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- Cefuroxime Axetil
- Cefuroxime Sodium
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Intravenous, as sodium [strength expressed as base]:
Zinacef in D5W: 750 mg (50 mL [DSC])
Zinacef in Sterile Water: 1.5 g (50 mL)
Solution Reconstituted, Injection, as sodium [strength expressed as base]:
Zinacef: 750 mg (1 ea); 1.5 g (1 ea); 7.5 g (1 ea)
Generic: 750 mg (1 ea); 1.5 g (1 ea); 7.5 g (1 ea); 75 g (1 ea); 225 g (1 ea)
Solution Reconstituted, Intravenous, as sodium [strength expressed as base]:
Zinacef: 750 mg (1 ea); 1.5 g (1 ea)
Generic: 750 mg (1 ea [DSC]); 1.5 g (1 ea); 7.5 g (1 ea [DSC])
Suspension Reconstituted, Oral, as axetil [strength expressed as base]:
Ceftin: 125 mg/5 mL (100 mL); 250 mg/5 mL (50 mL, 100 mL) [contains aspartame; tutti-frutti flavor]
Generic: 125 mg/5 mL (100 mL [DSC])
Tablet, Oral, as axetil [strength expressed as base]:
Ceftin: 250 mg [DSC], 500 mg [DSC]
Generic: 250 mg, 500 mg
Brand Names: U.S.
- Zinacef in D5W [DSC]
- Zinacef in Sterile Water
- Antibiotic, Cephalosporin (Second Generation)
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
Oral tablet: Increases with food
Widely to body tissues and fluids including bronchial secretions, synovial and pericardial fluid, kidneys, heart, liver, bone and bile; crosses blood-brain barrier; therapeutic concentrations achieved in CSF even when meninges are not inflamed
Cefuroxime axetil (oral) is hydrolyzed in the intestinal mucosa and blood to cefuroxime
Urine (66% to 100% as unchanged drug)
Time to Peak
Serum: IM: ~15 to 60 minutes; IV: 2 to 3 minutes; Oral: Children: ~3 to 4 hours; Adults: ~2 to 3 hours
PNA ≤3 days: Median: 5.8 hours (de Louvois 1982)
PNA ≥8 days: Median: 1.6-3.8 hours (de Louvois 1982)
Children and Adolescents: 1.4-1.9 hours
Adults: ~1 to 2 hours; prolonged with renal impairment
33% to 50%
Use: Labeled Indications
Acute bacterial maxillary sinusitis (tablets and oral suspension only): Treatment of mild to moderate acute bacterial maxillary sinusitis in adults and pediatric patients ≥3 months caused by Streptococcus pneumoniae, Haemophilus influenzae (non-beta-lactamase-producing strains only).
Limitations of use: Effectiveness for sinus infections caused by beta-lactamase–producing H. influenzae or M. catarrhalis in patients with acute bacterial maxillary sinusitis has not been established. Note: According to the IDSA guidelines for acute bacterial rhinosinusitis, cefuroxime is no longer recommended as monotherapy for initial empiric treatment (Chow 2012).
Acute bacterial exacerbations of chronic bronchitis (tablets only): Treatment of mild to moderate acute bacterial exacerbations of chronic bronchitis s in adults and adolescents ≥13 years caused by S. pneumoniae, H. influenzae (beta-lactamase negative strains), or Haemophilus parainfluenzae (beta-lactamase negative strains).
Acute otitis media (tablets and oral suspension only): Treatment of pediatric patients ≥3 months with acute bacterial otitis media caused by S. pneumoniae, H. influenzae (including beta-lactamase-producing strains), Moraxella catarrhalis (including beta-lactamase-producing strains), or Streptococcus pyogenes.
Bone and joint infections (injection only): Treatment of bone and joint infections caused by Staphylococcus aureus (penicillinase- and non-penicillinase-producing strains).
Lower respiratory tract infections (injection only): Treatment of lower respiratory tract infections, including pneumonia, caused by S. pneumoniae, H. influenzae (including ampicillin-resistant strains), Klebsiella spp., S. aureus (penicillinase- and non-penicillinase-producing strains), S. pyogenes, and Escherichia coli.
Lyme disease (early) (tablets only): Treatment of adults and adolescents ≥13 years with early Lyme disease caused by Borrelia burgdorferi.
Pharyngitis/tonsillitis (tablets and oral suspension only): Treatment of mild to moderate pharyngitis/tonsillitis caused by S. pyogenes in adults and pediatric patients ≥3 months
Limitations of use: The efficacy in the prevention of rheumatic fever has not been established in clinical trials. Efficacy in the treatment of penicillin-resistant strains of S. pyogenes has not been demonstrated.
Septicemia (injection only): Treatment of septicemia caused by S. aureus (penicillinase- and non-penicillinase-producing strains), S. pneumoniae, E. coli, H. influenzae (including ampicillin-resistant strains), and Klebsiella spp.
Skin and skin structure infection (impetigo) (oral suspension only): Treatment of pediatric patients 3 months to 12 years of age with skin or skin structure infections (impetigo) caused by S. aureus (including beta-lactamase-producing strains) or S. pyogenes.
Skin and skin structure infection (injection; tablets [uncomplicated infections only]): Treatment of adults and pediatric patients >3 months with skin and skin-structure infections (including impetigo) caused by S. aureus (penicillinase- and non-penicillinase-producing strains), S. pyogenes, E. coli, Klebsiella spp., and Enterobacter spp.
Surgical (perioperative) prophylaxis (injection only): Prophylaxis of infection in patients undergoing surgical procedures (eg, vaginal hysterectomy) that are classified as clean-contaminated or potentially contaminated procedures.
Urinary tract infections (tablets and injection only): Treatment of adults and pediatric patients >3 months with urinary tract infections caused by E. coli and Klebsiella spp.
Hypersensitivity to cefuroxime, any component of the formulation, or other beta-lactam antibacterial drugs (eg, penicillins and cephalosporins)
Note: Cefuroxime axetil film-coated tablets and oral suspension are not bioequivalent and are not substitutable on a mg/mg basis. All oral doses listed are for tablet formulation:
Acute bacterial maxillary sinusitis: Oral: 250 mg twice daily for 10 days
Bone and joint infections: IM, IV: 1.5 g every 8 hours (adjunctive surgical intervention may be necessary); upon completion of parenteral therapy follow with oral antibiotic therapy if indicated.
Acute bacterial exacerbations of chronic bronchitis:
Oral: 250 to 500 mg every 12 hours for 10 days
IV: 500 to 750 mg every 8 hours (complete therapy with oral dosing)
Cholecystitis, mild to moderate (off-label): IV: 1.5 g every 8 hours for 4 to 7 days (provided source controlled) (IDSA [Solomkin 2010])
Intra-abdominal infection, complicated, community-acquired, mild to moderate (in combination with metronidazole): (off-label): IV: 1.5 g every 8 hours for 4 to 7 days (provided source controlled) (IDSA [Solomkin 2010])
Lyme disease (early): Oral: 500 mg twice daily for 20 days
Pharyngitis/tonsillitis: Oral: 250 mg twice daily for 10 days
Note: Cefuroxime is considered an alternate therapy for CAP in adults caused by Streptococcus pneumoniae (with MICs <2 mcg/mL for penicillin); may also be used as outpatient empiric therapy in combination with a macrolide (preferred) or doxycycline (IDSA [Mandell 2007]).
Oral (off-label route in US): 500 mg twice daily for a minimum of 5 days (patients should be afebrile for ≥48 hours and clinically stable before discontinuing therapy) (IDSA [Mandell 2007])
Manufacturer's labeling: IM, IV: 750 mg every 8 hours
Alternate dosing: IV: 1.5 g every 8 hours. Note: This higher dose should be considered in hospitalized patients, especially if bacteremic (Caballero-Granado 1996)
Severe or complicated infections: IV: 1.5 g every 8 hours (up to 1.5 g every 6 hours in life-threatening infections)
Skin/skin structure infection, uncomplicated:
Oral: 250 to 500 mg every 12 hours for 10 days
IM, IV: 750 mg every 8 hours
Surgical (perioperative) prophylaxis: IV:
Manufacturer's labeling: 1.5 g 30 minutes to 1 hour prior to procedure (if procedure is prolonged can give 750 mg every 8 hours IV or IM)
Open heart: IV: 1.5 g every 12 hours for a total of 4 doses starting at anesthesia induction
Alternative recommendation: 1.5 g within 60 minutes prior to surgical incision. Doses may be repeated in 4 hours if procedure is lengthy or if there is excessive blood loss (Bratzler 2013).
Urinary tract infection, uncomplicated:
Oral: 250 mg twice daily for 7 to 10 days
IV, IM: 750 mg every 8 hours
Bite wounds (animal) (off-label use) (IDSA [Stevens 2014]): Oral: 500 mg twice daily in combination with clindamycin or metronidazole for anaerobic coverage
Refer to adult dosing.
Note: Cefuroxime axetil film-coated tablets and oral suspension are not bioequivalent and are not substitutable on a mg/mg basis.
Children ≥1 year:
Surgical (perioperative) prophylaxis: IV: 50 mg/kg within 60 minutes prior to surgical incision (maximum dose: 1,500 mg). Doses may be repeated in 4 hours if procedure is lengthy or if there is excessive blood loss (Bratzler 2013).
Infants ≥3 months and Children:
Acute bacterial maxillary sinusitis, acute otitis media:
Oral: Suspension: 30 mg/kg/day in 2 divided doses for 10 days (maximum dose: 1,000 mg/day); tablet: 250 mg twice daily for 10 days
IM, IV: 75 to 150 mg/kg/day divided every 8 hours (maximum dose: 6 g/day)
Bone and joint infection: IM, IV: 50 mg/kg/dose every 8 hours; maximum single dose: 1,500 mg. Upon completion of parenteral therapy follow with oral antibiotic therapy if indicated.
Oral: Suspension: 20 mg/kg/day (maximum: 500 mg/day) in 2 divided doses for 10 days
IM, IV: 75 to 150 mg/kg day divided every 8 hours (maximum: 6 g/day)
Skin and skin structure infection (impetigo): Oral: Suspension: 30 mg/kg/day in 2 divided doses for 10 days (maximum dose: 1,000 mg/day)
Urinary tract infection, uncomplicated (off-label dosing):
Infants and Children ≥2 months to 2 years: Oral: 20 to 30 mg/kg/day divided twice daily for 7 to 14 days (AAP 2011)
Children ≥2 years: Moderate to severe disease (possible pyelonephritis): Oral: 20 to 30 mg/kg/day divided twice daily (maximum dose: 1,000 mg/day) (Bradley 2012; Red Book [AAP 2012])
Acute bacterial exacerbations of chronic bronchitis: Oral: 250 to 500 mg every 12 hours for 10 days.
Acute bacterial maxillary sinusitis: Oral: 250 mg twice daily for 10 days.
Bone and joint infection: IM, IV: Refer to adult dosing.
Lyme disease (early): Oral: 500 mg twice daily for 20 days.
Pharyngitis/tonsillitis: Oral: 250 mg every 12 hours for 10 days.
Skin/skin structure infection, uncomplicated: Oral: 250 to 500 mg every 12 hours for 10 days.
Urinary tract infection, uncomplicated: Oral: 250 mg twice daily for 7 to 10 days.
Dosing: Renal Impairment
CrCl ≥30 mL/minute: No dosage adjustment necessary.
CrCl 10 to <30 mL/minute: Administer recommended dose based on indication every 24 hours
CrCl <10 mL/minute: Administer recommended dose based on indication every 48 hours
ESRD requiring intermittent hemodialysis (IHD): Additional recommended dose based on indication should be given at the end of each dialysis session.
Pediatric: There are no dosage adjustments provided in the manufacturer’s labeling; however, the following adjustments have been reported in the literature (Aronoff 2007): Note: Renally adjusted dose recommendations are based on doses of 30 mg/kg/day divided every 12 hours:
CrCl ≥30 mL/minute/1.73 m2: No dosage adjustment necessary.
CrCl 10 to 29 mL/minute/1.73 m2: 15 mg/kg/dose every 12 hours.
CrCl <10 mL/minute/1.73 m2: 15 mg/kg/dose every 24 hours.
Hemodialysis: Dialyzable: 15 mg/kg/dose every 24 hours
Peritoneal dialysis: 15 mg/kg/dose every 24 hours
CrCl >20 mL/minute: No dosage adjustment necessary.
CrCl 10 to 20 mL/minute: Administer recommended dose based on indication every 12 hours
CrCl <10 mL/minute: Administer recommended dose based on indication every 24 hours
Hemodialysis: Administer additional recommended dose based on indication at the end of dialysis
Infants >3 months, Children, and Adolescents: Administer recommended dose based on indication but decrease frequency similar to the adult recommendations.
Alternate dosing (Aronoff 2007):
Adults: Administer full dose every 24 hours
Children: 25 to 50 mg/kg dose every 24 hours
Continuous renal replacement therapy (CRRT):
Adults: 1 g every 12 hours
Children: 25 to 50 mg/kg every 8 hours
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer’s labeling.
Oral suspension: Refer to manufacturer’s product labeling for reconstitution instructions.
Duplex container: Unlatch side tab, unfold, and remove foil strip from drug chamber. Point set port in downward direction, fold container just below the diluent meniscus, and squeeze the diluent chamber until the seal between the diluent and drug powder opens. Shake until dissolved.
Oral suspension: Administer with food. Shake well before use.
Oral tablet: May administer with or without food. Swallow tablet whole (crushed tablet has strong, persistent, bitter taste).
IM: Inject deep IM into large muscle mass.
IV: Inject direct IV over 3 to 5 minutes. Infuse intermittent infusion over 15 to 30 minutes.
Some products may contain phenylalanine and/or sodium.
Oral suspension: Should be taken with food.
See Trissel’s IV Compatibility Database
Injection: Store intact vials at 15°C to 30°C (59°F to 86°F); protect from light. Reconstituted solution is stable for 24 hours at room temperature and 48 hours when refrigerated. IV infusion in NS or D5W solution is stable for 24 hours at room temperature, 7 days when refrigerated, or 26 weeks when frozen. After freezing, thawed solution is stable for 24 hours at room temperature or 21 days when refrigerated.
Duplex container: Store unactivated units at 20°C to 25°C (68°F to 77°F). Unactivated units with foil strip removed from the drug chamber must be protected from light and used within 7 days. Once activated, may be stored for up to 24 hours at room temperature or for 7 days under refrigeration. Do not freeze.
ADD-Vantage vials: Joined, but not activated, vials are stable for 14 days. Once activated, stable for 24 hours at room temperature and 7 days refrigerated. Do not freeze.
Premix Galaxy plastic containers: Store frozen at -20°C. Thaw container at room temperature or under refrigeration; do not force thaw. Thawed solution is stable for 24 hours at room temperature and 28 days refrigerated; do not refreeze.
Oral suspension: Prior to reconstitution, store at 2°C to 30°C (36°F to 86°F). Reconstituted suspension is stable for 10 days at 2°C to 8°C (36°F to 46°F).
Tablet: Store at 15°C to 30°C (59°F to 86°F).
Aminoglycosides: Cephalosporins (2nd Generation) may enhance the nephrotoxic effect of Aminoglycosides. Monitor therapy
Antacids: May decrease the serum concentration of Cefuroxime. Management: Consider administering antacids and cefuroxime at least 2 hours apart. Consider therapy modification
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Avoid combination
H2-Antagonists: May decrease the absorption of Cefuroxime. Separate oral doses by at least 2 hours. Monitor therapy
Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Monitor therapy
Probenecid: May increase the serum concentration of Cephalosporins. Monitor therapy
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Vaccination with live attenuated typhoid vaccine (Ty21a) should be avoided in patients being treated with systemic antibacterial agents. Use of this vaccine should be postponed until at least 3 days after cessation of antibacterial agents. Consider therapy modification
Vitamin K Antagonists (eg, warfarin): Cephalosporins may enhance the anticoagulant effect of Vitamin K Antagonists. Monitor therapy
Positive direct Coombs', false-positive urinary glucose test using cupric sulfate (Benedict's solution, Clinitest®, Fehling's solution); false-negative may occur with ferricyanide test. Glucose oxidase or hexokinase-based methods should be used.
>10%: Gastrointestinal: Diarrhea (4% to 11%, duration dependent)
1% to 10%:
Cardiovascular: Local thrombophlebitis (2%)
Dermatologic: Diaper rash (children 3%)
Endocrine & metabolic: Increased lactate dehydrogenase (1%)
Gastrointestinal: Nausea and vomiting (3% to 7%), unpleasant taste (children 5%)
Genitourinary: Vaginitis (≤5%)
Hematologic & oncologic: Decreased hematocrit (≤10%), decreased hemoglobin (≤10%), eosinophilia (1% to 7%)
Hepatic: Increased serum transaminases (2% to 4%), increased serum alkaline phosphatase (2%)
Immunologic: Jarisch-Herxheimer reaction (6%)
<1% (Limited to important or life-threatening): Anaphylaxis, angioedema, anorexia, brain disease, candidiasis, chest tightness, cholestasis, Clostridium difficile associated diarrhea, colitis, decreased creatinine clearance, drug fever, dyspepsia, dysuria, erythema, erythema multiforme, gastrointestinal hemorrhage, gastrointestinal infection, glossitis, headache, hearing loss, hemolytic anemia, hepatitis, hyperactivity, hyperbilirubinemia, hypersensitivity, hypersensitivity angiitis, increased blood urea nitrogen, increased liver enzymes, increased serum creatinine, increased thirst, interstitial nephritis, irritability, joint swelling, leukopenia, muscle cramps, muscle rigidity, muscle spasm (neck), neutropenia, oral mucosa ulcer, pancytopenia, positive direct Coombs test, prolonged prothrombin time, pseudomembranous colitis, renal insufficiency, renal pain, seizure, serum sickness-like reaction, sialorrhea, sinusitis, Stevens-Johnson syndrome, swollen tongue, tachycardia, thrombocytopenia (rare), toxic epidermal necrolysis, trismus, upper respiratory tract infection, urethral bleeding, urethral pain, urinary tract infection, vaginal discharge, vaginal irritation, viral infection, vulvovaginal candidiasis, vulvovaginal pruritus
Concerns related to adverse effects:
• Elevated INR: May be associated with increased INR, especially in nutritionally-deficient patients, prolonged treatment, hepatic or renal disease.
• Hypersensitivity reactions: Serious and occasionally severe or fatal hypersensitivity (anaphylactic) reactions have been reported in patients receiving beta-lactam drugs. Before initiating therapy, carefully investigate previous penicillin, cephalosporin, or other allergen hypersensitivity. Use caution if given to a patient with a penicillin or other beta-lactam allergy because cross sensitivity among beta-lactam antibacterial drugs has been established. If an allergic reaction occurs, discontinue and institute appropriate therapy.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
• Gastrointestinal disease: Use with caution in patients with a history of colitis.
• Renal impairment: Use with caution in patients with renal impairment; modify dosage in severe impairment.
• Seizure disorders: Use with caution in patients with a history of seizure disorder; cephalosporins have been associated with seizure activity, particularly in patients with renal impairment not receiving dose adjustments. Discontinue if seizures occur.
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.
• Phenylalanine: Some products may contain phenylalanine.
• Suspension/tablet bioequivalence: Tablets and oral suspension are not bioequivalent; do not substitute on a mg-per-mg basis.
• Tablets: Should not be crushed or chewed due to a strong, persistent bitter taste. Patients unable to swallow whole tablets should be prescribed the oral suspension.
Monitor renal, hepatic, and hematologic function periodically with prolonged therapy. Monitor prothrombin time in patients at risk of prolongation during cephalosporin therapy (nutritionally-deficient, prolonged treatment, renal or hepatic disease). Observe for signs and symptoms of anaphylaxis during first dose.
Pregnancy Risk Factor
Adverse events were not observed in animal reproduction studies. Cefuroxime crosses the placenta and reaches the cord serum and amniotic fluid. Placental transfer is decreased in the presence of oligohydramnios. Several studies have failed to identify an increased teratogenic risk to the fetus following maternal cefuroxime use.
During pregnancy, mean plasma concentrations of cefuroxime are 50% lower, the AUC is 25% lower, and the plasma half-life is shorter than nonpregnant values. At term, plasma half-life is similar to nonpregnant values and peak maternal concentrations after IM administration are slightly decreased. Pregnancy does not alter the volume of distribution. Cefuroxime is one of the antibiotics recommended for prophylactic use prior to cesarean delivery.
• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience nausea, vomiting, bad taste, or diarrhea. Have patient report immediately to prescriber severe injection site irritation, bruising, bleeding, urinary retention, change in amount of urine passed, severe loss of strength and energy, seizure, vaginitis, hearing impairment, or signs of Clostridium difficile (C. diff)-associated diarrhea (abdominal pain or cramps, severe diarrhea or watery stools, or bloody stools) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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- Drug class: second generation cephalosporins
- Cefuroxime Axetil (AHFS Monograph)
- Cefuroxime Sodium (AHFS Monograph)
- Cefuroxime Axetil Oral Suspension (FDA)
- Cefuroxime Dextrose (FDA)
- Cefuroxime Injection (FDA)