Meningitis: What It Is and How to Avoid It Watch Video

Claforan

Generic Name: Cefotaxime Sodium
Class: Third Generation Cephalosporins
VA Class: AM117
CAS Number: 64485-93-4

Introduction

Antibacterial; β-lactam antibiotic; third generation cephalosporin.a b

Uses for Claforan

Bone and Joint Infections

Treatment of serious bone and joint infections caused by susceptible S. aureus, streptococci (including S. pyogenes), Pseudomonas (including Ps. aeruginosa), or P. mirabilis.230

Genitourinary Tract Infections

Treatment of serious genitourinary tract infections caused by susceptible S. aureus (including penicillinase-producing strains), S. epidermidis, enterococci, Citrobacter, Enterobacter, E. coli, Klebsiella, Morganella morganii, P. mirabilis, P. vulgaris, Providencia stuartii, P. rettgeri, Pseudomonas (including Ps. aeruginosa), or S. marcescens.230

GI Infections

Empiric treatment of infectious diarrhea.412 Alternative for empiric treatment of severe diarrhea in HIV-infected individuals; ciprofloxacin is drug of choice.412

Treatment of gastroenteritis caused by Salmonella.197 245 275 412 (See Typhoid Fever and Other Salmonella Infections under Uses.)

Treatment of GI infections caused by Yersinia enterocolitica or Y. pseudotuberculosis.218 245 275 Usually self-limited infections, but anti-infectives may be indicated in immunocompromised individuals, for severe infections, or when septicemia or other invasive disease occurs.218 245 275

Gynecologic Infections

Treatment of gynecologic infections (including pelvic inflammatory disease [PID], endometritis, pelvic cellulitis) caused by susceptible S. epidermidis, streptococci (including enterococci), E. coli, Enterobacter, Klebsiella, P. mirabilis, Bacteroides (including B. fragilis), Clostridium, Fusobacterium (including F. nucleatum), Peptococcus, and Peptostreptococcus.230

When parenteral regimen is used for treatment of PID, CDC recommends IV cefoxitin or cefotetan given in conjunction with oral doxycycline or IV clindamycin given in conjunction with gentamicin.167 While other parenteral cephalosporins (e.g., cefotaxime, ceftriaxone) also may be effective, CDC states these drugs are less active than cefoxitin or cefotetan against anaerobic bacteria.167

When oral regimen is used for treatment of mild to moderately severe acute PID, CDC recommends a single IM dose of ceftriaxone, cefoxitin (with oral probenecid), or cefotaxime given in conjunction with oral doxycycline (with or without oral metronidazole).167

Intra-abdominal Infections

Treatment of serious intra-abdominal infections (including peritonitis) caused by susceptible streptococci, E. coli, Klebsiella, P. mirabilis, Clostridium, Bacteroides, or anaerobic cocci (including Peptococcus and Peptostreptococcus).230

Meningitis and Other CNS Infections

Treatment of meningitis and ventriculitis caused by susceptible H. influenzae, N. meningitidis, S. pneumoniae,230 275 291 294 296 335 E. coli, or K. pneumoniae.230 275 291 294 296 336

A drug of choice when a third generation cephalosporin is indicated for empiric treatment of bacterial meningitis;275 290 296 319 should not be used alone for empiric treatment when Listeria monocytogenes, enterococci, staphylococci, or Ps. aeruginosa may be involved.275 290 296 319

Treatment of brain abscesses and other CNS infections (e.g., subdural empyema, intracranial epidural abscesses).319 336 347 Concomitant metronidazole usually recommended for empiric therapy;319 347 used in conjunction with a penicillinase-resistant penicillin or vancomycin if staphylococci suspected.319 347

Slideshow: The Shocking Truth About Antibiotic Resistance

Respiratory Tract Infections

Treatment of serious lower respiratory tract infections, including community-acquired pneumonia (CAP)197 269 342 caused by susceptible Streptococcus pneumoniae, S. pyogenes (group A β-hemolytic streptococci), other streptococci (except enterococci), Staphylococcus aureus (including penicillinase-producing strains), Escherichia coli, Klebsiella, Haemophilus influenzae (including ampicillin-resistant strains), H. parainfluenzae, Proteus mirabilis, indole-positive Proteus, Serratia marcescens, Enterobacter, or Pseudomonas (including Ps. aeruginosa).230

Recommended by ATS and IDSA as an alternative for treatment of CAP caused by penicillin-susceptible S. pneumoniae and as a preferred drug for treatment of CAP caused by penicillin-resistant S. pneumoniae, provided in vitro susceptibility has been demonstrated.269 Also recommended in certain combination regimens used for empiric treatment of CAP.269 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).269

For empiric inpatient treatment of CAP in patients not requiring treatment in an intensive care unit (non-ICU patients), IDSA and ATS recommend monotherapy with a fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin) or, alternatively, a combination regimen that includes a β-lactam (usually cefotaxime, ceftriaxone, or ampicillin) given in conjunction with a macrolide (azithromycin, clarithromycin, erythromycin).269

For empiric inpatient treatment of CAP in ICU patients when Pseudomonas and oxacillin-resistant (methicillin-resistant) S. aureus are not suspected, IDSA and ATS recommend a combination regimen that includes a β-lactam (cefotaxime, ceftriaxone, fixed combination of ampicillin and sulbactam) given in conjunction with either azithromycin or a fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin).269

Septicemia

Treatment of bacteremia/septicemia caused by E. coli, Klebsiella, S. marcescens, S. aureus, or streptococci (including S. pneumoniae).230 An aminoglycoside often is used concomitantly.230

Select anti-infective for treatment of sepsis syndrome based on probable source of infection, causative organism, immune status of patient, and local patterns of bacterial resistance.197

For initial treatment of life-threatening sepsis in adults, some clinicians suggest that a third or fourth generation cephalosporin (cefepime, cefotaxime, ceftriaxone, ceftazidime), the fixed combination of piperacillin and tazobactam, or a carbapenem (doripenem, imipenem, meropenem) be used in conjunction with vancomycin; some also suggest including an aminoglycoside or fluoroquinolone during initial few days of treatment.197

Skin and Skin Structure Infections

Treatment of serious skin and skin structure infections caused by susceptible S. aureus, S. epidermidis, S. pyogenes, other streptococci (including enterococci), Acinetobacter, E. coli, Citrobacter (including C. freundii), Enterobacter, Klebsiella, P. mirabilis, P. vulgaris, M. morganii, P. rettgeri, Pseudomonas, Serratia, Bacteroides (including B. fragilis), Fusobacterium (including F. nucleatum), or anaerobic cocci (including Peptococcus and Peptostreptococcus).230

Capnocytophaga Infections

Alternative to penicillin G for treatment of infections caused by Capnocytophaga (e.g., septicemia, meningitis, endocarditis).197

Gonorrhea and Associated Infections

Alternative for treatment of uncomplicated cervical, urethral, or rectal gonorrhea caused by susceptible Neisseria gonorrhoeae in adults or adolescents.167 230 275 366 367 Drug of choice is IM ceftriaxone.167 275 Although IM cefotaxime may be effective for urogenital and anorectal gonorrhea, CDC states it offers no advantages over IM ceftriaxone and has uncertain efficacy for pharyngeal gonorrhea.167

Alternative for initial treatment of disseminated gonococcal infections caused by susceptible N. gonorrhoeae.167 275 Ceftriaxone is drug of choice for initial parenteral treatment of disseminated gonorrhea in adults, adolescents, or children.167 275

Treatment of disseminated gonococcal infections,167 275 gonococcal scalp abscesses,167 275 and gonococcal ophthalmia neonatorum in neonates.167 275

Lyme Disease

Treatment of early neurologic Lyme disease with acute neurologic manifestations such as meningitis or radiculopathy.273 275 351 354 IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.273 275 351 354 Although an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) may be effective for early localized or early disseminated Lyme disease associated with erythema migrans in the absence of specific neurologic manifestations or advanced atrioventricular (AV) heart block,270 273 275 284 285 286 287 338 351 353 355 356 357 a parenteral regimen usually is recommended when there are acute neurologic manifestations.270 273 275 284 285 286 287 338 351 353 355 356

Treatment of Lyme carditis when a parenteral regimen is indicated.273 275 351 354 IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.273 275 351 354 Although a parenteral regimen usually is recommended for initial treatment of hospitalized patients, an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) can be used to complete therapy and for the treatment of outpatients.273 275 351 354

Treatment of Lyme arthritis when a parenteral regimen is indicated.273 275 351 354 361 IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.273 275 351 354 361 Although the comparative safety and efficacy of oral versus IV anti-infectives for treatment of Lyme arthritis have not been fully evaluated,351 those with concomitant neurologic disease generally should receive a parenteral regimen.273 275 351 354 361

Treatment of late neurologic Lyme disease affecting the CNS or peripheral nervous system (e.g., encephalopathy, neuropathy).351 IV ceftriaxone is the drug of choice; alternatives are IV cefotaxime or IV penicillin G.351

Typhoid Fever and Other Salmonella Infections

Treatment of typhoid fever (enteric fever) or septicemia caused by Salmonella typhi or S. paratyphi, including multidrug-resistant strains.275 306

Treatment of gastroenteritis caused by Salmonella (e.g., S. enteritidis, S. typhimurium) in individuals with severe Salmonella gastroenteritis and in those who are at increased risk of invasive disease.197 245 275 412

Alternative for treatment of Salmonella gastroenteritis in HIV-infected individuals to prevent extraintestinal spread of the infection.412 CDC, NIH, and IDSA recommend ciprofloxacin as drug of choice for treatment of Salmonella gastroenteritis (with or without bacteremia) in HIV-infected adults; other fluoroquinolones (levofloxacin, moxifloxacin) also may be effective.412 Depending on in vitro susceptibility, alternatives are co-trimoxazole or third generation cephalosporins (ceftriaxone, cefotaxime).412

Vibrio Infections

Treatment of severe Vibrio parahaemolyticus infection when anti-infective therapy is indicated in addition to supportive care.218

Treatment of infections caused by V. vulnificus.197 250 Optimum anti-infective therapy has not been identified; a tetracycline or third generation cephalosporin (e.g., cefotaxime, ceftazidime) is recommended.197 218 250 Because the case fatality rate associated with V. vulnificus is high, initiate anti-infective therapy promptly if indicated.250 294

Perioperative Prophylaxis

Has been used for perioperative prophylaxis in patients undergoing liver transplantation; some experts recommend a regimen of cefotaxime and ampicillin for such prophylaxis.169

Has been used for perioperative prophylaxis to reduce the incidence of infection in patients undergoing contaminated or potentially contaminated surgery (e.g., biliary tract, colorectal, other intra-abdominal or GI surgery, genitourinary surgery, abdominal or vaginal hysterectomy) and in patients undergoing cesarean section.169 230 Other anti-infectives (e.g., cefazolin) usually recommended for these procedures.168 169

First or second generation cephalosporins (cefazolin, cefotetan, cefoxitin, cefuroxime) generally preferred when a cephalosporin is used for perioperative prophylaxis.168 169 Third generation cephalosporins (cefotaxime, ceftriaxone, ceftazidime) and fourth generation cephalosporins (cefepime) not usually recommended for perioperative prophylaxis since they are expensive, some are less active against staphylococci than first or second generation cephalosporins, they have wider spectrums of activity than necessary for organisms encountered in elective surgery, and their use for prophylaxis may promote emergence of resistant organisms.168 169

Claforan Dosage and Administration

Administration

Administer by IV injection or infusion or by deep IM injection.230

IV route preferred in patients with septicemia, bacteremia, peritonitis, meningitis, or other severe or life-threatening infections or in patients with lowered resistance resulting from debilitating conditions (e.g., malnutrition, trauma, surgery, diabetes, heart failure, malignancy), particularly if shock is present.230

Large IM doses may be painful; IV administration may be preferred when large doses are indicated.b

Cefotaxime ADD-Vantage vials and the commercially available frozen cefotaxime injection in dextrose should be used only for IV infusion.

For solution and drug compatibility information, see Compatibility under Stability.

IV Injection

Reconstitution

Reconstitute vials containing 500 mg, 1 g, or 2 g of cefotaxime with 10 mL of sterile water for injection to provide solutions containing approximately 50, 95, or 180 mg/mL, respectively.230

Rate of Administration

Inject directly into a vein over a period of 3-5 minutes or slowly into the tubing of a freely flowing compatible IV solution.230

Do not inject IV over <3 minutes; rapid (over <1 minute) injection is associated with potentially life-threatening arrhythmias.230

IV Infusion

Reconstitution and Dilution

Reconstitute infusion bottles containing 1 or 2 g of cefotaxime with 50–100 mL of 0.9% sodium chloride injection or 5% dextrose injection to provide solutions containing 10–20 or 20–40 mg/mL, respectively.230 May be diluted further in 50 mL to 1 L of compatible IV solution.230

Reconstitute 10-g pharmacy bulk package according to the manufacturer’s directions and then dilute further in a compatible IV solution.230

Reconstitute ADD-Vantage vials or infusion bottles containing 1 or 2 g of cefotaxime according to the manufacturer’s directions.230

Thaw the commercially available premixed injection (frozen) at room temperature or in a refrigerator; do not thaw by immersion in a water bath or by exposure to microwave radiation.230 A precipitate may have formed in the frozen injection, but should dissolve with little or no agitation after reaching room temperature.230 Discard thawed injection if an insoluble precipitate is present or if container seals or outlet ports are not intact or leaks are found.230 Do not use in series connections with other plastic containers; 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.230

Rate of Administration

For intermittent IV infusion, infuse over 20–30 minutes via butterfly or scalp vein-type needles.b

During infusion, discontinue other IV solutions flowing through a common administration tubing or site230 unless the solutions are known to be compatible and the flow-rate is adequately controlled.b

IM Injection

Inject IM deeply into a large muscle mass such as the upper outer quadrant of the gluteus maximus.230 Use aspiration to avoid inadvertent injection into a blood vessel.230

2-g IM doses should be divided and administered at 2 different injection sites.230

Reconstitution

Reconstitute vials containing 500 mg, 1 g, or 2 g of cefotaxime with 2, 3, or 5 mL, respectively, of sterile or bacteriostatic water for injection to provide solutions containing approximately 230, 300, or 330 mg/mL, respectively.230

Dosage

Available as cefotaxime sodium; dosage expressed in terms of cefotaxime.230

Pediatric Patients

General Dosage for Neonates
IV or IM

Manufacturer recommends 50 mg/kg every 12 hours for those <1 week of age and 50 mg/kg every 8 hours for those 1–4 weeks of age.230 366 367

Neonates ≤7 days of age: AAP recommends 50 mg/kg every 12 hours, regardless of weight.275

Neonates 8–28 days of age: AAP recommends 50 mg/kg every 8–12 hours in those weighing ≤2 kg and 50 mg/kg every 8 hours in those weighing >2 kg.275

General Dosage for Infants and Children 1 Month to 12 Years of Age
IV or IM

50–180 mg/kg daily given in 4–6 equally divided doses in those weighing <50 kg.230 366 367 The higher dosage should be used for more severe or serious infections.230 366 367

Children beyond neonatal period: AAP recommends 50–180 mg/kg daily given in 3 or 4 equally divided doses for treatment of mild to moderate infections and 200–225 mg/kg daily given in 4 or 6 equally divided doses for treatment of severe infections.275

Children weighing >50 kg should receive the usual adult dosage.230 366 367 (See Adult Dosage under Dosage and Administration.)

Meningitis and Other CNS Infections
IV

Manufacturers recommend that children 1 month to 12 years of age weighing <50 kg receive dosage at the high end of the range of 50–180 mg/kg daily.230 366 367 Some clinicians recommend that infants and children <18 years of age with meningitis receive 50 mg/kg IV every 6 hours.296 Others recommend 100–150 mg/kg daily given in divided doses every 8–12 hours in neonates ≤7 days of age, 150–200 mg/kg daily given in divided doses every 6–8 hours in neonates 8–28 days of age, and 225–300 mg/kg daily given in divided doses every 6–8 hours in older infants and children.365

AAP recommends up to 300 mg/kg daily given in 4 or 6 divided doses for treatment of meningitis in pediatric patients beyond the neonatal period.275

Duration of treatment is 7 days for uncomplicated meningitis caused by susceptible H. influenzae or N. meningitidis; ≥10–14 days for complicated cases or meningitis caused by S. pneumoniae; and ≥21 days for meningitis caused by susceptible Enterobacteriaceae.275 296 318

Gonorrhea and Associated Infections
Disseminated Gonococcal Infection or Gonococcal Scalp Abscess in Neonates
IV or IM

25 mg/kg every 12 hours for 7 days recommended by CDC and AAP; if meningitis is documented, continue for 10–14 days.167 275

Disseminated Gonorrhea in Children ≥8 Years of Age or Weighing ≥45 kg
IV

CDC recommends 1 g every 8 hours; continue for 24–48 hours after improvement begins and switch to an oral regimen (cefixime) to complete ≥1 week of treatment.167

Uncomplicated Urethral, Cervical, or Rectal Gonorrhea in Adolescents
IM

Single 500-mg dose recommended by CDC and AAP.167 275

Lyme Disease
Early Neurologic Lyme Disease
IV

150–200 mg/kg daily (up to 6 g daily) given in divided doses every 6–8 hours for 14 days (range: 10–28 days) recommended by IDSA and others for early Lyme disease in children with acute neurologic manifestations (e.g., meningitis, radiculopathy).273 351 354

Lyme Carditis
IV

150–200 mg/kg daily (up to 6 g daily) given in divided doses every 6–8 hours for 14 days (range: 14–21 days) recommended by IDSA and others for those with AV heart block and/or myopericarditis associated with early Lyme disease when a parenteral regimen is indicated (e.g., hospitalized patients).273 351 354

Parenteral regimen can be switched to an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) to complete therapy when clinically indicated.351

Lyme Arthritis
IV

150–200 mg/kg daily (up to 6 g daily) given in divided doses every 6–8 hours for 14 days (range: 14–28 days) for children with evidence of neurologic disease or when arthritis has not responded to an oral regimen.351

Late Neurologic Lyme Disease
IV

150–200 mg/kg daily (up to 6 g daily) given in divided doses every 6–8 hours for 14 days (range: 14–28 days) recommended by IDSA for children with late neurologic disease affecting the CNS or peripheral nervous system.273 351

Response to anti-infective treatment usually is slow and may be incomplete in such patients.351 IDSA states that retreatment is not recommended unless relapse is shown by reliable objective measures.351

Adults

General Adult Dosage
Uncomplicated Infections
IV or IM

1 g every 12 hours.230 366 367

Moderate to Severe Infections
IV or IM

1–2 g every 8 hours.230 366 367

Severe or Life-threatening Infections
IV

2 g every 6–8 hours.230 366 367 For life-threatening infections, 2 g every 4 hours.230 366 367

Meningitis and Other CNS Infections
IV

2 g every 6–8 hours for 7–21 days.230 296 Some clinicians recommend 8–12 g daily in divided doses every 4–6 hours.365

Duration of treatment is 7 days for uncomplicated meningitis caused by susceptible H. influenzae or N. meningitidis; ≥10–14 days for complicated cases or meningitis caused by S. pneumoniae; and ≥21 days for meningitis caused by susceptible Enterobacteriaceae.275 296 318

Meningitis Caused by S. pneumoniae
IV

Initially, 350 mg/kg daily given in 4 divided doses; reduce dosage to 225 mg/kg daily given in 3 divided doses if organism is susceptible to penicillin.327 335

GI Infections
Infectious Diarrhea
IV

HIV-infected: 1 g every 8 hours.412 If no clinical response after 5–7 days, consider stool culture and in vitro susceptibility testing.412

Salmonella Gastroenteritis
IV

HIV-infected: 1 g every 8 hours.412

Recommended duration is 7–14 days if CD4+ T-cells ≥200 cells/mm3 (≥14 days if patient is bacteremic or infection is complicated) or 2–6 weeks if CD4+ T-cells <200 cells/mm3.412

Respiratory Tract Infections
Community-acquired Pneumonia
IV or IM

1 g every 6–8 hours.269

Duration of treatment depends on the causative pathogen, illness severity at the onset of anti-infective therapy, response to treatment, comorbid illness, and complications.269

Gonorrhea and Associated Infections
Uncomplicated Urethral, Cervical, or Rectal Gonorrhea
IM

Single 500-mg dose recommended by CDC.167

Manufacturers recommend single 500-mg dose for treatment of gonococcal urethritis/cervicitis in males and females and rectal gonorrhea in females and single 1-g dose for treatment of rectal gonorrhea in males.230 366 367

Disseminated Gonorrhea
IV

CDC recommends 1 g every 8 hours; continue for 24–48 hours after improvement begins and switch to an oral regimen (cefixime) to complete ≥1 week of treatment.167

Lyme Disease
Early Neurologic Lyme Disease
IV

2 g every 8 hours for 14 days (range: 10–28 days) recommended by IDSA and others for adults with acute neurologic manifestations (e.g., meningitis, radiculopathy).273 351 354

Lyme Carditis
IV

2 g every 8 hours for 14 days (range: 14–21 days) recommended by IDSA and others for adults with AV heart block and/or myopericarditis associated with early Lyme disease when a parenteral regimen is indicated (e.g., hospitalized patients).351 354

Parenteral regimen can be switched to an oral regimen (doxycycline, amoxicillin, cefuroxime axetil) to complete therapy when clinically indicated.351

Lyme Arthritis
IV

2 g every 8 hours for 14 days (range: 14–28 days) recommended by IDSA for adults with evidence of neurologic disease or when arthritis has not responded to an oral regimen.351

Late Neurologic Lyme Disease
IV

2 g every 8 hours for 14 days (range: 14–28 days) recommended by IDSA for adults with late neurologic disease affecting the CNS or peripheral nervous system.273 351

Response to anti-infective treatment usually is slow and may be incomplete in such patients.351 IDSA states that retreatment is not recommended unless relapse is shown by reliable objective measures.351

Perioperative Prophylaxis
Contaminated or Potentially Contaminated Surgery
IV or IM

Manufacturers recommend 1 g 30–90 minutes prior to surgery.230

Some experts recommend 1 g in most adults and 2 g in obese patients given within 60 minutes prior to surgical incision.169

If procedure is prolonged (>3–4 hours) or if major blood loss occurs, additional intraoperative doses may be given every 3 hours.169 Duration of prophylaxis should be <24 hours for most procedures;168 no evidence to support continuing prophylaxis after wound closure or until all indwelling drains and intravascular catheters are removed.168 169

Cesarean Section
IV or IM

Manufacturers recommend 1 g IV as soon as the umbilical cord is clamped, followed by additional 1-g IM or IV doses given 6 and 12 hours after the first dose.230

Prescribing Limits

Pediatric Patients

Maximum 12 g daily for children weighing >50 kg.230 366 367

Adults

Maximum 12 g daily.230 366 367

Special Populations

Hepatic Impairment

No dosage adjustments required.289 290

Renal Impairment

Patients with Clcr <20 mL/minute per 1.73 m2 should receive 50% of the usual dose given at the usual time intervals.230

Patients undergoing hemodialysis should receive 0.5–2 g as a single daily dose with a supplemental dose after each dialysis period.265

Cautions for Claforan

Contraindications

  • Known hypersensitivity to cefotaxime or other cephalosporins.230

Warnings/Precautions

Warnings

Superinfection/Clostridium difficile-associated Diarrhea and Colitis

Possible emergence and overgrowth of nonsusceptible organisms, especially Enterobacter, Pseudomonas, enterococci, or Candida.230 Careful observation of the patient is essential.230 Institute appropriate therapy if superinfection occurs.230

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.230 342 344 345 C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including cefotaxime, and may range in severity from mild diarrhea to fatal colitis.230 342 344 345 C. difficile produces toxins A and B which contribute to development of CDAD;230 342 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.230

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.230 342 344 345 Obtain careful medical history since CDAD may occur as late as 2 months or longer after anti-infective therapy is discontinued.230 342

If CDAD is suspected or confirmed, discontinue anti-infectives not directed against C. difficile whenever possible.230 342 Initiate 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.230 342 344 345

Cardiac Effects

Potentially life-threatening arrhythmia reported with rapid injection (<1 minute) through a central venous catheter.230 Do not inject IV over <3 minutes.230 (See IV Injection under Dosage and Administration.)

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.230

If a hypersensitivity reaction occurs, discontinue cefotaxime and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, and maintenance of an adequate airway and oxygen).230

Cross-hypersensitivity

Partial cross-allergenicity among cephalosporins and other β-lactam antibiotics, including penicillins and cephamycins.a

Prior to initiation of therapy, make careful inquiry concerning previous hypersensitivity reactions to cephalosporins, penicillins, or other drugs.230 Cautious use recommended in individuals hypersensitive to penicillins: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

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of cefotaxime and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.230

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.230 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.230

History of GI Disease

Use with caution in patients with a history of GI disease, particularly colitis.230 (See Superinfection/Clostridium difficile-associated Diarrhea and Colitis under Cautions.)

Local Effects

May be locally irritating to tissues.230 Inflammation, phlebitis, and thrombophlebitis reported with IV administration;b pain, induration, and tenderness may occur at IM injection sites.230

Perivascular extravasation responds to changing the infusion site;230 extensive perivascular extravasation may result in tissue damage requiring surgery.230

Regularly monitor infusion sites and change site when appropriate.230

Hematologic Effects

Possible transient neutropenia, granulocytopenia, leukopenia, eosinophilia, or thrombocytopenia.230

Agranulocytosis may occur rarely during prolonged therapy.230 Monitor blood cell counts if treatment lasts >10 days.230

CNS Effects

Seizures reported with some cephalosporins, especially in patients with renal impairment who received dosages inappropriate for the degree of renal impairment.230

If seizures occur, discontinue cefotaxime and administer anticonvulsant therapy as indicated.230

Sodium Content

Contains approximately 50.5 mg (2.2 mEq) of sodium per g of cefotaxime.230 366 367

Specific Populations

Pregnancy

Category B.230

Lactation

Distributed into milk; use with caution.230

Pediatric Use

Adverse effects similar to those reported in adults.291

Safety of the chemical components that may leach out of the plastic containing commercially available frozen cefotaxime sodium injections not established.230

Geriatric Use

No overall differences in safety or 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.230 366 367

Substantially eliminated by kidneys; risk of toxicity may be greater in those with impaired renal function.230 366 367 Select dosage with caution and consider monitoring renal function because of age-related decreases in renal function.230 366 367 (See Renal Impairment under Dosage and Administration.)

Hepatic Impairment

Possible increased plasma half-life and clearance of cefotaxime and its major metabolite.117 289

Renal Impairment

Plasma half-life of cefotaxime and its major metabolite increased in severe renal impairment.13 16 19 Possibility of seizures if dosage is inappropriately high for the degree of renal impairment.230

Dosage adjustment recommended in those with Clcr <20 mL/minute per 1.73 m3.230

Common Adverse Effects

Local reactions at injection sites, hypersensitivity reactions, GI effects.230

Interactions for Claforan

Specific Drugs and Laboratory Tests

Drug or Test

Interaction

Comments

Aminoglycosides

Possible increased risk of nephrotoxicity.230

In vitro evidence of additive or synergistic antibacterial activity; antagonism also reported.a

Closely monitor renal function, especially if high aminoglycoside dosage is used or therapy is prolonged.230

Administer separately; do not admix.230

Probenecid

Decreased renal clearance and increased concentrations of cefotaxime and its metabolites.b

Tests for glucose

Possible false-positive reactions in urine glucose tests using Clinitest, Benedict’s solution, or Fehling’s solution.a

Use glucose tests based on enzymatic glucose oxidase reactions (e.g., Clinistix, Tes-Tape.)a

Claforan Pharmacokinetics

Absorption

Bioavailability

Not appreciably absorbed from GI tract; must be administered parenterally.b

Following IM administration, peak serum concentrations attained within 30 minutes.6 8 11 230

Distribution

Extent

Widely distributed into body tissues and fluids, including aqueous humor, bronchial secretions,224 sputum, middle ear effusions, bone,115 bile,115 116 and ascitic,117 pleural, and prostatic fluids.9

Distributed into CSF; highest concentrations attained in those with inflamed meninges.263 264 288 290 b

Crosses the placenta21 and is distributed into milk.21

Plasma Protein Binding

13–38%.2 6 11

Elimination

Metabolism

Partially metabolized in the liver to desacetylcefotaxime, which has antibacterial activity.2 7 14 Desacetylcefotaxime is further metabolized into inactive metabolites in the liver.2 7 14 18

Elimination Route

Cefotaxime and its metabolites excreted principally in urine.2 14 In adults with normal renal function, 40–60% of a dose excreted as unchanged drug; 24% excreted as the active metabolite.b

Half-life

Terminal serum half-life of cefotaxime and desacetylcefotaxime is 0.9–1.7 and 1.4–1.9 hours, respectively.2 7 10 11 13 14 19

Special Populations

Terminal half-lives of cefotaxime and desacetylcefotaxime may be prolonged in patients with hepatic impairment.117 289

Terminal half-life of cefotaxime only slightly prolonged in adults with Clcr ≥20 mL/minute per 1.73 m2.13 16 In those with Clcr of ≤10 mL/minute per 1.73 m2, terminal half-lives of 1.4–11.5 and 8.2–56.8 hours reported for cefotaxime and desacetylcefotaxime, respectively.13 16 19

Stability

Storage

Parenteral

Powder for Injection or IV Infusion

15–30°C;230 366 367 protect from light.230 366 367

Following reconstitution with sterile water for injection, IV solutions containing 50 or 95 mg/mL are stable for 24 hours at room temperature (≤22°C) or 7 days when refrigerated (≤5°C).230 IV solutions reconstituted with 0.9% sodium chloride injection or 5% dextrose injection and further diluted in a compatible IV solution are stable for 24 hours at room temperature (≤22°C) or at least 5 days when refrigerated (≤5°C).230

Following reconstitution with sterile or bacteriostatic water for injection, IM solutions containing 230–330 mg/mL are stable in their original containers for 12 hours at room temperature (≤22°C) or 10 days when refrigerated (≤5°C).230

Powder for injection and solutions may darken.230

For Injection, for IV Infusion

Claforan ADD-Vantage vials: <30°C; protect from light.230 After reconstitution as directed in 0.9% sodium chloride injection or 5% dextrose injection, stable for 24 hours at ≤22°C;230 do not freeze.230

Injection (Frozen)

-20°C or lower.230 Thawed solution stable 24 hours at room temperature (≤22°C) or 7 days under refrigeration (≤5°C).230

Do not refreeze after thawing.230

Compatibility

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

Parenteral

Cefotaxime sodium is most stable at a pH of 5–7 and should not be diluted with IV solutions that have a pH >7.5 (e.g., sodium bicarbonate).230

Solution Compatibility

Compatible

Dextrose 5 or 10% in waterHID 230

Dextrose 5% in sodium chloride 0.2, 0.45, or 0.9%230

Invert sugar 10%230

Ringer’s injection, lactated230

Sodium chloride 0.9%HID

Sodium lactate (1/6) M230

Travasol 8.5% without electrolytes230

Drug Compatibility
Admixture CompatibilityHID

Compatible

Clindamycin phosphate

Metronidazole

Metronidazole HCl

Verapamil HCl

Variable

Amikacin sulfate

Gentamicin sulfate

Y-site CompatibilityHID

Compatible

Acyclovir sodium

Amifostine

Aztreonam

Bivalirudin

Cyclophosphamide

Dexmedetomidine HCl

Diltiazem HCl

Docetaxel

Etoposide phosphate

Famotidine

Fenoldopam mesylate

Fludarabine phosphate

Granisetron HCl

Hetastarch in lactated electrolyte injection (Hextend)

Hydromorphone HCl

Levofloxacin

Lorazepam

Magnesium sulfate

Melphalan HCl

Meperidine HCl

Midazolam HCl

Milrinone lactate

Morphine sulfate

Ondansetron HCl

Pemetrexed disodium

Perphenazine

Propofol

Remifentanil HCl

Sargramostim

Teniposide

Thiotepa

Tolazoline HCl

Vinorelbine tartrate

Incompatible

Allopurinol sodium

Azithromycin

Filgrastim

Fluconazole

Gemcitabine HCl

Hetastarch in sodium chloride 0.9%

Pentamidine isethionate

Variable

Vancomycin HCl

Actions and Spectrum

  • Based on spectrum of activity, classified as a third generation cephalosporin.a Usually less active in vitro against susceptible staphylococci than first generation cephalosporins; has an expanded spectrum of activity against gram-negative bacteria compared with first and second generation cephalosporins.a b

  • Usually bactericidal.a

  • Like other β-lactam antibiotics, antibacterial activity results from inhibition of bacterial cell wall synthesis.230 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.a

  • Gram-positive aerobes: active in vitro and in clinical infections against S. pneumoniae, S. pyogenes (group A β-hemolytic streptococci), S. agalactiae (group B streptococci), S. aureus (including β-lactamase-producing strains), and some enterococci (e.g., Enterococcus faecalis).230 a b Also active in vitro against some viridans streptococci.350 Oxacillin-resistant (methicillin-resistant) staphylococci and some enterococci are resistant.a b

  • Gram-negative aerobes: active in vitro and in clinical infections against Acinetobacter, Citrobacter, Enterobacter, E. coli, H. influenzae (including ampicillin-resistant strains), H. parainfluenzae, Klebsiella, M. morganii, N. gonorrhoeae, N. meningitidis, P. mirabilis, P. vulgaris, P. rettgeri, P. stuartii, and Serratia.230 a b Also active in vitro against Campylobacter,222 223 Capnocytophaga,312 314 315 Eikenella corrodens,220 221 249 Moraxella,232 236 240 244 Salmonella,a b Shigella,a b and Vibrio vulnificus.292 Active against some strains of Pseudomonas aeruginosa, but less active against susceptible Ps. aeruginosa than ceftazidime.b

  • Anaerobes and other organisms: active in vitro and in clinical infections against Bacteroides, Eubacterium, Fusobacterium, Peptococcus, Peptostreptococcus, Propionibacterium, Veillonella, and some strains of Clostridium.230 265 a b Also active against the spirochete Borrelia burgdorferi.265

Advice to Patients

  • Advise patients that antibacterials (including cefotaxime) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).230

  • Importance of completing full course of therapy, even if feeling better after a few days.230

  • 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 cefotaxime or other antibacterials in the future.230

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.230 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.230

  • Importance of informing clinicians if an allergic reaction occurs.230

  • Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs as well as any concomitant illnesses.230

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.230

  • Importance of informing patients of other important precautionary information.230 (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

Cefotaxime Sodium

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injection

500 mg (of cefotaxime)*

Cefotaxime Sodium for Injection

Claforan

Sanofi-Aventis

1 g (of cefotaxime)*

Cefotaxime Sodium for Injection

Claforan

Sanofi-Aventis

2 g (of cefotaxime)*

Cefotaxime Sodium for Injection

Claforan

Sanofi-Aventis

10 g (of cefotaxime) pharmacy bulk package*

Cefotaxime Sodium for Injection

Claforan

Sanofi-Aventis

For injection, for IV infusion

1 g (of cefotaxime)

Claforan

Sanofi-Aventis

Claforan ADD-Vantage

Sanofi-Aventis

2 g (of cefotaxime)

Claforan

Sanofi-Aventis

Claforan ADD-Vantage

Sanofi-Aventis

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

Cefotaxime Sodium in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection (frozen), for IV infusion

20 mg (of cefotaxime) per mL (1 g) in 3.4% Dextrose*

Cefotaxime Sodium Iso-osmotic in Dextrose Injection (Galaxy [Baxter])

40 mg (of cefotaxime) per mL (2 g) in 1.4% Dextrose*

Cefotaxime Sodium Iso-osmotic in Dextrose Injection (Galaxy [Baxter])

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions September 30, 2013. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

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