 or 16 mL, respectively, of sterile water for injection to provide solutions containing approximately 90 mg/mL; the entire contents of the vial should be withdrawn for each dose.1
The appropriate dose should then be injected directly into a vein over a 3- to 5-minute period or injected slowly into the tubing of a freely flowing compatible IV solution.1
Store commercially available cefuroxime sodium sterile powder for injection at 20-25°C and protect from light.1
Following reconstitution of vials containing 750 mg or 1.5 g of cefuroxime or the pharmacy bulk vial containing 7.5 g of the drug with sterile water for injection according to the manufacturer's directions, solutions for IV administration are stable for 24 hours at room temperature or 48 hours (750-mg and 1.5-g vials) or 7 days (7.5-g pharmacy bulk vial) when refrigerated (5°C).1, 214 More dilute solutions, such as 750 mg or 1.5 g in 100 mL of sterile water for injection, 5% dextrose injection, or 0.9% sodium chloride injection also are stable for 24 hours at room temperature or 7 days when refrigerated.1
Cefuroxime sodium sterile powder and solutions of the drug tend to darken, depending on storage conditions; however, this discoloration does not necessarily indicate a change in potency.1
Intermittent or Continuous IV Infusion
Reconstitute the 7.5-g pharmacy bulk vial with 77 mL of sterile water for injection to provide a solution containing approximately 750 mg of cefuroxime per 8 mL; then, further dilute in a compatible IV infusion solution.214 The pharmacy bulk vial is not intended for direct IV infusion.214
The manufacturer states that cefuroxime sodium solutions prepared using the 750-mg or 1.5-g vials or the 7.5-g pharmacy bulk vial may be frozen immediately after reconstitution and dilution;1 the entire contents from the reconstituted 750-mg or 1.5-g vial or 8 or 16 mL from the 7.5-g vial should be immediately withdrawn and added to an appropriate container containing a compatible solution and frozen (please see the labeling for more information).1, 214 These extemporaneously prepared solutions are stable for 6 months when frozen at <20°C.1, 214 After thawing at room temperature, these solutions are stable for 24 hours at room temperature or 7 days when refrigerated; these solutions should not be refrozen.1, 214
Other IV solutions flowing through a common administration tubing or site should be discontinued while cefuroxime is being infused.1, 214 If an aminoglycoside is administered concomitantly with cefuroxime, the drugs should be administered at separate sites.1, 214
Intermittent IV infusions of cefuroxime generally are infused over 15-60 minutes.44
IM injections of cefuroxime sodium are prepared by adding 3 mL of sterile water for injection to a vial labeled as containing 750 mg of cefuroxime to provide a suspension containing approximately 225 mg/mL.1 The suspension should be shaken gently prior to administration, and the entire contents of the vial should be withdrawn for each dose.1
IM injections should be made deeply into a large muscle mass such as the gluteus or lateral aspect of the thigh.1 The plunger of the syringe should be drawn back before IM injection to ensure that the needle is not in a blood vessel.1
IM injections containing 225 mg/mL of cefuroxime prepared using the 750-mg vial and sterile water for injection according to the manufacturer's directions are stable for 24 hours at room temperature or 48 hours when refrigerated (5°C).1
Dosage of cefuroxime axetil is expressed in terms of cefuroxime.79 Cefuroxime axetil tablets and oral suspension (no longer commercially available in US) are not bioequivalent and are not substitutable on a mg/mg basis.79
Dosage of cefuroxime sodium also is expressed in terms of cefuroxime and is identical for IM or IV administration.1
The usual parenteral adult dosage of cefuroxime given as cefuroxime sodium is 750 mg to 1.5 g every 8 hours for 5-10 days.1 Severe or complicated infections in adults generally require 1.5 g every 8 hours and life-threatening infections or infections caused by less susceptible organisms may require 1.5 g every 6 hours.1
For the treatment of bone and joint infections in adults, the manufacturer recommends a parenteral cefuroxime dosage of 1.5 g every 8 hours.1
Gonorrhea and Associated Infections
For the parenteral treatment of uncomplicated gonorrhea caused by Neisseria gonorrhoeae , including penicillinase-producing strains (PPNG), the manufacturer recommends that adults receive a single 1.5-g IM dose of cefuroxime and 1 g of oral probenecid; the cefuroxime dose should be divided and given at 2 different sites.1 For the parenteral treatment of disseminated gonococcal infections, the manufacturer recommends that adults receive 750 mg of cefuroxime IM or IV every 8 hours.1
For the oral treatment of uncomplicated urethral or endocervical gonorrhea caused by N. gonorrhoeae or for the oral treatment of uncomplicated rectal gonorrhea in females caused by nonpenicillinase-producing strains of the organism, adults and adolescents ≥13 years of age have received a single 1-g dose of cefuroxime.79, 125, 144
The US Centers for Disease Control and Prevention (CDC) does not recommend oral or parenteral cefuroxime for the treatment of gonococcal infections.36, 68
For the treatment of early Lyme disease manifested as erythema migrans, the manufacturer recommends that adults and adolescents ≥13 years of age receive 500 mg of oral cefuroxime every 12 hours for 20 days.79
IDSA/AAN/ACR and other clinicians recommend that adults receive 500 mg of oral cefuroxime twice daily for 14 days for the treatment of early localized or early disseminated Lyme disease manifested as erythema migrans, in the absence of specific neurologic involvement or advanced atrioventricular (AV) heart block.182, 208, 209
If an oral regimen is used for the treatment of Lyme carditis†, IDSA/AAN/ACR and other clinicians recommend that adults receive 500 mg of oral cefuroxime twice daily for 14-21 days.182 208
If an oral regimen is used for the treatment of uncomplicated Lyme arthritis† in patients without clinical evidence of neurologic disease, IDSA/AAN/ACR and other clinicians recommend that adults receive 500 mg of oral cefuroxime twice daily for 28 days.182 208
For the treatment of meningitis in adults, the manufacturer recommends a parenteral cefuroxime dosage of up to 3 g every 8 hours.1
For perioperative prophylaxis in adults undergoing open-heart surgery, the manufacturer recommends that a single 1.5-g dose of cefuroxime be given IV at the time of induction of anesthesia and every 12 hours thereafter for a total dosage of 6 g (i.e., up to 48 hours).1 Some experts recommend that 1.5 g of cefuroxime be given within 1 hour prior to surgical incision and that additional 1.5-g doses be given every 4 hours during prolonged procedures (longer than 4 hours) or if major blood loss occurs.71, 213 Various data support a duration of perioperative prophylaxis ranging from a single preoperative dose to continuation of prophylaxis for 24 hours postoperatively; there is no evidence of benefit beyond 48 hours71 and no evidence to support continuing prophylaxis until all drains and indwelling catheters are removed.71, 213
If cefuroxime is used for perioperative prophylaxis in other clean-contaminated or potentially contaminated surgery (e.g., vaginal hysterectomy), the manufacturer recommends that adults receive 1.5 g of cefuroxime IV just prior to surgery (approximately 30-60 minutes before the initial incision) and, in lengthy operations, 750 mg of the drug IV or IM every 8 hours.1 For most procedures, postoperative doses are usually unnecessary and may increase the risk of bacterial resistance.71 If the procedure is prolonged (longer than 4 hours) or if major blood loss occurs, 1.5-g doses of cefuroxime may be given IV every 4 hours.71, 213
For the treatment of mild to moderate pharyngitis and tonsillitis caused by Streptococcus pyogenes (group A β-hemolytic streptococci) in adults and adolescents ≥13 years of age, the usual oral dosage of cefuroxime given as cefuroxime axetil tablets is 250 mg every 12 hours for 10 days.79
For the treatment of mild to moderate acute bacterial maxillary sinusitis in adults and adolescents ≥13 years of age, the usual oral dosage of cefuroxime given as cefuroxime axetil tablets is 250 mg every 12 hours for 10 days.79 For the treatment of mild to moderate acute bacterial exacerbations of chronic bronchitis in adults and adolescents ≥13 years of age, the usual oral dosage of cefuroxime given as cefuroxime axetil tablets is 250 or 500 mg every 12 hours for 10 days.79 For the treatment of secondary bacterial infections of acute bronchitis†, a dosage of cefuroxime of 250 mg twice daily for 5-10 days has been used.124 While there is evidence that a 5-day regimen of cefuroxime axetil is as effective as a 10-day regimen of the drug for the treatment of secondary bacterial infections of acute bronchitis,124 efficacy of the shorter regimen for the treatment of acute exacerbations of chronic bronchitis has not been established.79
If cefuroxime axetil is used for the outpatient treatment of community-acquired pneumonia† (CAP) in adults, the American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA) recommend an oral dosage of 500 mg of cefuroxime twice daily.51 For empiric treatment of CAP, cefuroxime must be used in conjunction with other anti-infectives.51
For the treatment of uncomplicated pneumonia in adults, the manufacturer recommends a parenteral cefuroxime dosage of 750 mg every 8 hours.1 In severe or complicated infections, a dosage of 1.5 g every 8 hours is recommended.1
Skin and Skin Structure Infections
For the treatment of uncomplicated skin and skin-structure infections in adults and adolescents ≥13 years of age, the usual oral dosage of cefuroxime given as cefuroxime axetil tablets is 250 or 500 mg every 12 hours for 10 days.79
For the treatment of uncomplicated skin and skin-structure infections in adults, a parenteral cefuroxime dosage of 750 mg every 8 hours is recommended.1 For the treatment of severe or complicated skin and skin structure infections in adults, a parenteral cefuroxime dosage of 1.5 g every 8 hours is recommended.1
For the treatment of uncomplicated urinary tract infections in adults and adolescents ≥13 years of age, an oral cefuroxime dosage of 250 mg every 12 hours for 7-10 days is recommended.79
For the treatment of uncomplicated urinary tract infections in adults, a parenteral cefuroxime dosage of 750 mg every 8 hours is recommended.1 For the treatment of severe or complicated urinary tract infections in adults, a parenteral cefuroxime dosage of 1.5 g every 8 hours is recommended.1
Cefuroxime axetil film-coated tablets and oral suspension (no longer commercially available in the US) are not bioequivalent and are not substitutable on a mg/mg basis.79
For the treatment of most susceptible infections (except bone and joint infections or meningitis) in children ≥3 months of age, the manufacturer recommends a cefuroxime dosage of 50-100 mg/kg daily given IM or IV in equally divided doses every 6-8 hours; the manufacturer states that 100 mg/kg daily (not to exceed the maximum adult dosage) should be given IM or IV for more severe infections.1 The IM or IV dosage of cefuroxime recommended by the manufacturers for the treatment of bone and joint infections in children ≥3 months of age is 150 mg/kg daily in 3 divided doses every 8 hours.1
The American Academy of Pediatrics (AAP) recommends that neonates with a gestational age (GA) of ≤31 weeks and 6 days and a postnatal age (PNA) of <7 days receive IM or IV cefuroxime in a dosage of 50 mg/kg every 12 hours.757 Neonates with GA ≤31 weeks and 6 days and PNA of 7-28 days should receive a dosage of 50 mg/kg every 8 hours.757 AAP recommends that neonates with GA ≥32 weeks and PNA of ≤7 days receive IM or IV cefuroxime in a dosage of 50 mg/kg every 12 hours.757 Neonates with GA ≥32 weeks and PNA of 8-28 days should receive a dosage of 50 mg/kg every 8 hours.757
For pediatric patients beyond the neonatal period, the AAP recommends an IM or IV cefuroxime dosage of 100-150 mg/kg daily (maximum 6 g/day) given in 3 equally divided doses.757 These clinicians recommend that children beyond the neonatal period receive oral cefuroxime in a dosage of 20-30 mg/kg daily (maximum 1 g/day) in 2 equally divided doses for the treatment of mild to moderate infections.143 AAP recommends an oral cefuroxime dosage of up to 100 mg/kg daily (maximum 3 g/day) in 3 divided doses for the treatment of bone or joint infections in pediatric patients beyond the neonatal period.757
For the treatment of acute otitis media in children 3 months to 12 years of age who can swallow tablets whole, the usual oral dosage of cefuroxime as cefuroxime axetil film-coated tablets is 250 mg every 12 hours for 10 days.79
Cefuroxime axetil has been administered in a 5-day regimen† for the treatment of acute otitis media in children 3 months to 12 years of age.198, 200 The AAP states that oral anti-infective regimens of <10 days' duration are not recommended for the treatment of AOM in children <2 years of age or in patients with severe symptoms.184
Acute Exacerbations of Chronic Bronchitis
For the treatment of mild to moderate acute exacerbations of chronic bronchitis in pediatric patients ≥13 years of age, the usual oral dosage of cefuroxime as cefuroxime axetil film-coated tablets is 250 or 500 mg every 12 hours for 10 days.79 The efficacy of regimens <10 days in duration has not been established.79
For the treatment of acute bacterial maxillary sinusitis in children 3 months to 12 years of age and in adolescents ≥13 years of age, who can swallow tablets whole, the usual oral dosage of cefuroxime as cefuroxime axetil film-coated tablets is 250 mg every 12 hours for 10 days.79 .
For the treatment of bone and joint infections in children ≥3 months of age, the usual dosage of cefuroxime is 150 mg/kg daily (not to exceed the maximum adult dosage) given IV or IM in divided doses every 8 hours.1
For the oral treatment of uncomplicated urethral or endocervical gonorrhea caused by N. gonorrhoeae or for the oral treatment of uncomplicated rectal gonorrhea in females caused by nonpenicillinase-producing strains of the organism, adolescents ≥13 years of age have received a single 1-g dose of cefuroxime.79, 125, 144 Cefuroxime is not recommended by the CDC as treatment for gonorrhea.36, 68
For the treatment of Lyme disease manifested as erythema migrans, in the absence of specific neurologic involvement or advanced AV heart block, the manufacturer, IDSA/AAN/ACR, AAP, and other clinicians recommend that children receive oral cefuroxime in a dosage of 30 mg/kg daily administered in 2 divided doses (up to 500 mg per dose) for 14 days.141, 143, 181, 182, 208, 209, 744
If an oral regimen is used for the treatment of Lyme carditis†, IDSA/AAN/ACR and others recommend that children receive oral cefuroxime in a dosage of 30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 14-21 days.182, 208, 744
If an oral regimen is used for the treatment of uncomplicated Lyme arthritis† in patients without clinical evidence of neurologic disease, IDSA/AAN/ACR and AAP recommend that children receive oral cefuroxime in a dosage of 30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 28 days.143 182, 208, 744
For the treatment of bacterial meningitis in children ≥3 months of age, the usual dosage of IV cefuroxime is 200-240 mg/kg daily given in divided doses every 6-8 hours.1, 19, 49
If cefuroxime is used for perioperative prophylaxis in children, some clinicians recommend that 50 mg/kg of cefuroxime be given within 1 hour prior to surgical incision.213 If the procedure is prolonged (longer than 4 hours) or if major blood loss occurs, additional 50-mg/kg doses may be given IV.213 Various data support a duration of perioperative prophylaxis ranging from a single preoperative dose to continuation of prophylaxis for 24 hours postoperatively; there is no evidence of benefit beyond 48 hours71 and no evidence to support continuing prophylaxis until all drains and indwelling catheters are removed.71, 213
For the treatment of pharyngitis and tonsillitis caused by Streptococcus pyogenes (group A β-hemolytic streptococci) in children 4-12 years of age who can swallow tablets whole, an oral dosage of cefuroxime as cefuroxime axetil film-coated tablets of 125 mg every 12 hours for 10 days has been used.91 Alternatively, children 2-15 years of age have received cefuroxime as cefuroxime axetil oral suspension (no longer commercially available in the US) in a dosage of 20 mg/kg daily in 2 divided doses for 10 days.169 For the treatment of mild to moderate pharyngitis and tonsillitis, the manufacturer recommends that adolescents ≥13 years of age receive 250 mg of oral cefuroxime every 12 hours for 10 days.79
Skin and Skin Structure Infections
For the treatment of uncomplicated skin and skin structure infections, the manufacturer recommends that adolescents ≥13 years of age receive 250 or 500 mg of oral cefuroxime every 12 hours for 10 days.79
For the treatment of uncomplicated UTIs, the manufacturer recommends that adolescents ≥13 years of age receive 250 mg of oral cefuroxime every 12 hours for 7-10 days.79
The duration of cefuroxime therapy depends on the type of infection but should generally be continued for at least 48-72 hours after the patient becomes afebrile or evidence of eradication of the infection is obtained.1
For the treatment of uncomplicated UTIs, the manufacturer recommends that therapy with cefuroxime axetil tablets be continued for 7-10 days.79 For the treatment of uncomplicated skin and skin-structure infections, or acute otitis media caused by susceptible organisms, the manufacturer recommends that therapy with cefuroxime axetil tablets be continued for 10 days.79
Chronic urinary tract infections may require several weeks of cefuroxime therapy, and bacteriologic and clinical assessments should be made frequently during therapy and for several months after the drug is discontinued.1 When cefuroxime is used in the treatment of staphylococcal and other infections involving a collection of pus, surgical drainage should be performed when indicated.1
Systemic exposure to cefuroxime is not expected to be altered in patients with hepatic impairment.1
Modification of usual dosage of parenteral cefuroxime is unnecessary in patients with creatinine clearances >20 mL/minute.1, 18 However, in patients with creatinine clearances of ≤20 mL/minute, doses and/or frequency of administration of parenteral cefuroxime must be modified in response to the degree of renal impairment, severity of the infection, and susceptibility of the causative organism.1, 112, 113, 114, 115 The manufacturer and some clinicians recommend that adults with creatinine clearances of 10-20 mL/minute receive 750 mg of cefuroxime IM or IV every 12 hours and that adults with creatinine clearances <10 mL/minute receive 750 mg IM or IV every 24 hours.1, 112, 113, 114 In children with impaired renal function, the manufacturer recommends that the frequency of administration of parenteral cefuroxime be modified based on the recommendations for adults with impaired renal function.1
In patients with creatinine clearances <30 mL/minute, adjustment of the dosage interval of oral cefuroxime axetil tablets is necessary.79 In patients with a creatinine clearance of 10 to <30 mL/minute, the standard individual oral cefuroxime dose should be given once every 24 hours.79 In patients with a creatinine clearance of <10 mL/minute who are not undergoing hemodialysis, the standard individual oral cefuroxime dose should be given once every 48 hours.79
In patients undergoing hemodialysis, a supplemental dose of parenteral or oral cefuroxime should be given after each dialysis period.1, 3, 30, 79
The manufacturers state that age-based dosage adjustment does not appear to be necessary.1, 79 However, because geriatric patients are more likely to have decreased renal function, dosage should be selected with caution in these patients and monitoring of renal function may be useful.1, 79
Clostridioides difficile-associated Diarrhea and Colitis (CDAD)
Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridioides difficile .1, 79, 185, 186, 187
C. difficile infection (CDI) and C. difficile -associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) have been reported with nearly all anti-infectives, including cefuroxime, and may range in severity from mild diarrhea to fatal colitis.1, 31, 79, 104, 105, 108, 185, 186, 187C. difficile produces toxins A and B, which contribute to the development of CDAD;1, 79, 185 hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.1, 79
Consider CDAD in the differential diagnosis in patients who develop diarrhea during or after anti-infective therapy and manage accordingly.1, 79, 185, 186, 187 Careful medical history is necessary since CDAD has been reported to occur as late as 2 months or longer after anti-infective therapy is discontinued.1, 79, 185
If CDAD is suspected or confirmed, anti-infectives not directed against C. difficile may need to be discontinued.1, 79, 185 Manage patients with appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.1, 79, 185, 186, 187
Hypersensitivity reactions, including rash, pruritus, fever, eosinophilia, urticaria, potentially fatal anaphylaxis, erythema multiforme, interstitial nephritis, Stevens-Johnson syndrome, and toxic epidermal necrolysis, have been reported in patients receiving cefuroxime.1, 79 If an allergic reaction occurs, discontinue cefuroxime and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, maintenance of an adequate airway and oxygen).1, 79
There is clinical evidence of partial cross-allergenicity among cephalosporins and other β-lactam antibiotics including penicillins;1, 79 however, the true incidence of cross-allergenicity among these anti-infectives has not been established.30, 178
Prior to initiation of therapy, make a careful inquiry concerning previous hypersensitivity reactions to cephalosporins, penicillins, or other drugs.1, 79 Use cefuroxime with caution in individuals hypersensitive to penicillins or other drugs;1, 79 the manufacturer of cefuroxime axetil states that the drug is contraindicated in patients with known hypersensitivity to β-lactam antibiotics.79
Potential for Microbial Overgrowth
Emergence and overgrowth of nonsusceptible organisms may occur with prolonged cefuroxime therapy.1, 31, 79, 88, 92, 101, 103, 104, 105 Careful observation of the patient is essential.1 Institute appropriate therapy if superinfection occurs.1
Cefuroxime should be used with caution in patients with a history of GI disease, particularly colitis.1
Because some cephalosporins have been associated with a decrease in prothrombin activity, the manufacturers state that prothrombin time (PT) should be monitored when cefuroxime is used in patients with renal or hepatic impairment, in patients with poor nutritional status, in patients receiving a protracted course of anti-infective therapy, or in those previously stabilized on anticoagulant therapy.1 Vitamin K should be administered if indicated.1
Periodically evaluate renal status during therapy, especially in seriously ill patients receiving maximum dosage.1
Use caution if cefuroxime is used concomitantly with nephrotoxic drugs (e.g., aminoglycosides, potent diuretics).1
Selection and Use of Anti-infectives
To reduce development of drug-resistant bacteria and maintain effectiveness of cefuroxime and other antibacterials, use cefuroxime only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.1, 79
When selecting or modifying anti-infective therapy, use the results of culture and in vitro susceptibility testing.1, 79 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.1, 79
Interference with Glucose Tests
A false-positive result for glucose in the urine may occur with copper reduction tests, and a false-negative result for blood/plasma glucose may occur with ferricyanide tests in patients receiving cefuroxime axetil.79
Mild to severe hearing loss has been reported in a few pediatric patients receiving cefuroxime sodium for the treatment of meningitis.1 Persistence of positive CSF cultures at 18-36 hours has been observed with cefuroxime sodium injection; however, the clinical relevance of this finding is unknown.1
Cefuroxime sodium contains approximately 54.2 mg (2.4 mEq) of sodium per g of cefuroxime.1
Reproduction studies in mice and rabbits using cefuroxime sodium in dosages up to 6 and 2 times the maximum recommended human dosage based on mg/m2, respectively, and reproduction studies in mice and rats using cefuroxime axetil in dosages up to 14 and 9 times, respectively, the maximum recommended human dosage based on mg/m2 have not revealed evidence of impaired fertility or harm to the fetus.1, 79 There are no adequate and controlled studies to date using cefuroxime in pregnant women, and cefuroxime should be used during pregnancy only when clearly needed.1 The manufacturer of cefuroxime axetil states that while available studies cannot definitively establish the absence of risk, published data from epidemiologic studies, case series, and case reports over several decades have not identified an association with the use of cephalosporins (including cefuroxime axetil) during pregnancy and major birth defects, miscarriage, or other adverse maternal or fetal outcomes.79
Because cefuroxime is distributed into milk,1, 79 cefuroxime sodium should be used with caution in nursing women.1
Based on published case reports, the estimated breastfed infant dose is expected to be <1% of the adult dose.79 No data are available on the effects of the drug on the breastfed infant or the effects of the drug on milk production.79 Consider the developmental and health benefits of breastfeeding along with the mother's clinical need for cefuroxime and any potential adverse effects on the breastfed infant from cefuroxime or from the underlying maternal condition.79
Safety and efficacy of oral cefuroxime axetil79 or parenteral cefuroxime sodium1 in children <3 months of age have not been established. Other cephalosporins accumulate in neonates resulting in prolonged serum half-life.1
In vitro studies indicate that cefuroxime does not appear to displace bilirubin appreciably from albumin binding sites in neonates.111
Safety and efficacy of oral cefuroxime for treatment of acute bacterial maxillary sinusitis in pediatric patients 3 months to 12 years of age have been established based on safety and efficacy of the drug in adults.79 In addition, use of oral cefuroxime in pediatric patients is supported by pharmacokinetic and safety data in adult and pediatric patients, clinical and microbiologic data from adequate and well-controlled studies of the treatment of acute bacterial maxillary sinusitis in adults and acute otitis media with effusion in pediatric patients, and postmarketing surveillance of adverse effects.79
Tablets should not be crushed for pediatric administration since the drug has a strong, persistent, bitter taste;79, 82, 99, 101 vomiting was induced aversively in some children who received crushed tablets.101 The oral suspension (no longer commercially available in the US) should be used in children who cannot swallow tablets whole.79
Of the 1,914 subjects who received parenteral cefuroxime in 24 clinical studies, 47% were ≥65 years of age while 22% were ≥75 years of age.1 Of the total number of subjects who received cefuroxime axetil in 20 clinical trials, 375 were ≥65 years of age while 151 were ≥75 years of age.79 No overall differences in safety or effectiveness of oral or parenteral cefuroxime were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between geriatric patients and younger adults; however, greater susceptibility of some older individuals to effects of the drug cannot be ruled out.1, 79
Cefuroxime is substantially eliminated by kidneys; the risk of toxicity may be greater in those with impaired renal function.1, 79 Limited data indicate that mean serum elimination half-life of cefuroxime is prolonged in geriatric patients (mean age: 83.9 years) who have a mean creatinine clearance of approximately 35 mL/minute.79 Despite this prolonged elimination, the manufacturers state that age-based dosage adjustment does not appear to be necessary.79 However, because geriatric patients are more likely to have decreased renal function, dosage should be selected with caution in these patients and monitoring of renal function may be useful.1, 79
Cefuroxime pharmacokinetics are not expected to be altered in patients with hepatic impairment.1
In patients with renal impairment, the serum half-life of cefuroxime is prolonged.1, 2, 3, 79
In patients with creatinine clearances of ≤20 mL/minute, doses and/or frequency of administration of parenteral cefuroxime must be modified in response to the degree of renal impairment, severity of the infection, and susceptibility of the causative organism.1, 112, 113, 114, 115
In patients with creatinine clearances of <30 mL/minute, adjustment of the dosage interval of cefuroxime axetil tablets is necessary.79
In patients undergoing hemodialysis, a supplemental dose of oral or parenteral cefuroxime should be given after each dialysis period.1, 3, 30, 79
Common adverse effects reported in patients receiving cefuroxime sodium injection include local reactions at IV injection sites, reported in approximately 2% of patients.1
Common adverse effects reported in ≥3% of patients receiving oral cefuroxime axetil include diarrhea, nausea/vomiting, and, in patients receiving the drug for early Lyme disease, Jarisch-Herxheimer reaction and vaginitis.79
In vitro studies indicate that the antibacterial activity of cefuroxime and aminoglycosides may be additive or synergistic against some organisms including Enterobacter ,2, 6 Escherichia coli ,2, 6 Klebsiella ,2, 6 Proteus mirabilis ,6 and Serratia marcescens .2, 6
Concurrent use of aminoglycosides and certain cephalosporins reportedly may increase the risk of nephrotoxicity during therapy.1, 16 Although this effect has not been reported to date with cefuroxime, the possibility that nephrotoxicity may be potentiated should be considered if the drug is used concomitantly with an aminoglycoside.1, 16, 30
Drugs that reduce gastric acidity may result in a lower bioavailability of cefuroxime axetil compared with administration in the fasting state.79 Administration of drugs that reduce gastric acidity may negate the food effect of increased absorption of cefuroxime axetil when administered in the postprandial state.79 Administer cefuroxime axetil tablets at least 1 hour before or 2 hours after administration of short-acting antacids.79
Antagonistic effects have been observed in vitro with the combination of chloramphenicol and cefuroxime.1
The manufacturers state that cefuroxime should be used with caution in patients receiving potent diuretics because concurrent use of these drugs may increase the risk of adverse renal effects.1
Histamine H2-receptor Antagonists
Drugs that reduce gastric acidity may result in a lower bioavailability of cefuroxime axetil compared with administration in the fasting state.79 Administration of drugs that reduce gastric acidity may negate the food effect of increased absorption of cefuroxime axetil when administered in the postprandial state.79 Avoid concomitant use of cefuroxime axetil with H2-receptor antagonists.79
Oral probenecid administered shortly before or concomitantly with cefuroxime usually slows the rate of tubular secretion of cefuroxime and produces higher and more prolonged serum concentrations of cefuroxime.1, 2, 21, 30 This effect has been used to therapeutic advantage in the treatment of gonorrhea.1 Peak serum concentrations of cefuroxime and the half-life of the drug are reportedly increased by up to 30% when probenecid is administered concomitantly with cefuroxime sodium;1, 2, 21, 30, 79 concomitant administration of probenecid with cefuroxime axetil increased the area under the concentration-time curve (AUC) of cefuroxime by about 50%.79 Concomitant administration of probenecid also reportedly decreases the apparent volume of distribution of cefuroxime by about 20%.3 The manufacturer of oral cefuroxime axetil states that concomitant use of probenecid with cefuroxime axetil is not recommended.79
Drugs that reduce gastric acidity may result in a lower bioavailability of cefuroxime axetil compared with administration in the fasting state.79 Administration of drugs that reduce gastric acidity may negate the food effect of increased absorption of cefuroxime axetil when administered in the postprandial state.79 Avoid concomitant use of cefuroxime axetil with proton pump inhibitors.79
Positive direct antiglobulin (Coombs') test results have been reported in patients receiving cefuroxime axetil or cefuroxime sodium.1, 79, 103
Like most other cephalosporins, cefuroxime reportedly causes false-positive results in urine glucose determinations using cupric sulfate solution (Benedict's solution, Fehling's solution, Clinitest®); however, glucose oxidase tests are unaffected by the drug.1, 79
Cefuroxime may cause false-negative results when ferricyanide methods are used to determine blood glucose concentrations.1, 79 Use of either the glucose oxidase or hexokinase method is recommended to determine blood glucose levels in patients receiving cefuroxime.1, 79
Cefuroxime does not interfere with the assay of serum and urine creatinine by the alkaline picrate method.1, 79
Cefuroxime is usually bactericidal in action.1, 2, 79 Like other cephalosporins, the antibacterial activity of the drug results from inhibition of mucopeptide synthesis in the bacterial cell wall.1, 2 Based on its spectrum of activity, cefuroxime is classified as a second generation cephalosporin.3, 6, 10, 18, 48 Susceptibility to cefuroxime will vary with geography and time; consult local susceptibility data if available.79
Like other available second generation cephalosporins (e.g., cefaclor, cefamandole, cefprozil), cefuroxime generally is more active in vitro against gram-negative bacteria than first generation cephalosporins but has a narrower spectrum of activity against gram-negative bacteria than third generation cephalosporins.4, 10, 18, 30, 48 The spectrum of activity of cefuroxime resembles that of cefamandole and, to a lesser extent, that of cefoxitin.13, 14 Cefuroxime has activity in the presence of some β-lactamases, both penicillinases and cephalosporinases, of gram-negative and gram-positive bacteria.1, 79 Cefuroxime is more resistant to hydrolysis by β-lactamases than cefamandole and is active against some strains of gram-negative bacteria (e.g., Escherichia coli , Enterobacter , Klebsiella , Neisseria ) that are resistant to cefamandole.6, 8, 30 Cefoxitin is active against several organisms that generally are resistant to cefuroxime (e.g., Serratia marcescens , Proteus vulgaris , Bacteroides fragilis ).6, 13, 14
Parenteral cefuroxime is active in vitro and in clinical infections against Staphylococcus aureus , Streptococcus pneumoniae , and S. pyogenes (group A β-hemolytic streptococci).1 Cefuroxime axetil is active in vitro and in clinical infections against S. aureus (methicillin-susceptible isolates only), S. pneumoniae , and S. pyogenes .79 Parenteral cefuroxime is active in vitro against Staphylococcus epidermidis, but clinical efficacy has not been established.1 Cefuroxime axetil is active in vitro against S. epidermidis (methicillin-susceptible isolates only), Staphylococcus saprophyticus (methicillin-susceptible isolates only), and Streptococcus agalactiae, but clinical efficacy has not been established.79
Strains of staphylococci resistant to penicillinase-resistant penicillins (oxacillin-resistant [methicillin-resistant] staphylococci) should be considered resistant to cefuroxime and cefuroxime axetil, although results of in vitro susceptibility tests may indicate that the organisms are susceptible to the drug.79 In addition, β-lactamase-negative, ampicillin-resistant (BLNAR) strains of H. influenzae should be considered resistant to cefuroxime and cefuroxime axetil despite the fact that results of in vitro susceptibility tests may indicate that the organisms are susceptible to the drug.79 Most extended spectrum β-lactamase (ESBL)-producing and carbapenemase-producing isolates are resistant to cefuroxime axetil.79
In vitro, cefuroxime concentrations of 0.5-1 mcg/mL inhibit most strains of S. aureus (including penicillinase-producing and nonpenicillinase-producing strains)3, 4, 6, 30 and concentrations of 1-2 mcg/mL inhibit most strains of S. epidermidis .2, 3, 30 Most strains of staphylococci resistant to penicillinase-resistant penicillins also are resistant to cefuroxime.4, 6 In vitro, α-hemolytic2, 3, 4, 30 and β-hemolytic streptococci4, 30 are usually inhibited by cefuroxime concentrations of 0.05-0.5 mcg/mL and S. pneumoniae is usually inhibited by concentrations of 0.01-0.13 mcg/mL.3, 4, 30 Most strains of enterococci, including E. faecalis , are generally resistant to cefuroxime.2, 4, 6, 30 Listeria monocytogenes generally is resistant to cefuroxime.2, 6
Cefuroxime is active in vitro against most gram-negative aerobic cocci and many gram-negative aerobic bacilli including Enterobacteriaceae .1, 6, 30 Pseudomonas aeruginosa is resistant to cefuroxime.6, 10, 13, 14, 30 Acinetobacter calcoaceticus is also usually resistant to the drug.2, 3
Parenteral cefuroxime is active in vitro and in clinical infections against Enterobacter , Escherichia coli , Haemophilus influenzae (including ampicillin-resistant strains), Klebsiella (including K. pneumoniae 2, 3, 6, 14, 30 ), Neisseria gonorrhoeae , and N. meningitidis .1 Cefuroxime axetil is active in vitro and in clinical infections against E. coli , K. pneumoniae , H. influenzae , Haemophilus parainfluenzae , Moraxella catarrhalis , and N. gonorrhoeae .79 Parenteral cefuroxime is active in vitro against Citrobacter , Providencia rettgeri , H. parainfluenzae , Proteus mirabilis , M. catarrhalis , Morganella morganii , Salmonella , and Shigella , but clinical efficacy has not been established.1 Cefuroxime axetil is active in vitro against M. morganii , Proteus inconstans , P. mirabilis , and P. rettgeri, but clinical efficacy has not been established.79
Generally, cefuroxime is active in vitro against the following Enterobacteriaceae: Citrobacter diversus ,30 C. freundii ,3, 6 Enterobacter aerogenes ,3, 6, 15, 30 Escherichia coli ,1, 2, 3, 6, 15, 30, 79 Klebsiella pneumoniae ,2, 3, 6, 14, 30, 79 Proteus mirabilis ,1, 2, 3, 6, 14, 15, 30, 79 Salmonella ,1, 6, 15, 30 and Shigella .1, 6, 30 Although cefuroxime is active in vitro against some strains of Morganella morganii (formerly Proteus morganii ), Providencia rettgeri 1, 79 (formerly Proteus rettgeri ), and Proteus vulgaris , most strains of these organisms are resistant to the drug.2, 4, 6, 15 Most susceptible Enterobacteriaceae are inhibited in vitro by cefuroxime concentrations of 1-12.5 mcg/mL.2, 3, 4, 14, 15, 30, 40 In vitro on a weight basis, the activity of cefuroxime against susceptible Enterobacteriaceae is approximately equal to that of cefoxitin14, 15 but less than that of cefotaxime.14, 15, 34, 40 Cefuroxime may be active in vitro against some strains of E. aerogenes that are resistant to cefoxitin;15, 30 however, cefotaxime and, to a lesser extent, cefoxitin may be active in vitro against some strains of P. vulgaris and Serratia resistant to cefuroxime.10, 14, 40
Cefuroxime is active in vitro against H. influenzae (including ampicillin-resistant strains)1, 2, 3, 4, 6, 30, 79 and H. parainfluenzae .1, 79 Most susceptible strains of H. influenzae are inhibited in vitro by cefuroxime concentrations of 0.1-2 mcg/mL.2, 3, 4, 6, 28, 30
Cefuroxime is active in vitro and in clinical infections against N. gonorrhoeae (including both penicillinase-producing and nonpenicillinase-producing strains) and N. meningitidis .1 The MIC90 (minimum inhibitory concentration of the drug at which 90% of strains tested are inhibited) of cefuroxime reported for N. gonorrhoeae (including both penicillinase-producing and nonpenicillinase-producing strains) is 0.1-0.5 mcg/mL.2, 4, 6, 9, 30
Cefuroxime is active in vitro against some anaerobic bacteria, including Actinomyces ,6 Eubacterium ,6 Fusobacterium ,30 Lactobacillus ,6 Peptococcus ,2, 6, 30, 79 Peptostreptococcus ,2, 6, 30 Propionibacterium ,6 and Veillonella .6 Cefuroxime axetil is active in vitro against Peptococcus niger .79 Cefuroxime is active in vitro against some strains of Clostridioides , but clinical efficacy has not been established;2, 6, 30 however, C. difficile is usually resistant to the drug.6
Most susceptible anaerobes are inhibited in vitro by cefuroxime concentrations of 0.5-16 mcg/mL.2, 6 Although cefuroxime concentrations of 16 mcg/mL inhibit some strains of Bacteroides fragilis in vitro, most strains of the organism are resistant to the drug.2, 4, 6, 30
Cefuroxime is active in vitro and in vivo against Borrelia burgdorferi , the causative organism of Lyme disease.79, 129, 132 In vitro, the MIC of cefuroxime for B. burgdorferi reportedly is 0.13 mcg/mL129 and the minimum bactericidal concentration (MBC) is 1 mcg/mL.132
Because cefuroxime contains a methoxyimino group that protects the β-lactam ring from hydrolysis by many penicillinases and cephalosporinases, the drug is more resistant to hydrolysis by β-lactamases than are first generation cephalosporins13, 30 or cefamandole.30 Cefuroxime is generally resistant to hydrolysis by β-lactamases classified as Richmond-Sykes types I, II, III, IV, and V2, 6, 13, 23, 30 and most β-lactamases produced by N. gonorrhoeae ,2, 6, 30 H. influenzae ,2, 6, 30 and staphylococci.2, 6, 30 However, cefuroxime is hydrolyzed by β-lactamases produced by B. fragilis, 13 and some type I β-lactamases produced by Serratia ,30 P. vulgaris ,12, 13, 14, 15 and P. rettgeri .30 Results of one in vitro study indicate that cefuroxime is hydrolyzed more rapidly than cefotaxime by β-lactamases produced by P. vulgaris and B. fragilis .13 Although cefuroxime is resistant to hydrolysis by β-lactamases produced by P. aeruginosa , these organisms are resistant to cefuroxime because the drug cannot penetrate their cell wall.8
Resistance to cefuroxime is primarily through hydrolysis by β-lactamase, alteration of penicillin-binding proteins (PBPs), decreased permeability, and the presence of bacterial efflux pumps.1, 79
Following oral administration of cefuroxime axetil, the drug is absorbed from the GI tract and rapidly hydrolyzed to cefuroxime.79, 82, 92, 93, 97, 98, 99, 104, 105, 106, 107, 108 Cefuroxime axetil has little, if any, microbiologic activity until hydrolyzed in vivo to cefuroxime.82, 116 Cefuroxime axetil oral suspension (no longer commercially available in the US) is not bioequivalent to cefuroxime axetil tablets.79
In adults receiving cefuroxime axetil film-coated tablets, peak serum concentrations are attained approximately 2-3 hours after the dose.79, 81 Following oral administration of the oral suspension (no longer commercially available in the US) given with milk or milk products in children, peak serum concentrations are attained within 2.7-3.6 hours.148
In adults, bioavailability following oral administration of film-coated tablets averages about 37% when given in the fasting state and 52% when given with or shortly after food.79, 81 Absorption is increased when cefuroxime axetil is given with milk or infant formula.98 The extent (but not the rate) of absorption is substantially greater when cefuroxime axetil is administered concomitantly with milk compared with applesauce or fasting.98
Cefuroxime sodium is not appreciably absorbed from the GI tract and must be given parenterally.1, 2, 6, 21, 30 Following IM administration of cefuroxime sodium in healthy adults, peak serum concentrations are attained within 15-60 minutes.1, 2, 3, 6, 21, 30 In women, serum cefuroxime concentrations are lower when IM injections are given into the gluteus maximus rather than into the thigh.30
Following IM or IV administration, cefuroxime is widely distributed into body tissues and fluids including pleural fluid, joint fluid, bile, sputum, bone, and aqueous humor.1 Therapeutic concentrations may be attained in CSF following IV administration in patients with inflamed meninges.2, 3, 7, 18, 22, 26, 29, 30, 43 Cefuroxime readily crosses the placenta2, 24 and is distributed into milk.1, 79 Cefuroxime is 33-50% bound to serum proteins.1, 2, 6, 21, 30, 79
Following oral administration, cefuroxime axetil is rapidly hydrolyzed to cefuroxime by nonspecific esterases in the intestinal mucosa and blood;79, 82, 92, 93, 97, 98, 99, 104, 105, 106, 107, 108 the axetil moiety (the 1-[acetyloxy]ethyl ester)is metabolized to acetaldehyde and acetic acid.79, 105, 106 Cefuroxime is not metabolized and is excreted unchanged principally in urine by both glomerular filtration and tubular secretion.2, 6, 21, 27, 30
In adults with normal renal function, 90-100% of a single IM or IV dose of cefuroxime is excreted unchanged in urine within 24 hours;3, 21, 27, 30 most of the dose is excreted within the first 6 hours following administration.30
In adults, the serum or plasma half-life of cefuroxime following oral administration of commercially available cefuroxime axetil tablets or oral suspension (no longer commercially available in the US) ranges from 1.2-1.6 hours.79, 81, 98 In adults with normal renal function, the serum half-life of cefuroxime following IM or IV administration reportedly ranges from 1-2 hours.1, 3, 18, 21, 27, 30 In adults, approximately 50% of an administered dose of cefuroxime axetil is recovered in the urine within 12 hours.79
In patients with renal impairment, the serum half-life of the drug is prolonged1, 2, 3, 79 and generally ranges from 1.9-16.1 hours depending on the degree of impairment.3, 30 In one study, the serum half-life of cefuroxime was 1 hour in patients with creatinine clearances of 50-79 mL/minute, 2.55 hours in patients with creatinine clearances of 25-46 mL/minute, 5.1 hours in patients with creatinine clearances of 10-24 mL/minute, and 14.8 hours in patients with creatinine clearances less than 10 mL/minute.6 A serum half-life of 15-22 hours has been reported in anuric patients.18, 30
In neonates and children, the serum half-life of cefuroxime is inversely proportional to age.6, 25, 30 Following oral administration of cefuroxime axetil oral suspension in children 3 months to 12 years of age, the serum half-life of cefuroxime averages 1.4-1.9 hours.148 The serum half-life of cefuroxime following IM or IV administration is reportedly 5.1-5.8 hours in neonates 3 days of age or younger,6, 25, 30 2-4.2 hours in neonates 6-14 days of age,6, 25, 30 and 1-1.5 hours in neonates 3-4 weeks of age.6, 25 The manufacturers of cefuroxime axetil state that the urinary pharmacokinetics of cefuroxime axetil have not been determined in children and that the renal pharmacokinetics of oral cefuroxime axetil as established in the adult population should not be extrapolated to children.79
Additional Information
The American Society of Health-System Pharmacists, Inc. represents that the information provided in the accompanying monograph was formulated with a reasonable standard of care, and in conformity with professional standards in the field. Readers are advised that decisions regarding use of drugs are complex medical decisions requiring the independent, informed decision of an appropriate health care professional, and that the information contained in the monograph is provided for informational purposes only. The manufacturer's labeling should be consulted for more detailed information. The American Society of Health-System Pharmacists, Inc. does not endorse or recommend the use of any drug. The information contained in the monograph is not a substitute for medical care.
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Oral | Tablets, film-coated | 125 mg (of cefuroxime)* | Cefuroxime Axetil Tablets | |
250 mg (of cefuroxime)* | Cefuroxime Axetil Tablets | |||
500 mg (of cefuroxime)* | Cefuroxime Axetil Tablets |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
Routes | Dosage Forms | Strengths | Brand Names | Manufacturer |
|---|---|---|---|---|
Parenteral | For injection | 750 mg (of cefuroxime)* | Cefuroxime Sodium for Injection | |
1.5 g (of cefuroxime)* | Cefuroxime Sodium for Injection | |||
7.5 g (of cefuroxime) pharmacy bulk package* | Cefuroxime Sodium for Injection |
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
1. Hikma Pharmaceuticals USA Inc. Cefuroxime powder for injection prescribing information. Berkeley Heights, NJ; 2021 May.
2. Glaxo Inc. Product information monograph on Zinacef®. Research Triangle Park, NC; 1983.
3. Gold B, Rodriquez WJ. Cefuroxime: mechanisms of action, antimicrobial activity, pharmacokinetics, clinical application, adverse reactions and therapeutic indications. Pharmacotherapy . 1983; 3:82-100. [PubMed 6344037]
4. Eykyn S, Jenkins C, King A et al. Antibacterial activity of cefuroxime, a new cephalosporin antibiotic, compared with that of cephaloridine, cephalothin, and cefamandole. Antimicrob Agents Chemother . 1976; 9:690-5. [PubMed 1267441]
6. Smith BR, LeFrock JL. Cefuroxime: antimicrobial activity, pharmacology, and clinical efficacy. Ther Drug Monit . 1983; 5:149-60. [PubMed 6349019]
7. Johansson O, Cronberg S, Hoffstedt B et al. Cefuroxime versus ampicillin and chloramphenicol for the treatment of bacterial meningitis—report from a Swedish study group. Lancet . 1982; 1:295-8. [PubMed 6120310]
8. Browning AK, House CA. Pharmacokinetics of cefuroxime compared to other cephalosporins. In: Cefuroxime update. Royal Society of Medicine International Congress and Symposium Series No. 38. London; 1981. 87-99.
9. Lossick JG, Thompson SE, Smeltzer MP. Comparison of cefuroxime and penicillin in the treatment of uncomplicated gonorrhea. Antimicrob Agents Chemother . 1982; 22:409-13. [PubMed 6814355]
10. Weinstein AJ. The cephalosporins: activity and clinical use. Drugs . 1980; 20:137-54. [PubMed 6995096]
12. O'Callaghan CH. Description and classification of the newer cephalosporins and their relationship with the established compounds. J . Antimicrob Chemother. 1979; 5:635-71.
13. King A, Warren C, Shannon K et al. The in vitro antibacterial activity of cefotaxime compared with that of cefuroxime and cefoxitin. J Antimicrob Chemother . 1980; 6:479-94. [PubMed 6253433]
14. Legakis NJ, Kafetzis DA, Papadatos CJ et al. Antibacterial activity of HR-756, cefoxitin and cefuroxime against multiple antibiotic-resistant strains of Enterobacteriaceae and Pseudomonas aeruginosa. Chemotherapy. 1980; 26:334-43.
15. Masuyoshi S, Arai S, Miyamoto M et al. In vitro antimicrobial activity of cefotaxime, a new cephalosporin. Antimicrob Agents Chemother . 1980; 18:1-8. [PubMed 6251749]
16. Mannion JC, Bloch R, Popovich NG. Cephalosporin-aminoglycoside synergistic nephrotoxicity: fact or fiction? Drug Intell Clin Pharm. 1981; 15:248-56.
18. Nelson JD. Cefuroxime: a cephalosporin with unique applicability to pediatric practice. Pediatr Infect Dis . 1983; 2:394-6. [PubMed 6356062]
19. Corbeel L. Cefuroxime for treatment of bacterial meningitis. Lancet . 1982; 1:750. [PubMed 6122048]
20. Price JD, Fluker JL. The efficacy of cefuroxime for the treatment of acute gonorrhoea in men. Br J Vener Dis . 1978; 54:165-7. [PubMed 656890]
21. Foord RD. Cefuroxime: human pharmacokinetics. Antimicrob Agents Chemother . 1976; 9:741-7. [PubMed 949172]
22. Muller C, Netland A, Dawson AF et al. The penetration of cefuroxime into the cerebrospinal fluid through inflamed and non-inflamed meninges. J Antimicrob Chemother . 1980; 6:279-83. [PubMed 7380771]
23. Mathew M. Plasmid-mediated β-lactamases of gram-negative bacteria: properties and distribution. J Antimicrob Chemother . 1979; 5:349-58. [PubMed 385575]
24. Philipson A, Stiernstedt G. Pharmacokinetics of cefuroxime in pregnancy. Am J Obstet Gynecol . 1982; 142:823-8. [PubMed 7065060]
25. De Louvois J, Mulhall A, Hurley R. Cefuroxime in the treatment of neonates. Arch Dis Child . 1982; 57:59-62. [PubMed 7065695]
26. Pfenninger J, Schaad UB, Lutschg J et al. Cefuroxime in bacterial meningitis. Arch Dis Child . 1982; 57:539-43. [PubMed 7103546]
27. Gower PE, Dash CH. The pharmacokinetics of cefuroxime after intravenous injection. Eur J Pharmacol . 1977; 12:221-7.
28. Ball AP, Brooks GR, Farrell ID et al. Studies with cefuroxime: a new beta-lactamase resistant cephalosporin. Chemotherapy . 1979; 25:214-21. [PubMed 110540]
29. Corbeel L, Van Acker G, Eeckels R et al. Cefuroxime plasma and CSF levels in children with meningitis. Arch Dis Child . 1979; 54:729-30. [PubMed 518117]
30. Brogden RN, Heel RC, Speight TM et al. Cefuroxime: a review of its antibacterial activity, pharmacological properties and therapeutic use. Drugs . 1979; 17:233-66. [PubMed 37064]
31. Keighley MR. Antibiotic-associated pseudomembranous colitis: pathogenesis and management. Drugs . 1980; 20:49-56. [PubMed 7398539]
34. Fu KP, Neu HC. Beta-lactamase stability of HR 756, a novel cephalosporin, compared to that of cefuroxime and cefoxitin. Antimicrob Agents Chemother . 1978; 14:322-6. [PubMed 101128]
36. Workowski KA, Bachmann LH, Chan PA et al. Sexually transmitted infections treatment guidelines, 2021. MMWR Recomm Rep. 2021; 70:1-187
40. Fu KP, Neu HC. Antibacterial activity of ceftizoxime, a β-lactamase-stable cephalosporin. Antimicrob Agents Chemother . 1980; 17:583-90. [PubMed 6967294]
43. Sirinavin S, Chiemchanya S, Visudhipan P et al. Cefuroxime treatment of bacterial meningitis in infants and children. Antimicrob Agents Chemother . 1984; 25:273-5. [PubMed 6608921]
44. Reviewer's comments (personal observations); 1984 Feb 29.
45. Gerber MA, Baltimore RS, Eaton CB et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation . 2009; 119:1541-51. [PubMed 19246689]
48. Tartaglione TA, Polk RE. Review of the new second generation cephalosporins: cefonicid, ceforanide, and cefuroxime. Drug Intell Clin Pharm . 1985; 19:188-98. [PubMed 3884304]
49. Eichenwald HF. Antimicrobial therapy in infants and children: update 1976-1985. Part 1. J Pediatr . 1985; 107:161-8. [PubMed 4020539]
50. Nadelman RB, Luger SW, Frank E et al. Comparison of cefuroxime axetil and doxycycline in the treatment of early Lyme disease. Ann Intern Med . 1992; 117:273-280. [PubMed 1637021]
51. Metlay JP, Waterer GW, Long AC et al. Diagnosis and treatment of adults with community-acquired pneumonia: an official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019; 200:e45-e67.
58. Anon. Drugs for bacterial infections. Med Lett Treat Guid . 2010; 8:43-52.
62. Luger SW, Paparone P, Wormser GP et al. Comparison of cefuroxime axetil and doxycycline in treatment of patients with early Lyme disease associated with erythema migrans. Antimicrob Agents Chemother . 1995; 39:661-7. [PubMed 7793869]
64. Marks WA, Stutman HR, Marks MI et al. Cefuroxime versus ampicillin plus chloramphenicol in childhood bacterial meningitis: a multicenter randomized controlled trial. J Pediatr . 1986; 109:123-30. [PubMed 3522832]
66. Slama TG, Sklar SJ, Misinski J et al. Randomized comparison of cefamandole, cefazolin, and cefuroxime prophylaxis in open-heart surgery. Antimicrob Agents Chemother . 1986; 29:744-7. [PubMed 3524428]
68. Centers for Disease Control and Prevention (CDC). Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep . 2012; 61:590-4. [PubMed 22874837]
71. . Antimicrobial prophylaxis for surgery. Treat Guidel Med Lett . 2012; 10:73-8; quiz 79-80. [PubMed 22996382]
79. American Health Packaging. Cefuroxime axetil tablets prescribing information. Columbus, OH; 2022 Sep.
81. Finn A, Straughn A, Meyer M et al. Effect of dose and food on the bioavailability of cefuroxime axetil. Biopharm Drug Dispos . 1987; 8:519-26. [PubMed 3427209]
82. Marx MA, Fant WK. Cefuroxime axetil. Drug Intell Clin Pharm . 1988; 22:651-8. [PubMed 3063476]
83. Wanas TM, Williams PE. Oral cefuroxime axetil compared with oral ampicillin treating uncomplicated gonorrhoea. Genitourin Med . 1986; 62:221-3. [PubMed 3733084]
84. Fong IW, Linton W, Simbul M et al. Comparative clinical efficacy of single oral doses of cefuroxime axetil and amoxicillin in uncomplicated gonococcal infections. Antimicrob Agents Chemother . 1986; 30:321-2. [PubMed 3094443]
85. Reichman RC, Nolte FS, Wolinsky SM et al. Single-dose cefuroxime axetil in the treatment of uncomplicated gonorrhea: a controlled trial. Sex Transm Dis . 1985; 12:184-7. [PubMed 3936198]
86. Gottlieb A, Mills J. Cefuroxime axetil for treatment of uncomplicated gonorrhea. Antimicrob Agents Chemother . 1986; 30:333-4. [PubMed 3767347]
87. Schift R, Van Ulsen J, Ansink-Schipper MC et al. Comparison of oral treatment of uncomplicated urogenital and rectal gonorrhoea with cefuroxime axetil ester or clavulanic acid potentiated amoxycillin (Augmentin). Genitourin Med . 1986; 62:313-7. [PubMed 3533755]
88. McLinn SE, Werner K, Cocchetto DM. Clinical trial of cefuroxime axetil versus cefaclor for acute otitis media with effusion. Curr Ther Res . 1988; 43:1-11.
89. Hebblethwaite EM, Brown GW, Cox DM. A comparison of the efficacy and safety of cefuroxime axetil and augmentin in the treatment of upper respiratory tract infections. Drugs Exp Clin Res . 1987; 13:91-4. [PubMed 3582135]
90. Gooch WM, Higbee MD, Cocchetto DM et al. Cefuroxime axetil and penicillin V compared in the treatment of group A beta-hemolytic streptococcal pharyngitis. Clin Ther . 1987; 9:670-7. [PubMed 3125976]
91. Pichichero ME, Disney FA, Aronovitz GH et al. A multicenter, randomized, single-blind evaluation of cefuroxime axetil and phenoxymethyl penicillin in the treatment of streptococcal pharyngitis. Clin Pediatr . 1987; 26:453-8.
92. Cooper TJ, Ladusans E, Williams PE et al. A comparison of oral cefuroxime axetil and oral amoxycillin in lower respiratory tract infections. J Antimicrob Chemother . 1985; 16:373-8. [PubMed 4055545]
93. Spencer RC, Griggs JV, Brown GW. A dose-ranging study of cefuroxime axetil in the treatment of lower respiratory tract infections in general practice. Drugs Exp Clin Res . 1987; 13:101-3. [PubMed 3582133]
94. Parish LC, Cocchetto DM, Werner K et al. Cefuroxime axetil in the treatment of cutaneous infections. Int J Dermatol . 1987; 26:389-93. [PubMed 3305394]
95. Cox CE, Sherrill JM, Cocchetto DM. Evaluation of cefuroxime axetil, cefaclor, and cephalexin in the treatment of urinary tract infections in adults. Curr Ther Res . 1987; 42:124-37.
96. Williams KJ, Hebblethwaite EM, Brown GW et al. Cefuroxime axetil in the treatment of uncomplicated UTI: a comparison with cefaclor and Augmentin. Drugs Exp Clin Res . 1987; 13:95-9. [PubMed 3556123]
97. Williams PE, Harding SM. The absolute bioavailability of oral cefuroxime axetil in male and female volunteers after fasting and after food. J Antimicrob Chemother . 1984; 13:191-6. [PubMed 6706890]
98. Ginsburg CM, McCracken GH, Petruska M et al. Pharmacokinetics and bactericidal activity of cefuroxime axetil. Antimicrob Agents Chemother . 1985; 28:504-7. [PubMed 3878129]
99. Peterson SE (Glaxo, Research Triangle Park, NC): personal communications; 1988 Sep.
101. Carson JWK, Watters K, Taylor MRH et al. Clinical trial of cefuroxime axetil in children. J Antimicrob Chemother . 1987; 19:109-12. [PubMed 3494006]
102. Finn AL, Sherrill JM, Debussey SS. A comparative study of cefuroxime axetil and cefaclor in the treatment of otitis media with effusion. Proceedings of ICAAC Minneapolis 1985. 1985:202. Abstract No. 600.
103. Schleupner CJ, Anthony WC, Tan J et al. Blinded comparison of cefuroxime to cefaclor for lower respiratory tract infections. Arch Intern Med . 1988; 148:343-8. [PubMed 3277562]
104. Adams DH, Wood MJ, Farrell ID et al. Oral cefuroxime axetil: clinical pharmacology and comparative dose studies in urinary tract infection. J Antimicrob Chemother . 1985; 16:359-66. [PubMed 4055543]
105. Sommers D, Van Wyk M, Williams PEO et al. Pharmacokinetics and tolerance of cefuroxime axetil in volunteers during repeated dosing. Antimicrob Agents Chemother . 1984; 25:344-7. [PubMed 6721467]
106. Campbell CJ, Langley C. Measurement of rat-intestinal cefuroxime axetil esterase activity: comparison of an h.p.l.c. and coupled-enzyme assay. Xenobiotica . 1985; 15:1011-9. [PubMed 2936009]
107. Campbell CJ, Chantrell LJ, Eastmond R. Purification and partial characterization of rat intestinal cefuroxime axetil esterase. Biochem Pharmacol . 1987; 36:2317-24. [PubMed 3606643]
108. Harding SM, Williams PEO, Ayrton J. Pharmacology of cefuroxime as the 1-acetoxyethyl ester in volunteers. Antimicrob Agents Chemother . 1984; 25:78-82. [PubMed 6703686]
110. Aronovitz GH. Treatment of otitis media with cefuroxime axetil. South Med J . 1988; 81:978-80. [PubMed 3043692]
111. Wadsworth SJ, Suh B. In vitro displacement of bilirubin by antibiotics and 2-hydroxybenzoylglycine in newborns. Antimicrob Agents Chemother . 1988; 32:1571-5. [PubMed 3190184]
112. Cantu TG, Fantozzi D. Cefuroxime dosage in renal failure. Ann Intern Med . 1988; 109:989-90. [PubMed 3195883]
113. Aronoff GR. Cefuroxime dosage in renal failure. Ann Intern Med . 1988; 109:990. [PubMed 3195884]
114. Walstad RA, Nilsen OG, Berg KJ. Pharmacokinetics and clinical effects of cefuroxime in patients with severe renal insufficiency. Eur J Clin Pharmacol . 1983; 24:391-8. [PubMed 6861853]
115. Chan MK, Browning AK, Poole CJM et al. Cefuroxime pharmacokinetics in continuous and intermittent peritoneal dialysis. Nephron . 1985; 41:161-5. [PubMed 4047273]
116. Fus AF (Glaxo Inc, Research Triangle Park, NC): Personal communication; 1989 Jan 30.
117. St Claire RL III, Wilbourne DK, Caudill WL. Stability of cefuroxime axetil in apple juice. Pediatr Infect Dis J . 1988; 7:744. [PubMed 3186346]
123. St. Claire III RL, Caudill WL. Stability of cefuroxine axetil in beverages. Am J Hosp Pharm . 1989; 46:256.
124. Henry D, Ruoff GE, Rhudy J et al. Effectiveness of short-course therapy (5 days) with cefuroxime axetil in treatment of secondary bacterial infections of acute bronchitis. Antimicrob Agents Chemother . 1995; 39:2528-34. [PubMed 8585739]
125. Baddour L, Gibbs RS, Mertz G et al. Clinical comparison of single-oral-dose cefuroxime axetil and amoxicillin with probenecid for uncomplicated gonococcal infections in women. Antimicrob Agents Chemother . 1989; 33:801-4. [PubMed 2764526]
126. Moran JS, Levine WC. Drugs of choice for the treatment of uncomplicated gonococcal infections. Clin Infect Dis . 1995; 20(Suppl):S47-65.
127. Kinghorn GR, Spencer RC, Smith TK et al. Comparative study of cefuroxime axetil and procaine penicillin in the treatment of uncomplicated gonorrhoea. Int J STD AIDS . 1990; 1:285-7. [PubMed 2128472]
129. Agger WA, Callister SM, Jobe DA. In vitro susceptibility of Borrelia burgdorferi to five oral cephalosporins and ceftriaxone. Antimicrob Agents Chemother . 1992; 36:1788-90. [PubMed 1416868]
132. Johnson RC, Kodner CB, Jurkovich PJ et al. Comparative in vitro and in vivo susceptibilities of the Lyme disease spirochete Borrelia burgdorferi to cefuroxime and other antimicrobial agents. Antimicrob Agents Chemother . 1990; 34:2133-6. [PubMed 2073103]
134. Luft BJ, Gorevic PD, Halperin JJ et al. A perspective on the treatment of Lyme borreliosis. Rev Infect Dis . 1989; 11(Suppl 6):S1518-25.
135. Eichenfield AH, Athreya BH. Lyme disease: of ticks and titers. J Pediatr . 1989; 114:328-33. [PubMed 2644410]
141. Nadelman RB, Wormser GP. Erythema migrans and early Lyme disease. Am J Med . 1995; 98(4A):15-23S.
143. American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
144. Thorpe EM Jr, Schwebke JR, Hook EW III et al. Comparison of single-dose cefuroxime axetil with ciprofloxacin in treatment of uncomplicated gonorrhea caused by penicillinase-producing and non-penicillinase-producing Neisseria gonorrhoeae strains. Antimicrob Agents Chemother . 1996; 40:2775-80. [PubMed 9124839]
145. Perry CM, Brogden RN. Cefuroxime axetil: a review of its antibacterial activity, pharmacokinetic properties and therapeutic efficacy. Drugs . 1996; 52:125-58. [PubMed 8799689]
146. Glaxo Wellcome Inc. Ceftin® tablets: efficacy in uncomplicated gonorrhea. Research Triangle Park, NC.
147. Glaxo Wellcome Inc. Ceftin® tablets: use in Lyme disease. Research Triangle Park, NC.
148. Powell DA, James NC, Ossi MJ et al. Pharmacokinetics of cefuroxime axetil suspension in infants and children. Antimicrob Agents Chemother . 1991; 35:2042-5. [PubMed 1759825]
153. Camacho AE, Cobo R, Otte J et al. Clinical comparison of cefuroxime axetil and amoxicillin/clavulanate in the treatment of patients with acute bacterial maxillary sinusitis. Am J Med . 1992; 93:271-6. [PubMed 1524078]
157. Paris MM, Ramilo O, McCracken GH. Management of meningitis caused by penicillin-resistant Streptococcus pneumoniae . Antimicrob Agents Chemother . 1995; 39:2171-5. [PubMed 8619561]
158. American Academy of Pediatrics Committee on Infectious Disease. Therapy for children with invasive pneumococcal infections. Pediatrics . 1997; 99:289-99. [PubMed 9024464]
159. Schaad UB, Suter S, Gianella-Borradori A et al. A comparison of ceftriaxone and cefuroxime for the treatment of bacterial meningitis in children. N Engl J Med . 1990; 322:141-7. [PubMed 2403654]
160. Mendelman PM, Chaffin DO, Krilov LR et al. Cefuroxime treatment failure of nontypable Haemophilus influenzae . meningitis associated with alteration of penicillin-binding proteins. J Infect Dis . 1990; 162:1118-23. [PubMed 2230238]
161. Lebel MH, Hoyt MJ, McCracken GH. Comparative efficacy of ceftriaxone and cefuroxime for treatment of bacterial meningitis. J Pediatr . 1989; 114:1049-54. [PubMed 2656960]
162. Arditi M, Herold BC, Yogev R. Cefuroxime treatment failure and Haemophilus influenzae . meningitis: case report and review of literature. Pediatrics . 1989; 84:132-5. [PubMed 2662131]
163. Vogel F, Droszcz W, Vondra V et al. Sequential therapy with cefuroxime followed by cefuroxime axetil in acute exacerbations of chronic bronchitis. J Antimicrob Chemother . 1997; 40:863-71. [PubMed 9462439]
164. Klein GL, Whalen E, Echols RM et al. Ciprofloxacin versus cefuroxime axetil in the treatment of adult patients with acute bacterial sinusitis. J Otolaryngol . 1998; 27:10-6. [PubMed 9511113]
165. Quagliarello VJ, Scheld WM. Treatment of bacterial meningitis. N Engl J Med . 1997; 336:708-16. [PubMed 9041103]
166. Sydnor A, Gwaltney JM, Cocchetto DM et al. Comparative evaluation of cefuroxime axetil and cefaclor for treatment of acute bacterial maxillary sinusitis. Arch Otolaryngol Head Neck Surg . 1989; 115:1430-3. [PubMed 2510772]
167. Van den Brande P, Vondra V, Vogel F et al. Sequential therapy with cefuroxime followed by cefuroxime axetil in community-acquired pneumonia. Chest . 1997; 112:406-15. [PubMed 9266876]
169. Aujard Y, Boucot I, Brahimi N et al. Comparative efficacy and safety of four-day cefuroxime axetil and ten-day penicillin treatment of group A beta-hemolytic streptococcal pharyngitis in children. Pediatr Infect Dis J . 1995; 14:295-300. [PubMed 7603811]
170. Mehra S, Van Moerkerke M, Welck J et al. Short course therapy with cefuroxime axetil for group A streptococcal tonsillopharyngitis in children. Pediatr Infect Dis J . 1998; 17:452-7. [PubMed 9655533]
171. Shulman ST, Bisno AL, Clegg HW et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis . 2012; 55:1279-82. [PubMed 23091044]
173. Pichichero ME, Cohen R. Shortened course of antibiotic therapy for acute otitis media, sinusitis and tonsillopharyngitis. Pediatr Infect Dis J . 1997; 16:680-95. [PubMed 9239773]
174. Tack KJ, Henry DC, Gooch WM et al et al. Five-day cefdinir treatment for streptococcal pharyngitis. Antimicrob Agents Chemother . 1998; 42:1073-5. [PubMed 9593129]
175. Pichichero ME. Cephalosporins are superior to penicillin for treatment of streptococcal tonsillopharyngitis: is the difference worth it? Pediatr Infect Dis . 1993; 12:268-74.
176. Milatovic D. Evaluation of cefadroxil, penicillin and erythromycin in the treatment of streptococcal tonsillopharyngitis. Pediatr Infect Dis J . 1991; 10:S61-3. [PubMed 1945599]
177. Adam D, Hostalek U, Troster K. 5-day cefixime therapy for bacterial pharyngitis and/or tonsillitis: comparison with 10-day penicillin V therapy. Infection . 1995; 23(Supp 2):S83-6. [PubMed 8537138]
178. Kishiyam JL, Adelman DC. The cross-reactivity and immunology of β-lactam antibiotics. Drug Saf . 1994; 10:318-27. [PubMed 8018304]
181. Nadelman RB, Wormser GP. Lyme borreliosis. Lancet . 1998; 352:557-65. [PubMed 9716075]
182. Antibacterial drugs for Lyme disease. Med Lett Drugs Ther . 2021;63:73-5.
183. Rahn DW, Felz MW. Lyme disease update. Current approach to early, disseminated, and late disease. Postgrad Med . 1998; 103:51-4, 57-9, 63-4. [PubMed 9590986]
184. Lieberthal AS, Carroll AE, Chonmaitree T et al. The diagnosis and management of acute otitis media. Pediatrics . 2013; 131:e964-99. [PubMed 23439909]
185. Cohen SH, Gerding DN, Johnson S et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp Epidemiol . 2010; 31:431-55. [PubMed 20307191]
186. Fekety R for the American College of Gastroenterology Practice Parameters Committee. Guidelines for the diagnosis and management of Clostridium difficile -associated diarrhea and colitis. Am J Gastroenterol . 1997; 92:739-50. [PubMed 9149180]
187. American Society of Health-System Pharmacists Commission on Therapeutics. ASHP therapeutic position statement on the preferential use of metronidazole for the treatment of Clostridium difficile -associated disease. Am J Health-Syst Pharm . 1998; 55:1407-11. [PubMed 9659970]
193. Nooyen SM, Overbeek BP, de la Riviere B et al. Prospective randomised comparison of single-dose versus multiple-dose cefuroxime for prophylaxis in coronary artery bypass grafting. Eur J Clin Microbiol Infect Dis . 1994; 1033-7.
194. Meyer JM. Comparative study of ceftriaxone and cefuroxime for perioperative prophylaxis in orthopedic surgery. Am J Surg . 1984; 148(Suppl 4A):27-9. [PubMed 6091477]
195. Wymenga A, van Horn J, Theeuwes A et al. Cefuroxime for prevention of postoperative cositis. One versus three doses tested in a randomized multicenter study of 2,651 arthroplasties. Acta Orthop Scand . 1992; 63:19-24. [PubMed 1738963]
196. Doebbeling BN, Pfaller MA, Kuhns KR et al. Cardiovascular surgery prophylaxis. A randomized, controlled comparison of cefazolin and cefuroxime. J Thorac Cardiovasc Surg . 1990; 99:981-9. [PubMed 2193200]
197. Vuorisalo S, Pokela R, Syrjala H. Comparison of vancomycin and cefuroxime for infection prophylaxis in coronary artery bypass surgery. Infect Control Hosp Epidemiol . 1998; 19:234-9. [PubMed 9605271]
198. Gooch WM, Blair E, Puopolo A et al. Effectiveness of five days of therapy with cefuroxime axetil suspension for treatment of acute otitis media. Pediatr Infect Dis J . 1996; 15:157-64. [PubMed 8822290]
199. McLinn SE, Moskal M, Goldfarb J et al. Comparison of cefuroxime axetil and amoxicillin-clavulanate suspensions in treatment of acute otitis media with effusion in children. Antimicrob Agents Chemother . 1994; 38:315-8. [PubMed 8192458]
200. Pessey JJ, Gehanno P, Thoroddsen E et al. Short course therapy with cefuroxime axetil for acute otitis media: results of a randomized multicenter comparison with amoxicillin/clavulanate. Pediatr Infect Dis J . 1999; 18:854-9. [PubMed 10530579]
201. Brodie DP, Griggs JV, Cunningham K. Comparative study of cefuroxime axetil suspension and amoxycillin syrup in the treatment of acute otitis media in general practice. J Int Med Res . 1990; 18:235-9. [PubMed 2113874]
202. Gooch WM 3rd, Blair E, Puopolo A et al. Clinical comparison of cefuroxime axetil suspension and amoxicillin/clavulanate suspension in the treatment of pediatric patients with acute otitis media with effusion. Clin Ther . 1995; 17:838-51. [PubMed 8595636]
203. Turik MA, Johns D Jr. Comparison of cefaclor and cefuroxime axetil in the treatment of acute otitis media with effusion in children who failed amoxicillin therapy. J Chemother . 1998; 10:306-12. [PubMed 9720470]
204. Pichichero M, Aronovitz GH, Gooch WM et al. Comparison of cefuroxime axetil, cefaclor, and amoxicillin-clavulanate potassium suspensions in acute otitis media in infants and children. South Med J . 1990; 83:1174-7. [PubMed 2218657]
208. Lantos PM, Rumbaugh J, Bockenstedt LK et al. Clinical practice guidelines by the Infectious Diseases Society of America, American Academy of Neurology, and American College of Rheumatology: 2020 guidelines for the prevention, diagnosis, and treatment of Lyme disease. Neurology. 2021; 96:262-73.
209. Steere AC. Lyme disease. N Engl J Med . 2001; 345:115-25. [PubMed 11450660]
210. Thompson C, Speilman A, Krause P. Coinfecting deer-associated zoonoses: Lyme disease, babesiosis, and ehrlichiosis. Clin Infect Dis . 2000; 33:676-85.
213. Bratzler DW, Dellinger EP, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm . 2013; 70:195-283. [PubMed 23327981]
214. Hikma Pharmaceuticals USA, Inc. Cefuroxime for injection pharmacy bulk package prescribing information. Berkeley Heights, NJ; 2021 Nov.
217. Tunkel AR, Hartman BJ, Kaplan SL et al. Practice guidelines for the management of bacterial meningitis. Clin Infect Dis . 2004; 39:1267-84. [PubMed 15494903]
219. Chow AW, Benninger MS, Brook I et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis . 2012; 54:e72-e112. [PubMed 22438350]
220. Wald ER, Applegate KE, Bordley C et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics . 2013; :. [PubMed 23796742]
513. Bradley JS, Byington CL, Shah SS et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011; 53:e25-76. Updates may be available at IDSA website at www.idsociety.org.
744. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Lyme Disease (Lyme Borreliosis, Borrelia burgdorferi sensu lato Infection). Grove Village, IL: American Academy of Pediatrics; 2024: 549-56.
750. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Systems-based Treatment Table. Grove Village, IL: American Academy of Pediatrics; 2024:1-17.
751. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Streptococcus pneumoniae (Pneumococcal) Infections. Grove Village, IL: American Academy of Pediatrics; 2024:810-22.
754. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Meningococcal Infections. Grove Village, IL: American Academy of Pediatrics; 2024:585-99.
755. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Haemophilus influenzae Infections. Grove Village, IL: American Academy of Pediatrics; 2024:400-9.
756. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Group B Streptococcal Infections. Grove Village, IL: American Academy of Pediatrics; 2024:799-806.
757. Red Book: 2024-2027 Report of the Committee on Infectious Diseases. 33rd ed. Tables of Antibacterial Drug Dosages. Grove Village, IL: American Academy of Pediatrics; 2024:987-1006.