Class: Second Generation Cephalosporins
Note: This monograph also contains information on Cefuroxime Axetil
Chemical Name: [6R - [6α,7β(Z)]] - 3 - [[(2 - Aminocarbonyl)oxy]methyl] - 7 - [2 - furanyl(methoxyimino)acetyl]amino] - 8 - oxo - 5 - thia - 1 - azabicyclo[4.2.0]oct - 2 - ene - 2 - carboxylic acid monosodium salt
Molecular Formula: C₁₆H₁₆N₄O₈S
CAS Number: 56238-63-2
Brands: Ceftin, Zinacef

Introduction

Antibacterial; β-lactam antibiotic; second generation cephalosporin.^{1 3}

Uses for Cefuroxime Sodium

Acute Otitis Media (AOM)

Treatment of AOM caused by Streptococcus pneumoniae, Haemophilus influenzae (including β-lactamase-producing strains), Moraxella catarrhalis (including β-lactamase-producing strains), or S. pyogenes.^{79 82 88 89 102 110 145 198 199 200 215}

Not a drug of first choice; considered a preferred alternative to amoxicillin or amoxicillin and clavulanate when these drugs are ineffective or cannot be used (e.g., in patients with a history of non-type 1 hypersensitivity reactions to penicillin).^{143 211}

Bone and Joint Infections

Parenteral treatment of bone and joint infections caused by susceptible Staphylococcus aureus (including penicillinase-producing strains).¹

Meningitis

Parenteral treatment of meningitis caused by susceptible S. pneumoniae, H. influenzae (including ampicillin-resistant strains), Neisseria meningitidis, or S. aureus (including penicillinase-producing strains).^{7 25 26 43 44 64 159 161}

Not a drug of choice for meningitis;^{58 143 165 217} treatment failures have been reported, especially in meningitis caused by H. influenzae.^{160 162} In addition, bacteriologic response to cefuroxime appears to be slower than that reported with ceftriaxone, which may increase the risk for hearing loss and neurologic sequelae.^{159 161} When a cephalosporin is indicated for the treatment of bacterial meningitis, a parenteral third generation cephalosporin (usually ceftriaxone or cefotaxime) generally recommended.^{58 143 157 158 165}

Pharyngitis and Tonsillitis

Treatment of pharyngitis and tonsillitis caused by S. pyogenes (group A β-hemolytic streptococci).^{79 90 91 145 175 215} Generally effective in eradicating S. pyogenes from the nasopharynx, but efficacy in prevention of subsequent rheumatic fever has not been established.^{79 215}

CDC, AAP, IDSA, AHA, and others recommend oral penicillin V or IM penicillin G benzathine as treatments of choice;^{45 46 58 143 171 172 173} oral cephalosporins and oral macrolides considered alternatives.^{45 46 58 143 171} Amoxicillin sometimes used instead of penicillin V, especially for young children.^{143 171}

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Respiratory Tract Infections

Treatment of acute maxillary sinusitis caused by susceptible S. pneumoniae or H. influenzae (non-β-lactamase-producing strains only).^{79 145 153 164 166 215} Data insufficient to date to establish efficacy for treatment of acute maxillary sinusitis known or suspected to be caused by β-lactamase-producing strains of H. influenzae or M. catarrhalis.^{79 215}

Treatment of secondary bacterial 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).^{79 82 92 93 103 124 215}

Treatment of 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 93 103 163 215}

Parenteral treatment of lower respiratory tract infections (including pneumonia) caused by susceptible S. pneumoniae, S. aureus (including penicillinase-producing strains), S. pyogenes (group A β-hemolytic streptococci), H. influenzae (including ampicillin-resistant strains), Escherichia coli, or Klebsiella.¹

Treatment of community-acquired pneumonia (CAP).⁵¹ Recommended by ATS and IDSA as an alternative for treatment of CAP caused by penicillin-susceptible S. pneumoniae.⁵¹ Also recommended as an alternative in certain combination regimens used for empiric treatment of CAP.⁵¹ Select regimen for empiric treatment of CAP based on most likely pathogens and local susceptibility patterns; after pathogen is identified, modify to provide more specific therapy (pathogen-directed therapy).⁵¹

For empiric outpatient treatment of CAP when risk factors for drug-resistant S. pneumoniae are present (e.g., comorbidities such as chronic heart, lung, liver, or renal disease, diabetes, alcoholism, malignancies, asplenia, immunosuppression; use of anti-infectives within the last 3 months), ATS and IDSA recommend monotherapy with a fluoroquinolone active against S. pneumoniae (moxifloxacin, gemifloxacin, levofloxacin) or, alternatively, a combination regimen that includes a β-lactam active against S. pneumoniae (high-dose amoxicillin or fixed combination of amoxicillin and clavulanic acid or, alternatively, ceftriaxone, cefpodoxime, or cefuroxime) given in conjunction with a macrolide (azithromycin, clarithromycin, erythromycin) or doxycycline.⁵¹ Cefuroxime and cefpodoxime may be less active against S. pneumoniae than amoxicillin or ceftriaxone.⁵¹

If a parenteral cephalosporin is used as an alternative to penicillin G or amoxicillin for treatment of CAP caused by penicillin-susceptible S. pneumoniae, ATS and IDSA recommend ceftriaxone, cefotaxime or cefuroxime; if an oral cephalosporin is used for treatment of these infections, ATS and IDSA recommend cefpodoxime, cefprozil, cefuroxime, cefdinir, or cefditoren.⁵¹

Septicemia

Parenteral treatment of septicemia caused by susceptible S. aureus (including penicillinase-producing strains), S. pneumoniae, E. coli, H. 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 pending results of in vitro susceptibility tests.^{1 214}

Skin and Skin Structure Infections

Oral treatment of uncomplicated skin and skin structure infections caused by susceptible S. aureus (including β-lactamase-producing strains) or S. pyogenes.^{79 215}

Parenteral treatment of skin and skin structure infections caused by susceptible S. aureus (including β-lactamase-producing strains), S. pyogenes, E. coli, Klebsiella, or Enterobacter.¹

Urinary Tract Infections (UTIs)

Oral treatment of uncomplicated UTIs caused by susceptible E. coli or K. pneumoniae.^{1 79 215}

Parenteral treatment of UTIs caused by susceptible E. coli or K. pneumoniae.^{1 79}

Gonorrhea and Associated Infections

Oral or parenteral treatment of uncomplicated gonorrhea caused by susceptible N. gonorrhoeae.^{1 9 20 79 215 218} May be effective in urethral, endocervical, and rectal gonorrhea;^{125 144 212} not recommended for pharyngeal infections.²¹² Not a drug of choice for treatment of uncomplicated gonococcal infections;^{36 65 143 218} oral cefuroxime may be an alternative for uncomplicated urogenital and anorectal infections when IM ceftriaxone or oral cefixime cannot be used.^{36 218}

Parenteral treatment of disseminated gonococcal infections caused by susceptible N. gonorrhoeae.^{1 9 20} Not included in current CDC recommendations for disseminated gonococcal infections.^{36 218}

Lyme Disease

Treatment of early Lyme disease manifested as erythema migrans.^{50 58 62 79 143 145 147 181 182 183 208 209 210 215} IDSA, AAP, and other clinicians recommend oral doxycycline, oral amoxicillin, or oral cefuroxime axetil as first-line therapy for treatment of early localized or early disseminated Lyme disease associated with erythema migrans, in the absence of specific neurologic involvement or advanced atrioventricular (AV) heart block.^{58 143 182 208 209 210}

Treatment of early neurologic Lyme disease† in patients with cranial nerve palsy alone without evidence of meningitis (i.e., those with normal CSF examinations or those for whom CSF examination is deemed unnecessary because there are no clinical signs of meningitis).^{143 208 209} Parenteral anti-infectives (IV ceftriaxone, IV penicillin G sodium, or IV cefotaxime) recommended for treatment of early Lyme disease when there are acute neurologic manifestations such as meningitis or radiculopathy.^{143 182 208 209}

Treatment of Lyme carditis†.²⁰⁸ IDSA and others state that patients with AV heart block and/or myopericarditis associated with early Lyme disease may be treated with an oral regimen (doxycycline, amoxicillin, or cefuroxime axetil) or a parenteral regimen (IV ceftriaxone or, alternatively, IV cefotaxime or IV penicillin G sodium).^{143 182 208 209} A parenteral regimen usually recommended for initial treatment of hospitalized patients; an oral regimen can be used to complete therapy and for the treatment of outpatients.^{143 182 208 209}

Treatment of borrelial lymphocytoma†.²⁰⁸ Although experience is limited, IDSA states that available data indicate that borrelial lymphocytoma may be treated with an oral regimen (doxycycline, amoxicillin, or cefuroxime axetil).²⁰⁸

Treatment of uncomplicated Lyme arthritis† without clinical evidence of neurologic disease.^{143 208 209} An oral regimen (doxycycline, amoxicillin, or cefuroxime axetil) can be used,^{143 208 209} but a parenteral regimen (IV ceftriaxone or, alternatively, IV cefotaxime or IV penicillin G sodium) should be used in those with Lyme arthritis and concomitant neurologic disease.^{143 208} Patients with persistent or recurrent joint swelling after a recommended oral regimen should receive retreatment with the oral regimen or a switch to a parenteral regimen.^{182 208 209} Some clinicians prefer retreatment with an oral regimen for those whose arthritis substantively improved but did not completely resolve; these clinicians reserve parenteral regimens for those patients whose arthritis failed to improve or worsened.²⁰⁸ Allow several months for joint inflammation to resolve after initial treatment before an additional course of anti-infectives is given.²⁰⁸

Perioperative Prophylaxis

Perioperative prophylaxis in patients undergoing noncardiac thoracic or orthopedic surgery.^{71 194} A preferred agent.⁷¹

Has been used for perioperative prophylaxis in patients undergoing cardiac surgery,^{1 66 193 195 196 197 213} GI surgery,^{3 6} or gynecologic or obstetric surgery (e.g., vaginal hysterectomy).^{1 3 6} Other drugs usually preferred.⁷¹

Cefuroxime Sodium Dosage and Administration

Administration

Administer cefuroxime axetil orally.^{79 215} Administer cefuroxime sodium by IV injection or infusion or by deep IM injection.^{1 214}

IV route preferred in patients with septicemia or other severe or life-threatening infections or in patients with lowered resistance, particularly if shock is present.¹

Cefuroxime ADD-Vantage vials,¹ Duplex drug delivery system containing cefuroxime and dextrose injection in separate chambers,²¹⁴ and the commercially available premixed cefuroxime injection (frozen) should be used only for IV infusion.¹

Oral Administration

Oral suspension must be administered with food.⁷⁹

Tablets may be given orally without regard to meals,^{79 215} but administration with food maximizes bioavailability.^{79 81 82 97 99}

Children 3 months to 12 years of age unable to swallow tablets should receive the oral suspension.⁷⁹ Although the 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 manufacturers state that the drug should not be administered in this manner.^{79 215}

Reconstitution

Reconstitute powder for oral suspension at the time of dispensing by adding the amount of water specified on the bottle to provide a suspension containing 125 or 250 mg of cefuroxime per 5 mL of suspension.⁷⁹

Tap the bottle to thoroughly loosen the powder; add the water in a single portion and shake vigorously.⁷⁹ Shake suspension well just prior to each use and replace the cap securely after each opening.⁷⁹

IV Injection

Reconstitution

Reconstitute vials containing 750 mg or 1.5 g of cefuroxime with 8 or 16 mL of sterile water for injection, respectively, to provide solutions containing approximately 90 mg/mL.¹

Rate of Administration

Inject appropriate dose of reconstituted solution directly into a vein over a period of 3–5 minutes or slowly into the tubing of a freely flowing compatible IV solution.¹

IV Infusion

Other IV solutions flowing through a common administration tubing or site should be discontinued while cefuroxime is being infused unless the solutions are known to be compatible and the flow rate is adequately controlled.¹ If an aminoglycoside is administered concomitantly with cefuroxime, the drugs should be administered at separate sites.¹

Reconstitution and Dilution

For intermittent or continuous IV infusion, 100 mL of sterile water for injection, 5% dextrose injection, 0.9% sodium chloride injection, or other compatible IV solution may be added to an infusion pack labeled as containing 750 mg or 1.5 g of cefuroxime to provide solutions containing approximately 7.5 or 15 mg/mL, respectively.¹

Reconstitute 7.5-g pharmacy bulk package according to the manufacturer’s directions and then further dilute in a compatible IV infusion solution.¹

Reconstitute ADD-Vantage vials containing 750 mg or 1.5 g according to the manufacturer’s directions.¹

Reconstitute (activate) commercially available Duplex drug delivery system containing 750 mg or 1.5 g of crystalline cefuroxime and 50 mL of dextrose injection in separate chambers according to the manufacturer’s directions.²¹⁴

Thaw the commercially available premixed cefuroxime injection (frozen) at room temperature (25°C) or in a refrigerator (5°C); do not force thaw by immersion in a water bath or by exposure to microwave radiation.¹ A precipitate may have formed in the frozen injection, but should dissolve with little or no agitation after reaching room temperature.¹ Discard thawed injection if an insoluble precipitate is present or if container seals or outlet ports are not intact.¹ Do not use in series connections with other plastic containers, since such use could result in air embolism from residual air being drawn from the primary container before administration of fluid from the secondary container is complete.¹

Rate of Administration

Intermittent IV infusions generally infused over 15–60 minutes.^{41 44}

IM Injection

Administer IM injections deeply into a large muscle mass such as the gluteus or lateral aspect of the thigh.¹ Use aspiration to ensure needle is not in a blood vessel.¹

Reconstitution

Prepare IM injections by reconstituting vial containing 750 mg of cefuroxime with 3 mL of sterile water for injection to provide a suspension containing approximately 220 mg/mL.¹

Shake IM suspension gently prior to administration.¹

Dosage

Available as cefuroxime axetil⁷⁹ or cefuroxime sodium^{1 214} ; dosage expressed in terms of cefuroxime.^{1 79 214}

Tablets and oral suspension are not bioequivalent and are not substitutable on a mg/mg basis.^{79 215}

Pediatric Patients

General Pediatric Dosage

Mild to Moderate Infections

Oral

AAP recommends 20–30 mg/kg daily given in 2 divided doses in children >4 weeks of age.¹⁴³

IV or IM

AAP recommends 75–100 mg/kg daily given in 3 divided doses in children >4 weeks of age.¹⁴³

Manufacturer states 50–100 mg/kg daily given in 3 or 4 equally divided doses has been effective for most infections in children ≥3 months of age.¹

Severe Infections

Oral

Oral route inappropriate for severe infections per AAP.¹⁴³

IV or IM

AAP recommends 100–150 mg/kg daily given in 3 divided doses in children >4 weeks of age.¹⁴³

Manufacturer recommends 100 mg/kg daily given in 3 or 4 equally divided doses for children ≥3 months of age.¹

Acute Otitis Media (AOM)

Children 3 Months to 12 Years of Age

Oral

Tablets (for children able to swallow tablets whole): 250 mg twice daily for 10 days.^{79 215}

Oral suspension: 30 mg/kg daily (maximum 1 g daily) given in 2 divided doses for 10 days.^{79 211}

Bone and Joint Infections

Children 3 Months to 12 Years of Age

IV or IM

150 mg/kg daily given in equally divided doses every 8 hours.¹

Meningitis

Children 3 Months to 12 Years of Age

IV or IM

200–240 mg/kg daily given in equally divided doses every 6–8 hours.^{1 19 49 214}

Pharyngitis and Tonsillitis

Children 3 Months to 12 Years of Age

Oral

Oral suspension: 20 mg/kg daily (maximum 500 mg daily) in 2 divided doses for 10 days.⁷⁹

Adolescents ≥13 Years of Age

Oral

Tablets: 250 mg twice daily for 10 days.⁷⁹

Respiratory Tract Infections

Acute Sinusitis in Children 3 Months to 12 Years of Age

Oral

Tablets (for children able to swallow tablets whole): 250 mg twice daily for 10 days.^{79 215}

Oral suspension: 30 mg/kg daily (maximum 1 g daily) given in 2 divided doses for 10 days.⁷⁹

Acute Sinusitis in Adolescents ≥13 Years of Age

Oral

Tablets: 250 mg twice daily for 10 days.⁷⁹

Secondary Bacterial Infections of Acute Bronchitis in Adolescents ≥13 Years of Age

Oral

Tablets: 250 or 500 mg twice daily for 5–10 days.⁷⁹

Acute Exacerbations of Chronic Bronchitis in Adolescents ≥13 Years of Age

Oral

Tablets: 250 or 500 mg twice daily for 10 days.⁷⁹ Efficacy of regimens <10 days has not been established.⁷⁹

Skin and Skin Structure Infections

Impetigo in Children 3 Months to 12 Years of Age

Oral

Oral suspension: 30 mg/kg daily (maximum 1 g daily) in 2 divided doses for 10 days.⁷⁹

Uncomplicated Infections in Adolescents ≥13 Years of Age

Oral

Tablets: 250 or 500 mg twice daily for 10 days.⁷⁹

Urinary Tract Infections (UTIs)

Uncomplicated Infections in Adolescents ≥13 Years of Age

Oral

Tablets: 250 mg twice daily for 7–10 days.⁷⁹

Gonorrhea and Associated Infections

Uncomplicated Urethral, Cervical, or Rectal Gonorrhea In Adolescents ≥13 Years of Age

Oral

Tablets: 1 g as a single dose.^{79 218}

Lyme Disease

Early Localized or Early Disseminated Lyme Disease Manifested as Erythema Migrans

Oral

Tablets: 500 mg twice daily for 20 days in adolescents ≥13 years of age.⁷⁹

AAP, IDSA, and others recommend 30 mg/kg (maximum 500 mg) administered in 2 divided doses for 14days (range 14–21 days) in children without specific neurologic involvement or advanced AV heart block.^{141 143 181 182 208 209}

Early Neurologic Lyme Disease†

Oral

30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 14 days (range 14–21 days) recommended by IDSA for children with cranial nerve palsy alone without clinical evidence of meningitis.²⁰⁸

Lyme Carditis†

Oral

30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 14 days (range 14–21 days) recommended by IDSA.²⁰⁸

Borrelial Lymphocytoma†

Oral

30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 14 days (range 14–21 days) recommended by IDSA.²⁰⁸

Lyme Arthritis†

Oral

30 mg/kg daily in 2 equally divided doses (up to 500 mg per dose) for 28 days recommended by IDSA for children with uncomplicated Lyme arthritis without clinical evidence of neurologic disease.²⁰⁸

Perioperative Prophylaxis

Cardiac, Cardiothoracic, or Noncardiac Thoracic Surgery

IV

50 mg/kg given at induction of anesthesia (within 0.5–1 hour prior to incision).²¹³ Some experts suggest additional doses of 50 mg/kg every 8 hours for up to 48–72 hours; others state that prophylaxis for ≤24 hours is appropriate.²¹³

Adults

General Adult Dosage

IV or IM

750–1.5 g every 8 hours for 5–10 days.^{1 214}

Life-threatening Infections or Those Caused by Less Susceptible Organisms

IV or IM

1.5 g every 6 hours.^{1 214}

Bone and Joint Infections

IV or IM

1.5 g every 8 hours.^{1 214}

Meningitis

IV or IM

Up to 3 g every 8 hours.^{1 214}

Pharyngitis and Tonsillitis

Oral

Tablets: 250 mg twice daily for 10 days.^{79 215}

Respiratory Tract Infections

Acute Sinusitis

Oral

Tablets: 250 mg twice daily for 10 days.^{79 215}

Secondary Bacterial Infections of Acute Bronchitis

Oral

Tablets: 250 or 500 mg twice daily for 5–10 days.^{79 215}

Acute Exacerbations of Chronic Bronchitis

Oral

Tablets: 250 or 500 mg twice daily for 10 days.^{79 215} Efficacy of regimens <10 days has not been established.^{79 215}

Pneumonia

Oral

500 mg twice daily recommended by ATS and IDSA for empiric treatment of community-acquired pneumonia† (CAP).⁵¹ Must be used in conjunction with other anti-infectives for empiric treatment of CAP.⁵¹ (See Respiratory Tract Infections under Uses.)

IV or IM

750 mg every 8 hours.^{1 214} For severe or complicated infections, 1.5 g every 8 hours.^{1 214}

Skin and Skin Structure Infections

Uncomplicated Infections

Oral

Tablets: 250 or 500 mg twice daily for 10 days.^{79 215}

IV or IM

750 mg every 8 hours.^{1 214}

Severe or Complicated Infections

IV or IM

1.5 g every 8 hours.¹

Urinary Tract Infections (UTIs)

Uncomplicated Infections

Oral

Tablets: 250 mg twice daily for 7–10 days.^{79 215}

IV or IM

750 mg every 8 hours.^{1 214}

Severe or Complicated Infections

IV or IM

1.5 g every 8 hours.¹

Gonorrhea and Associated Infections

Uncomplicated Urethral, Cervical, or Rectal Gonorrhea

Oral

Tablets: 1 g as a single dose.^{79 125 144 215 218}

IM

1.5 g as a single dose; divide the dose, give at 2 different sites.¹ Given in conjunction with 1 g of oral probenecid.¹

Disseminated Gonococcal Infections

IV or IM

750 mg every 8 hours.¹

Lyme Disease

Early Localized or Early Disseminated Lyme Disease Manifested as Erythema Migrans

Oral

Tablets: 500 mg twice daily for 20 days.^{79 215}

IDSA and others recommend 500 mg twice daily for 14 days (range 14–21 days) in adults without specific neurologic involvement or advanced AV heart block.^{182 208 209}

Early Neurologic Lyme Disease†

Oral

500 mg twice daily for 14 days (range 14–21 days) recommended by IDSA for adults with cranial nerve palsy alone without clinical evidence of meningitis.²⁰⁸

Lyme Carditis†

Oral

500 mg twice daily for 14 days (range 14–21 days) recommended by IDSA.²⁰⁸

Borrelial Lymphocytoma†

Oral

500 mg twice daily for 14 days (range 14–21 days) recommended by IDSA.²⁰⁸

Lyme Arthritis†

Oral

500 mg twice daily for 28 days recommended by IDSA for adults with uncomplicated Lyme arthritis without clinical evidence of neurologic disease.²⁰⁸

Perioperative Prophylaxis

Noncardiac Thoracic or Orthopedic Surgery

IV

Single 1.5-g dose given within 60 minutes before the procedure.⁷¹

If surgery is prolonged >4 hours or major blood loss occurs, give additional doses every 3–4 hours during the procedure.^{71 213} Postoperative doses usually unnecessary and may increase risk of bacterial resistance.^{71 213}

Cardiac Surgery

IV

For open-heart surgery, manufacturers recommend 1.5 g given at the time of induction of anesthesia and 1.5 g every 12 hours thereafter for a total dosage of 6 g.^{1 214}

During prolonged procedures (>4 hours) or if major blood loss occurs, some clinicians state that additional anti-infective doses should be given every 3–4 hours during the procedure.⁷¹ There is some evidence that single-dose anti-infective prophylaxis may be as effective as 48-hour prophylaxis; there is no evidence of benefit beyond 48 hours.⁷¹

For cardiothoracic surgery and heart and/or lung transplantation, some experts suggest additional 1.5-g doses every 12 hours for up to 48–72 hours; others state that prophylaxis for ≤24 hours is appropriate.²¹³ There is no evidence to support continuing prophylaxis until chest and mediastinal drainage tubes are removed.²¹³

Other Surgery

IV or IM

Manufacturer recommends 1.5 g given IV just prior to surgery (approximately 0.5–1 hour prior to initial incision) and, in lengthy operations, 750 mg given IV or IM every 8 hours.¹ Postoperative doses usually unnecessary and may increase risk of bacterial resistance.⁷¹

Special Populations

Renal Impairment

Dosage adjustments of parenteral cefuroxime necessary in patients with Cl_cr ≤20 mL/minute.^{1 112 113 114 115}

Adults with impaired renal function: 750 mg IM or IV every 12 hours in those with Cl_cr 10–20 mL/minute or 750 mg IM or IV every 24 hours in those with Cl_cr <10 mL/minute.^{1 112 113 114}

Patients undergoing hemodialysis: Give a supplemental dose of parenteral cefuroxime after each dialysis period.^{1 3 30 214}

Children with impaired renal function: Make adjustments to dosing frequency for IM or IV cefuroxime similar to those recommended for adults with renal impairment.¹

Safety and efficacy of oral cefuroxime in patients with renal impairment not established.^{79 215}

Geriatric Patients

Cautious dosage selection because of age-related decreases in renal function.^{1 214} (See Renal Impairment under Dosage and Administration.)

Cautions for Cefuroxime Sodium

Contraindications

• Known hypersensitivity to cefuroxime or other cephalosporins.^{1 79 115}

Warnings/Precautions

Warnings

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible organisms with prolonged therapy.^{1 31 79 88 92 101 103 104 105 214} Careful observation of the patient is essential.^{1 79 214} Institute appropriate therapy if superinfection occurs.^{1 79 214}

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.^{1 79 214} C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) has been reported with nearly all anti-infectives, including cefuroxime, and may range in severity from mild diarrhea to fatal colitis.^{1 79 214} Hyper toxin-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.^{79 214}

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.^{1 79 214} 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.^{79 214}

If CDAD is suspected or confirmed, anti-infective therapy not directed against C. difficile may need to be discontinued.^{79 214} Some mild cases may respond to discontinuance alone.^{1 184 185 186 187 188} Manage moderate to severe cases with fluid, electrolyte, and protein supplementation, anti-infective therapy active against C. difficile (e.g., oral metronidazole or vancomycin), and surgical evaluation when clinically indicated.^{1 79 184 185 186 187 188 214}

Sensitivity Reactions

Hypersensitivity Reactions

Possible hypersensitivity reactions, including rash (maculopapular or erythematous), pruritus, fever, eosinophilia, urticaria, anaphylaxis, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis.^{1 a}

If an allergic reaction occurs, discontinue and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, maintenance of an adequate airway and oxygen).¹

Cross-hypersensitivity

Partial cross-sensitivity among cephalosporins and other β-lactam antibiotics, including penicillins and cephamycins.^{1 a}

Prior to initiation of therapy, make careful inquiry concerning previous hypersensitivity reactions to cephalosporins, penicillins, or other drugs.¹ Cautious use recommended in individuals hypersensitive to penicillins:^{1 a} avoid use in those who have had an immediate-type (anaphylactic) hypersensitivity reaction and administer with caution in those who have had a delayed-type (e.g., rash, fever, eosinophilia) reaction.^a

General Precautions

History of GI Disease

Used with caution in patients with a history of GI disease, particularly colitis.¹ (See Superinfection/Clostridium difficile-associated Diarrhea and Colitis under Cautions.)

Prolonged PT

Prolonged PT reported with some cephalosporins.¹

Monitor PT in patients at risk, including those with renal or hepatic impairment, poor nutritional state, receiving prolonged therapy, or stabilized on anticoagulant therapy.^{1 79 215} Administer vitamin K when indicated.^{1 79 215}

Renal Effects

Periodically evaluate renal status during therapy, especially in seriously ill patients receiving maximum dosage.¹

Caution if used concomitantly with nephrotoxic drugs (e.g., aminoglycosides, potent diuretics).¹ (See Interactions.)

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of cefuroxime and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.^{1 79 214}

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.^{1 79 214} In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.^{1 79 214}

Patients with Meningitis

Mild to moderate hearing loss reported rarely in pediatric patients who received cefuroxime for treatment of meningitis.^{1 214}

Persistence of positive CSF cultures at 18–36 hours reported; clinical importance unknown.^{1 214}

Phenylketonuria

Ceftin oral suspensions containing 125 or 250 mg of cefuroxime/5 mL contain aspartame (NutraSweet), which is metabolized in the GI tract to provide 11.8 or 25.2 mg of phenylalanine/5 mL, respectively.⁷⁹

Sodium Content

Cefuroxime sodium contains approximately 54.2 mg (2.4 mEq) of sodium per g of cefuroxime.^{1 214}

Specific Populations

Pregnancy

Category B.^{1 79 214}

Lactation

Distributed into milk; use with caution.^{1 79 214}

Pediatric Use

Safety and efficacy of oral or parenteral cefuroxime not established in children <3 months of age.^{1 79 214} Other cephalosporins accumulate in neonates resulting in prolonged serum half-life.^{1 214}

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 should be used in children who cannot swallow tablets whole.⁷⁹

To avoid overdosage, the commercially available Duplex drug delivery system containing 750 mg or 1.5 g of cefuroxime and 50 mL of dextrose injection in separate chambers should not be used in pediatric patients unless the entire 750-mg or 1.5-g dose is required.²¹⁴

Geriatric Use

No overall differences in safety and efficacy in those ≥65 years of age compared with younger adults, but the possibility of increased sensitivity in some geriatric individuals cannot be ruled out.^{1 79 215}

Substantially eliminated by kidneys; risk of toxicity may be greater in those with impaired renal function.^{1 214 215} Select dosage with caution; renal function monitoring may be useful because of age-related decreases in renal function.^{1 214 215} (See Renal Impairment under Dosage and Administration.)

Renal Impairment

Possible decreased clearance and increased serum half-life.^{1 79 214}

Dosage adjustments of parenteral cefuroxime necessary in patients with Cl_cr ≤20 mL/minute.^{1 214} (See Renal Impairment under Dosage and Administration.)

Safety and efficacy of oral cefuroxime in patients with renal impairment not established.^{79 215}

Common Adverse Effects

GI effects (nausea, vomiting, diarrhea/loose stools),^{1 79 214} hypersensitivity reactions,¹ local reactions at IV injection sites.^{1 214}

Interactions for Cefuroxime Sodium

Specific Drugs and Laboratory Tests

Drug or Test	Interaction	Comments
Aminoglycosides	Nephrotoxicity reported with concomitant use of some cephalosporins and aminoglycosides1 In vitro evidence of additive or synergistic antibacterial activity against some Enterobacteriaceae2 6	Administer separately; do not admix1
Diuretics	Possible increased risk of nephrotoxicity if used concomitantly with potent diuretics1	Use concomitantly with caution1
Estrogens or progestins	May affect gut flora, leading to decreased estrogen reabsorption and reduced efficacy of oral contraceptives containing estrogen and progestin1
Probenecid	Decreased clearance and increased serum concentrations and half-life of cefuroxime1 2 21 30 79
Tests for glucose	Possible false-positive reactions in urine glucose tests using Clinitest, Benedict’s solution, or Fehling’s solution1 79 a	Use glucose tests based on enzymatic glucose oxidase reactions (e.g., Clinistix, Tes-Tape)1 79 a

Cefuroxime Sodium Pharmacokinetics

Absorption

Bioavailability

Following oral administration of cefuroxime axetil, the drug is absorbed from the GI tract as the 1-(acetyloxy)ethyl ester 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}

Oral suspension is not bioequivalent to tablets.^{79 215}

In adults receiving film-coated tablets, peak serum concentrations attained approximately 2–3 hours after the dose.^{79 81}

Following oral administration of the oral suspension given with milk or milk products in children, peak serum concentrations attained within 2.7–3.6 hours.^{79 148}

Cefuroxime sodium not appreciably absorbed from the GI tract; must be given parenterally.^{1 2 6 21 30} Following IM administration in healthy adults, peak serum concentrations 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

Food

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 increased when cefuroxime axetil given with milk or infant formula.⁹⁸ The extent (but not rate) of absorption is substantially greater when administered concomitantly with milk compared with applesauce or fasting.⁹⁸

Distribution

Extent

Following IM or IV administration, 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}

Readily crosses the placenta^{1 2 24} and is distributed into milk.¹

Plasma Protein Binding

33–50%.^{1 2 6 21 30 79}

Elimination

Metabolism

Following oral administration, cefuroxime axetil 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}

Cefuroxime not metabolized.^{2 6 21 27 30}

Elimination Route

Eliminated unchanged principally in urine.^{2 6 21 27 30}

Half-life

Adults: 1.2–1.6 hours following oral administration^{79 81 98} and 1–2 hours following IV or IM administration.^{1 3 18 21 27 30}

Neonates and children: Half-life inversely proportional to age.^{6 25 30}

Special Populations

Patients with renal impairment: Serum half-life prolonged^{2 3 79} and generally ranges from 1.9–16.1 hours depending on the degree of impairment.^{3 30} Serum half-life of 15–22 hours has been reported in anuric patients.^{18 30}

Stability

Storage

Oral

Tablets

15–30°C in tight container.⁷⁹

For Suspension

2–30°C.⁷⁹ Following reconstitution, store immediately at 2–8°C; discard any unused suspension after 10 days.⁷⁹

Parenteral

Powder for Injection or Infusion

15–30°C; protect from light.¹

Powder for injection and solutions may darken; does not indicate loss of potency.¹

IV solutions containing 90 mg of cefuroxime/mL prepared using sterile water for injection are stable for 24 hours at room temperature or 48 hours at 5°C.¹ Reconstituted solutions further diluted in 100 mL of a compatible IV solution are stable for 24 hours at room temperature or 7 days at 5°C.¹

IM suspensions containing 220 mg/mL prepared using sterile water for injection are stable for 24 hours at room temperature or 48 hours at 5°C.¹

Powder For Injection, for IV Infusion

Reconstituted ADD-Vantage vials prepared using 5% dextrose injection or 0.9 or 0.45% sodium chloride injection are stable for 24 hours at room temperature or 7 days under refrigeration;¹ joined ADD-Vantage vials that have not been activated may be used within a 14-day period.¹

Store commercially available Duplex drug delivery system containing 750 mg or 1.5 g of cefuroxime and 50 mL of dextrose injection at 20–25°C (may be exposed to 15–30°C).²¹⁴ Following reconstitution (activation), use these IV infusions within 24 hours if stored at room temperature or within 7 days if stored in a refrigerator; do not freeze.²¹⁴

Injection (Frozen) for Infusion

-20°C or lower.¹ After thawing, stable for up to 24 hours at room temperature (25°C) or up to 28 days under refrigeration (5°C).¹

Do not refreeze after thawing.¹

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility^HID

Sodium bicarbonate not recommended as a diluent.¹

Compatible
Dextrose 5 or 10% in water1 HID
Dextrose 5% in sodium chloride 0.2, 0.45 or 0.9% 1
Invert sugar 10% in water1
Ringer’s injection1
Sodium chloride 0.9%1 HID
Sodium lactate (1/6) M1

Drug Compatibility

Admixture CompatibilityHID

Compatible
Clindamycin phosphate
Floxacillin sodium
Furosemide
Metronidazole
Midazolam HCl
Incompatible
Ciprofloxacin
Ranitidine HCl
Variable
Gentamicin sulfate

Y-Site CompatibilityHID

Compatible
Acyclovir sodium
Allopurinol sodium
Amifostine
Amiodarone HCl
Atracurium besylate
Aztreonam
Bivalirudin
Cyclophosphamide
Dexmedetomidine HCl
Diltiazem HCl
Docetaxel
Etoposide phosphate
Famotidine
Fenoldopam mesylate
Fludarabine phosphate
Foscarnet sodium
Gemcitabine HCl
Granisetron HCl
Hetastarch in lactated electrolyte injection (Hextend)
Hydromorphone HCl
Linezolid
Melphalan HCl
Meperidine HCl
Milrinone lactate
Morphine sulfate
Ondansetron HCl
Pancuronium bromide
Perphenazine
Propofol
Remifentanil HCl
Sargramostim
Tacrolimus
Teniposide
Thiotepa
Vecuronium bromide
Incompatible
Azithromycin
Clarithromycin
Filgrastim
Fluconazole
Midazolam HCl
Vinorelbine tartrate
Variable
Cisatracurium besylate
Vancomycin HCl

Actions and Spectrum

• Based on spectrum of activity, classified as a second generation cephalosporin.^{3 6 10 18 48 a} Generally no more active in vitro against susceptible gram-positive cocci than first generation cephalosporins, but has an expanded spectrum of activity against gram-negative bacteria compared with first generation drugs.^a

• Usually bactericidal.^{1 a}

• Like other β-lactam antibiotics, antibacterial activity results from inhibition of bacterial cell wall synthesis.^{1 a}

• Spectrum of activity includes many gram-positive aerobic bacteria, some gram-negative aerobic bacteria, and some anaerobic bacteria; inactive against Chlamydia, fungi, and viruses.^{1 a}

• Gram-positive aerobes: Active in vitro and in clinical infections against Staphylococcus aureus, S. epidermidis, Streptococcus pneumoniae, S. pyogenes (group A β-hemolytic streptococci), and other streptococci.^{1 a} Oxacillin-resistant (methicillin-resistant) staphylococci, Listeria monocytogenes, and most enterococci (e.g., Enterococcus faecalis) are resistant.^{1 a}

• Strains of staphylococci resistant to penicillinase-resistant penicillins (oxacillin-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.⁶³ 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.⁶³

• Gram-negative aerobes: Active in vitro and in clinical infections against Citrobacter, Enterobacter, Escherichia coli, Haemophilus influenzae (including ampicillin-resistant strains), H. parainfluenzae, Klebsiella (including K. pneumoniae), Moraxella catarrhalis (including ampicillin-resistant strains), Morganella morganii, Neisseria gonorrhoeae, N. meningitidis, Proteus mirabilis, Providencia rettgeri, Salmonella, and Shigella.^{1 a} Some strains of Citrobacter, E. cloacae, and M. morganii are resistant.¹ Acinetobacter calcoaceticus, Legionella, Campylobacter, Pseudomonas, P. vulgaris, Serratia usually are resistant.¹

• Anaerobes: Active in vitro against Bacteroides (except B. fragilis), Clostridium (except C. difficile), Fusobacterium, Peptococcus, and Peptostreptococcus.¹

Advice to Patients

• Advise patients that antibacterials (including cefuroxime) should only be used to treat bacterial infections; they do not treat viral infections (e.g., the common cold).^{1 79 214}

• Importance of completing full course of therapy, even if feeling better after a few days.^{1 79 214}

• Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with cefuroxime or other antibacterials in the future.^{1 79 214}

• Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.^{1 79 214} Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.^{1 79 214}

• Advise individuals with phenylketonuria and other individuals who must restrict their intake of phenylalanine that Ceftin oral suspensions contain aspartame (NutraSweet), which is metabolized in the GI tract to phenylalanine.⁷⁹

• Importance of informing clinicians if an allergic reaction occurs.^{1 79 214}

• Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.^{1 79 214}

• Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs as well as any concomitant illnesses.^{1 79 214}

• Importance of informing patients of other important precautionary information.^{1 79 214} (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Cefuroxime Axetil

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	For Suspension	125 mg (of cefuroxime) per 5 mL*	Ceftin	GlaxoSmithKline
			Cefuroxime Axetil for Suspension
		250 mg (of cefuroxime) per 5 mL*	Ceftin	GlaxoSmithKline
			Cefuroxime Axetil for Suspension
	Tablets, film-coated	125 mg (of cefuroxime)*	Cefuroxime Axetil Tablets
		250 mg (of cefuroxime)*	Ceftin	GlaxoSmithKline
			Cefuroxime Axetil Tablets
		500 mg (of cefuroxime)*	Ceftin	GlaxoSmithKline
			Cefuroxime Axetil Tablets

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Cefuroxime Sodium

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	For injection	750 mg (of cefuroxime)*	Cefuroxime Sodium for Injection
			Zinacef	GlaxoSmithKline
		1.5 g (of cefuroxime)*	Cefuroxime Sodium for Injection
			Zinacef	GlaxoSmithKline
		7.5 g (of cefuroxime) pharmacy bulk package*	Cefuroxime Sodium for Injection
			Zinacef	GlaxoSmithKline
	For injection, for IV infusion	750 mg (of cefuroxime)*	Cefuroxime for Injection and Dextrose Injection
			Zinacef ADD-Vantage	GlaxoSmithKline
			Zinacef Infusion Pack	GlaxoSmithKline
		1.5 g (of cefuroxime)*	Cefuroxime for Injection and Dextrose Injection
			Zinacef ADD-Vantage	GlaxoSmithKline
			Zinacef Infusion Pack	GlaxoSmithKline

Cefuroxime Sodium in Dextrose

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection (frozen), for IV infusion	15 mg (of cefuroxime) per mL (750 mg) in 2.8% Dextrose	Zinacef in Iso-osmotic Dextrose Injection (Galaxy [Baxter])	GlaxoSmithKline

Cefuroxime Sodium in Water

Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	Injection (frozen), for IV infusion	30 mg (of cefuroxime) per mL (1.5 g)	Zinacef Iso-osmotic in Sterile Water Injection (Galaxy [Baxter])	GlaxoSmithKline

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2013. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Ceftin 250MG Tablets (GLAXO SMITH KLINE): 20/$213.98 or 60/$601.95

Ceftin 500MG Tablets (GLAXO SMITH KLINE): 20/$359.97 or 60/$1,049.98

Cefuroxime Axetil 250MG Tablets (LUPIN PHARMACEUTICALS): 20/$73.99 or 60/$205.98

Cefuroxime Axetil 500MG Tablets (LUPIN PHARMACEUTICALS): 20/$98.99 or 60/$274.95