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CEFTIN
(cefuroxime axetil) Tablets, for Oral Use
CEFTIN
(cefuroxime axetil) for Oral Suspension
CEFTIN tablets and CEFTIN for oral suspension contain cefuroxime as cefuroxime axetil. CEFTIN is a semisynthetic, cephalosporin antibacterial drug for oral administration.
The chemical name of cefuroxime axetil (1-(acetyloxy) ethyl ester of cefuroxime) is (RS)-1- hydroxyethyl (6R,7R)-7-[2-(2-furyl)glyoxyl-amido]-3-(hydroxymethyl)-8-oxo-5-thia-1-azabicyclo[4.2.0]-oct-2-ene-2-carboxylate, 72-(Z)-(O-methyl-oxime), 1-acetate 3-carbamate. Its molecular formula is C20H22N4O10S, and it has a molecular weight of 510.48.
Cefuroxime axetil is in the amorphous form and has the following structural formula:
 |
Tablets are film-coated and contain the equivalent of 250 or 500 mg of cefuroxime as cefuroxime axetil. Tablets contain the inactive ingredients colloidal silicon dioxide, croscarmellose sodium, hydrogenated vegetable oil, hypromellose, methylparaben, microcrystalline cellulose, propylene glycol, propylparaben, sodium benzoate, sodium lauryl sulfate, and titanium dioxide.
Oral suspension, when reconstituted with water, provides the equivalent of 125 mg or 250 mg of cefuroxime (as cefuroxime axetil) per 5 mL. Oral suspension contains the inactive ingredients acesulfame potassium, aspartame, povidone K30, stearic acid, sucrose, tutti-frutti flavoring, and xanthan gum.
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (13 years and older) with mild-to-moderate pharyngitis/tonsillitis caused by susceptible strains of Streptococcus pyogenes.
CEFTIN for oral suspension is indicated for the treatment of pediatric patients aged 3 months to 12 years with mild-to-moderate pharyngitis/tonsillitis caused by susceptible strains of Streptococcus pyogenes.
CEFTIN tablets are indicated for the treatment of pediatric patients (who can swallow tablets whole) with acute bacterial otitis media caused by susceptible strains of Streptococcus pneumoniae, Haemophilus influenzae (including β-lactamase-producing strains), Moraxella catarrhalis (including β-lactamase-producing strains), or Streptococcus pyogenes.
CEFTIN for oral suspension is indicated for the treatment of pediatric patients aged 3 months to 12 years with acute bacterial otitis media caused by susceptible strains of Streptococcus pneumoniae, Haemophilus influenzae (including β-lactamase-producing strains), Moraxella catarrhalis (including β-lactamase-producing strains), or Streptococcus pyogenes.
CEFTIN tablets are indicated for the treatment of adult and pediatric patients (13 years and older) with mild-to-moderate acute bacterial maxillary sinusitis caused by susceptible strains of Streptococcus pneumoniae or Haemophilus influenzae (non-β-lactamase-producing strains only).
CEFTIN for oral suspension is indicated for the treatment of pediatric patients aged 3 months to 12 years with mild-to-moderate acute bacterial maxillary sinusitis caused by susceptible strains of Streptococcus pneumoniae or Haemophilus influenzae (non-β-lactamase-producing strains only).
The effectiveness of CEFTIN for sinus infections caused by β-lactamase-producing Haemophilus influenzae or Moraxella catarrhalis in patients with acute bacterial maxillary sinusitis was not established due to insufficient numbers of these isolates in the clinical trials [see Clinical Studies].
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with mild-to-moderate acute bacterial exacerbations of chronic bronchitis caused by susceptible strains of Streptococcus pneumoniae, Haemophilus influenzae (β-lactamase-negative strains), or Haemophilus para influenzae (β-lactamase-negative strains).
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with uncomplicated skin and skin-structure infections caused by susceptible strains of Staphylococcus aureus (including β-lactamase-producing strains) or Streptococcus pyogenes.
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with uncomplicated urinary tract infections caused by susceptible strains of Escherichia coli or Klebsiella pneumoniae.
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with uncomplicated gonorrhea, urethral and endocervical, caused by penicillinase producing and non-penicillinase-producing susceptible strains of Neisseria gonorrhoeae and uncomplicated gonorrhea, rectal, in females, caused by non-penicillinase-producing susceptible strains of Neisseria gonorrhoeae.
CEFTIN tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with early Lyme disease (erythema migrans) caused by susceptible strains of Borrelia burgdorferi.
CEFTIN for oral suspension is indicated for the treatment of pediatric patients aged 3 months to 12 years with impetigo caused by susceptible strains of Staphylococcus aureus (including Plactamase- producing strains) or Streptococcus pyogenes.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of CEFTIN and other antibacterial drugs, CEFTIN should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Administer CEFTIN tablets as described in the dosage guidelines table below with or without food.
Table 1: Adult Patients and Pediatric Patients Dosage
Guidelines for CEFTIN Tablets
| Infection | Dosage | Duration (Days) |
| Adults and Adolescents (13 years and older) | ||
| Pharyngitis/tonsillitis (mild to moderate) | 250 mg every 12 hours | 10 |
| Acute bacterial maxillary sinusitis (mild to moderate) | 250 mg every 12 hours | 10 |
| Acute bacterial exacerbations of chronic bronchitis (mild to moderate) | 250 or 500 mg every 12 hours | 10a |
| Uncomplicated skin and skin-structure infections | 250 or 500 mg every 12 hours | 10 |
| Uncomplicated urinary tract infections | 250 mg every 12 hours | 7 to 10 |
| Uncomplicated gonorrhea | 1,000 mg | single dose |
| Early Lyme disease | 500 mg every 12 hours | 20 |
| Pediatric Patients younger than 13 years (who can swallow tablets whole)b | ||
| Acute bacterial otitis media | 250 mg every 12 hours | 10 |
| Acute bacterial maxillary sinusitis | 250 mg every 12 hours | 10 |
| a The safety and effectiveness of CEFTIN
administered for less than 10 days in patients with acute exacerbations of
chronic bronchitis have not been established. b When crushed, the tablet has a strong, persistent bitter taste. Therefore, patients who cannot swallow the tablet whole should receive the oral suspension. |
||
Administer CEFTIN for oral suspension as described in the dosage guidelines table below with food.
Table 2: Pediatric Patients (3 Months to 12 Years)
Dosage Guidelines for CEFTIN for Oral Suspension
| Infection | Recommended Daily Dosea | Maximum Daily Dose | Duration (Days) |
| Pharyngitis/tonsillitis | 20 mg/kg | 500 mg | 10 |
| Acute bacterial otitis media | 30 mg/kg | 1,000 mg | 10 |
| Acute bacterial maxillary sinusitis | 30 mg/kg | 1,000 mg | 10 |
| Impetigo | 30 mg/kg | 1,000 mg | 10 |
| a Recommended daily dose given twice daily divided in equal doses. | |||
Prepare a suspension at the time of dispensing as follows:
Table 3: Amount of Water Required for Reconstitution
of Labeled Volumes of CEFTIN for Oral Suspension
| Oral Suspension | Amount of Water Required for Reconstitution | Labeled Volume after Reconstitution |
| 125 mg/5 mL | 37 mL | 100 mL |
| 250 mg/5 mL | 19 mL | 50 mL |
| 35 mL | 100 mL |
A dosage interval adjustment is required for patients whose creatinine clearance is less than 30 mL/min, as listed in Table 4 below, because cefuroxime is eliminated primarily by the kidney [see CLINICAL PHARMACOLOGY].
Table 4: Dosing in Adults with Renal Impairment
| Creatinine Clearance (mL/min) | Recommended Dosage |
| ≥30 | No dosage adjustment |
| 10 to <30 | Standard individual dose given every 24 hours |
| <10 (without hemodialysis) | Standard individual dose given every 48 hours |
| Hemodialysis | A single additional standard dose should be given at the end of each dialysis |
CEFTIN tablets are white, capsule-shaped, film-coated tablets available in the following strengths:
CEFTIN for oral suspension is provided as dry, white to off-white, tutti-frutti-flavored powder. When reconstituted as directed, the suspension provides the equivalent of 125 mg or 250 mg of cefuroxime (as cefuroxime axetil) per 5 mL.
CEFTIN tablets, 250 mg of cefuroxime (as cefuroxime axetil), are white, capsule-shaped, film-coated tablets engraved with “GX ES7” on one side and blank on the other side as follows: 20 Tablets/Bottle NDC 0173-0387-00
CEFTIN tablets, 500 mg of cefuroxime (as cefuroxime axetil), are white, capsule-shaped, film-coated tablets engraved with “GX EG2” on one side and blank on the other side as follows: Â 20 Tablets/Bottle NDC 0173-0394-00
Store the tablets between 15° and 30°C (59° and 86°F). Replace cap securely after each opening.
CEFTIN for oral suspension is provided as dry, white to off-white, tutti-frutti-flavored powder. When reconstituted as directed, the suspension provides the equivalent of 125 mg or 250 mg of cefuroxime (as cefuroxime axetil) per 5 mL. It is supplied in amber glass bottles as follows:
100-mL Suspension NDC 0173-0740-00
50-mL Suspension NDC 0173-0741-10
100-mL Suspension NDC 0173-0741-00
Before reconstitution, store dry powder between 2° and 30°C (36° and 86°F).
After reconstitution, immediately store suspension refrigerated between 2° and 8°C (36° and 46°F). DISCARD AFTER 10 DAYS.
GlaxoSmithKline, Research Triangle Park, NC 27709. Revised: Oct 2017
The following serious and otherwise important adverse reaction is described in greater detail in the Warnings and Precautions section of the label:
Anaphylactic Reactions [see WARNINGS AND PRECAUTIONS]
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in practice.
In multiple-dose clinical trials, 912 subjects were treated with CEFTIN (125 to 500 mg twice daily). It is noted that 125 mg twice daily is not an approved dosage. Twenty (2.2%) subjects discontinued medication due to adverse reactions. Seventeen (85%) of the 20 subjects who discontinued therapy did so because of gastrointestinal disturbances, including diarrhea, nausea, vomiting, and abdominal pain. The percentage of subjects treated with CEFTIN who discontinued study drug because of adverse reactions was similar at daily doses of 1,000, 500, and 250 mg (2.3%, 2.1%, and 2.2%, respectively). However, the incidence of gastrointestinal adverse reactions increased with the higher recommended doses.
The adverse reactions in Table 5 are for subjects (n = 912) treated with CEFTIN in multiple-dose clinical trials.
Table 5: Adverse Reactions (≥1%) after
Multiple-Dose Regimens with CEFTIN Tablets
| Adverse Reaction | CEFTIN (n = 912) |
| Blood and lymphatic system disorders | |
| Eosinophilia | 1% |
| Gastrointestinal disorders | |
| Diarrhea | 4% |
| Nausea/Vomiting | 3% |
| Investigations | |
| Transient elevation in AST | 2% |
| Transient elevation in ALT | 2% |
| Transient elevation in LDH | 1% |
The following adverse reactions occurred in less than 1% but greater than 0.1% of subjects (n = 912) treated with CEFTIN in multiple-dose clinical trials.
Immune System Disorders: Hives, swollen tongue.
Metabolism and Nutrition Disorders: Anorexia.
Nervous System Disorders: Headache.
Cardiac Disorders: Chest pain.
Respiratory Disorders: Shortness of breath.
Gastrointestinal Disorders: Abdominal pain, abdominal cramps, flatulence, indigestion, mouth ulcers.
Skin and Subcutaneous Tissue Disorders: Rash, itch.
Renal and Urinary Disorders: Dysuria.
Reproductive System and Breast Disorders: Vaginitis, vulvar itch.
General Disorders and Administration Site Conditions: Chills, sleepiness, thirst.
Investigations: Positive Coombs' test.
Two multicenter trials assessed CEFTIN 500 mg twice daily for 20 days. The most common drug-related adverse experiences were diarrhea (10.6%), Jarisch-Herxheimer reaction (5.6%), and vaginitis (5.4%). Other adverse experiences occurred with frequencies comparable to those reported with 7 to 10 days' dosing.
In clinical trials using a single 1,000-mg dose of CEFTIN, 1,061 subjects were treated for uncomplicated gonorrhea. The adverse reactions in Table 6 were for subjects treated with a single dose of 1,000 mg CEFTIN in U.S. clinical trials.
Table 6: Adverse Reactions (≥1%) after Single-Dose
Regimen with 1,000-mg CEFTIN Tablets
for Uncomplicated Gonorrhea
| Adverse Reaction | CEFTIN (n = 1,061) |
| Gastrointestinal disorders | |
| Nausea/Vomiting | 7% |
| Diarrhea | 4% |
The following adverse reactions occurred in less than 1% but greater than 0.1% of subjects (n = 1,061) treated with a single dose of CEFTIN 1,000 mg for uncomplicated gonorrhea in U.S. clinical trials.
Infections and Infestations: Vaginal candidiasis.
Nervous System Disorders: Headache, dizziness, somnolence.
Cardiac Disorders: Tightness/pain in chest, tachycardia.
Gastrointestinal Disorders: Abdominal pain, dyspepsia.
Skin and Subcutaneous Tissue Disorders: Erythema, rash, pruritus.
Musculoskeletal and Connective Tissue Disorders: Muscle cramps, muscle stiffness, muscle spasm of neck, lockjaw-type reaction.
Renal and Urinary Disorders: Bleeding/pain in urethra, kidney pain.
Reproductive System and Breast Disorders: Vaginal itch, vaginal discharge.
In clinical trials using multiple doses of CEFTIN, pediatric subjects (96.7% were younger than 12 years) were treated with CEFTIN (20 to 30 mg/kg/day divided twice daily up to a maximum dose of 500 or 1,000 mg/day, respectively). Eleven (1.2%) U.S. subjects discontinued medication due to adverse reactions. The discontinuations were primarily for gastrointestinal disturbances, usually diarrhea or vomiting. Thirteen (1.4%) U.S. pediatric subjects discontinued therapy due to the taste and/or problems with drug administration.
The adverse reactions in Table 7 are for U.S. subjects (n = 931) treated with CEFTIN in multiple-dose clinical trials.
Table 7: Adverse Reactions (>1%) after
Multiple-Dose Regimens with CEFTIN for Oral Suspension
| Adverse Reaction | CEFTIN (n = 931) |
| Gastrointestinal disorders | |
| Diarrhea | 9% |
| Dislike of taste | 5% |
| Nausea/vomiting | 3% |
| Skin and subcutaneous tissue disorders | |
| Diaper rash | 3% |
The following adverse reactions occurred in less than 1% but greater than 0.1% of U.S. subjects (n = 931) treated with CEFTIN for oral suspension in multiple-dose clinical trials.
Infections and Infestations: Gastrointestinal infection, candidiasis, viral illness, upper respiratory infection, sinusitis, urinary tract infection.
Blood and Lymphatic System Disorders: Eosinophilia.
Psychiatric Disorders: Hyperactivity, irritable behavior.
Gastrointestinal Disorders: Abdominal pain, flatulence, ptyalism.
Skin and Subcutaneous Tissue Disorders: Rash.
Musculoskeletal and Connective Tissue Disorders: Joint swelling, arthralgia.
Reproductive System and Breast Disorders: Vaginal irritation.
General Disorders and Administration Site Conditions: Cough, fever.
Investigations: Elevated liver enzymes, positive Coombs' test.
The following adverse reactions have been identified during post-approval use of CEFTIN. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia.
Pseudomembranous colitis [see WARNINGS AND PRECAUTIONS].
Hepatic impairment including hepatitis and cholestasis, jaundice.
Anaphylaxis, serum sickness-like reaction.
Investigations
Increased prothrombin time.
Seizure, encephalopathy.
Renal dysfunction.
Angioedema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria.
Cefuroxime axetil may affect the gut flora, leading to lower estrogen reabsorption and reduced efficacy of combined oral estrogen/progesterone contraceptives. Counsel patients to consider alternate supplementary (non-hormonal) contraceptive measures during treatment.
Drugs that reduce gastric acidity may result in a lower bioavailability of CEFTIN compared with administration in the fasting state. Administration of drugs that reduce gastric acidity may negate the food effect of increased absorption of CEFTIN when administered in the postprandial state. Administer CEFTIN at least 1 hour before or 2 hours after administration of short-acting antacids. Histamine-2 (H2) antagonists and proton pump inhibitors should be avoided.
Concomitant administration of probenecid with cefuroxime axetil tablets increases serum concentrations of cefuroxime [see CLINICAL PHARMACOLOGY]. Coadministration of probenecid with cefuroxime axetil is not recommended.
A false-positive reaction for glucose in the urine may occur with copper reduction tests (e.g., Benedict's or Fehling's solution), but not with enzyme-based tests for glycosuria. As a false-negative result may occur in the ferricyanide test, it is recommended that either the glucose oxidase or hexokinase method be used to determine blood/plasma glucose levels in patients receiving cefuroxime axetil. The presence of cefuroxime does not interfere with the assay of serum and urine creatinine by the alkaline picrate method.
Included as part of the PRECAUTIONS section.
Serious and occasionally fatal hypersensitivity (anaphylactic) reactions have been reported in patients on β-lactam antibacterials. These reactions are more likely to occur in individuals with a history of β-lactam hypersensitivity and/or a history of sensitivity to multiple allergens. There have been reports of individuals with a history of penicillin hypersensitivity who have experienced severe reactions when treated with cephalosporins. CEFTIN is contraindicated in patients with a known hypersensitivity to CEFTIN or other β-lactam antibacterial drugs [see CONTRAINDICATIONS]. Before initiating therapy with CEFTIN, inquire about previous hypersensitivity reactions to penicillins, cephalosporins, or other allergens. If an allergic reaction occurs, discontinue CEFTIN and institute appropriate therapy.
Clostridium difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including CEFTIN, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxinproducing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.
The possibility of superinfections with fungal or bacterial pathogens should be considered during therapy.
Prescribing CEFTIN either in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
CEFTIN for oral suspension 125 mg/5 mL contains phenylalanine 11.8 mg per 5 mL (1 teaspoonful) of reconstituted suspension. CEFTIN for oral suspension 250 mg/5 mL contains phenylalanine 25.2 mg per 5 mL (1 teaspoonful) of reconstituted suspension.
A false-positive result for glucose in the urine may occur with copper reduction tests, and a false-negative result for blood/plasma glucose may occur with ferricyanide tests in subjects receiving CEFTIN [see DRUG INTERACTIONS].
Although lifetime studies in animals have not been performed to evaluate carcinogenic potential, no mutagenic activity was found for cefuroxime axetil in a battery of bacterial mutation tests. Positive results were obtained in an in vitro chromosome aberration assay; however, negative results were found in an in vivo micronucleus test at doses up to 1.5 g/kg. Reproduction studies in rats at doses up to 1,000 mg/kg/day (9 times the recommended maximum human dose based on body surface area) have revealed no impairment of fertility.
Pregnancy Category B. There are no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, CEFTIN should be used during pregnancy only if clearly needed.
Reproduction studies have been performed in mice at doses up to 3,200 mg/kg/day (14 times the recommended maximum human dose based on body surface area) and in rats at doses up to 1,000 mg/kg/day (9 times the recommended maximum human dose based on body surface area) and have revealed no evidence of impaired fertility or harm to the fetus due to cefuroxime axetil.
Because cefuroxime is excreted in human milk, caution should be exercised when CEFTIN is administered to a nursing woman.
The safety and effectiveness of CEFTIN have been established for pediatric patients aged 3 months to 12 years for acute bacterial maxillary sinusitis based upon its approval in adults. Use of CEFTIN in pediatric patients is supported by pharmacokinetic and safety data in adults and pediatric patients, and by clinical and microbiological data from adequate and well-controlled trials of the treatment of acute bacterial maxillary sinusitis in adults and of acute otitis media with effusion in pediatric patients. It is also supported by postmarketing adverse events surveillance. [See INDICATIONS AND USAGE, DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS, CLINICAL PHARMACOLOGY]
Of the total number of subjects who received CEFTIN in 20 clinical trials, 375 were aged 65 and older while 151 were aged 75 and older. No overall differences in safety or effectiveness were observed between these subjects and younger adult subjects. Reported clinical experience has not identified differences in responses between the elderly and younger adult patients, but greater sensitivity of some older individuals cannot be ruled out.
Cefuroxime is substantially excreted by the kidney, and the risk of adverse reactions may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
Reducing the dosage of CEFTIN is recommended for adult patients with severe renal impairment (creatinine clearance <30 mL/min) [see DOSAGE AND ADMINISTRATION, CLINICAL PHARMACOLOGY].
Overdosage of cephalosporins can cause cerebral irritation leading to convulsions or encephalopathy. Serum levels of cefuroxime can be reduced by hemodialysis and peritoneal dialysis.
CEFTIN is contraindicated in patients with a known hypersensitivity (e.g., anaphylaxis) to CEFTIN or to other β-lactam antibacterial drugs (e.g., penicillins and cephalosporins).
CEFTIN is an antibacterial drug [see Microbiology].
After oral administration, cefuroxime axetil is absorbed from the gastrointestinal tract and rapidly hydrolyzed by nonspecific esterases in the intestinal mucosa and blood to cefuroxime. Serum pharmacokinetic parameters for cefuroxime following administration of CEFTIN tablets to adults are shown in Table 8.
Table 8: Pharmacokinetics of Cefuroxime Administered
in the Postprandial State as CEFTIN Tablets to Adultsa
| Doseb (Cefuroxime Equivalent) | Peak Plasma Concentration (mcg/mL) | Time of Peak Plasma Concentration (h) | Mean Elimination Half-life (h) | AUC (mcg•h/mL) |
| 125 mg | 2.1 | 2.2 | 1.2 | 6.7 |
| 250 mg | 4.1 | 2.5 | 1.2 | 12.9 |
| 500 mg | 7.0 | 3.0 | 1.2 | 27.4 |
| 1,000 mg | 13.6 | 2.5 | 1.3 | 50.0 |
| a Mean values of 12 healthy adult volunteers. b Drug administered immediately after a meal. |
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Absorption of the tablet is greater when taken after food (absolute bioavailability increases from 37% to 52%). Despite this difference in absorption, the clinical and bacteriologic responses of subjects were independent of food intake at the time of tablet administration in 2 trials where this was assessed.
All pharmacokinetic and clinical effectiveness and safety trials in pediatric subjects using the suspension formulation were conducted in the fed state. No data are available on the absorption kinetics of the suspension formulation when administered to fasted pediatric subjects.
Oral suspension was not bioequivalent to tablets when tested in healthy adults. The tablet and oral suspension formulations are NOT substitutable on a milligram-permilligram basis. The area under the curve for the suspension averaged 91% of that for the tablet, and the peak plasma concentration for the suspension averaged 71% of the peak plasma concentration of the tablets. Therefore, the safety and effectiveness of both the tablet and oral suspension formulations were established in separate clinical trials.
Cefuroxime is distributed throughout the extracellular fluids. Approximately 50% of serum cefuroxime is bound to protein.
The axetil moiety is metabolized to acetaldehyde and acetic acid.
Cefuroxime is excreted unchanged in the urine; in adults, approximately 50% of the administered dose is recovered in the urine within 12 hours. The pharmacokinetics of cefuroxime in pediatric subjects have not been studied. Until further data are available, the renal elimination of cefuroxime axetil established in adults should not be extrapolated to pediatric subjects.
In a trial of 28 adults with normal renal function or severe renal impairment (creatinine clearance <30 mL/min), the elimination half-life was prolonged in relation to severity of renal impairment. Prolongation of the dosage interval is recommended in adult patients with creatinine clearance <30 mL/min [see DOSAGE AND ADMINISTRATION].
Serum pharmacokinetic parameters for cefuroxime in pediatric subjects administered CEFTIN for oral suspension are shown in Table 9.
Table 9: Pharmacokinetics of Cefuroxime Administered
in the Postprandial State as CEFTIN for Oral Suspension to Pediatric Subjectsa
| Doseb (Cefuroxime Equivalent) | n | Peak Plasma Concentration (mcg/mL) | Time of Peak Plasma Concentration (h) | Mean Elimination Half-life (h) | AUC (mcg•h/mL) |
| 10 mg/kg | 8 | 3.3 | 3.6 | 1.4 | 12.4 |
| 15 mg/kg | 12 | 5.1 | 2.7 | 1.9 | 22.5 |
| 20 mg/kg | 8 | 7.0 | 3.1 | 1.9 | 32.8 |
| a Mean age = 23 months. b Drug administered with milk or milk products. |
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In a trial of 20 elderly subjects (mean age = 83.9 years) having a mean creatinine clearance of 34.9 mL/min, the mean serum elimination half-life was prolonged to 3.5 hours; however, despite the lower elimination of cefuroxime in geriatric patients, dosage adjustment based on age is not necessary [see Use In Specific Populations].
Concomitant administration of probenecid with cefuroxime axetil tablets increases the cefuroxime area under the serum concentration versus time curve and maximum serum concentration by 50% and 21%, respectively.
Cefuroxime axetil is a bactericidal agent that acts by inhibition of bacterial cell wall synthesis. Cefuroxime axetil has activity in the presence of some β-lactamases, both penicillinases and cephalosporinases, of gram-negative and gram-positive bacteria.
Resistance to cefuroxime axetil is primarily through hydrolysis by β-lactamase, alteration of penicillin-binding proteins (PBPs), decreased permeability, and the presence of bacterial efflux pumps.
Susceptibility to cefuroxime axetil will vary with geography and time; local susceptibility data should be consulted, if available. Beta-lactamase-negative, ampicillin-resistant (BLNAR) isolates of H. influenzae should be considered resistant to cefuroxime axetil.
Cefuroxime axetil has been shown to be active against most isolates of the following bacteria, both in vitro and in clinical infections [see INDICATIONS AND USAGE]:
Staphylococcus aureus (methicillin-susceptible isolates
only)
Streptococcus pneumoniae
Streptococcus pyogenes
Escherichia colia
Klebsiella pneumoniaea
Haemophilus influenzae
Haemophilus parainfluenzae
Moraxella catarrhalis
Neisseria gonorrhoeae
a Most extended spectrum β-lactamase
(ESBL)-producing and carbapenemase-producing isolates are resistant to
cefuroxime axetil.
Spirochetes
Borrelia Burgdorferi
The following in vitro data are available, but their clinical significance is unknown. At least 90 percent of the following microorganisms exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for cefuroxime axetil of 1 mcg/mL. However, the efficacy of cefuroxime axetil in treating clinical infections due to these microorganisms has not been established in adequate and well-controlled clinical trials.
Staphylococcus epidermidis (methicillin-susceptible
isolates only)
Staphylococcus saprophyticus (methicillin-susceptible
isolates only)
Streptococcus agalactiae
Morganella morganii
Proteus inconstans
Proteus mirabilis
Providencia rettgeri
Anaerobic Bacteria
Peptococcus niger
When available, the clinical microbiology laboratory should provide the results of in vitro susceptibility tests for antimicrobial drug products used in local hospitals and practice areas to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting an antibacterial drug product for treatment.
Quantitative methods are used to determine antimicrobial MICs. These MICs provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized test method (broth or agar).1, 2 The MIC values should be interpreted according to criteria provided in Table 10.2,3
Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size provides an estimate of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using a standardized test method.4 This procedure uses paper disks impregnated with 30 mcg cefuroxime axetil to test the susceptibility of microorganisms to cefuroxime axetil. The disk diffusion interpretive criteria are provided in Table 10.3
Table 10: Susceptibility Test Interpretive Criteria for
Cefuroxime Axetil
| Pathogen | Minimum Inhibitory Concentrations (mcg/mL) | Disk Diffusion Zone Diameters (mm) | ||||
| (S) Susceptible | (I) Intermediate | (R) Resistant | (S) Susceptible | (I) Intermediate | (R) Resistant | |
| Enterobacteriaceaea | ≤4 | 8 - 16 | ≥32 | ≥23 | 15 - 22 | ≤14 |
| Haemophilus spp.a,b | ≤4 | 8 | ≥16 | ≥20 | 17 - 19 | ≤16 |
| Moraxella catarrhalisa | ≤4 | 8 | ≥16 | - | - | - |
| Streptococcus pneumoniae | ≤1 | 2 | ≥4 | - | - | - |
| a For Enterobacteriaceae, Haemophilus spp.,
and Moraxella catarrhalis, susceptibility interpretive criteria are based on a
dose of 500 mg every 12 hours in patients with normal renal function. b Haemophilus spp. includes only isolates of H. influenzae and H. parainfluenzae. |
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Susceptibility of staphylococci to cefuroxime may be deduced from testing only penicillin and either cefoxitin or oxacillin.
Susceptibility of Streptococcus pyogenes may be deduced from testing penicillin.3
A report of “Susceptible” indicates that the antimicrobial drug is likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentration usually achievable at the site of infection. A report of “Intermediate” indicates that the result should be considered equivocal, and if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where a high dosage of drug can be used. This category also provides a buffer zone that prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of “Resistant” indicates that the antimicrobial drug is not likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentrations usually achievable at the infection site; other therapy should be selected.
Standardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the techniques of the individual performing the test.1,2,4 The QC ranges for MIC and disk diffusion testing using the 30-mcg disk are provided in Table 11.3
Table 11: Acceptable Quality Control (QC) Ranges for
Cefuroxime Axetil
| QC Strain | Minimum Inhibitory Concentrations (mcg/mL) | Disk Diffusion Zone Diameters (mm) |
| Escherichia coli ATCC 25922 | 2 to 8 | 20 to 26 |
| Staphylococcus aureus ATCC 25923 | - | 27 to 35 |
| Staphylococcus aureus ATCC 29213 | 0.5 to 2 | - |
| Streptococcus pneumoniae ATCC 49619 | 0.25 to 1 | - |
| Haemophilus influenzae ATCC 49766 | 0.25 to 1 | 28 to 36 |
| Neisseria gonorrhoeae ATCC 49226 | 0.25 to 1 | 33 to 41 |
| ATCC = American Type Culture Collection. | ||
One adequate and well-controlled trial was performed in subjects with acute bacterial maxillary sinusitis. In this trial, each subject had a maxillary sinus aspirate collected by sinus puncture before treatment was initiated for presumptive acute bacterial sinusitis. All subjects had radiographic and clinical evidence of acute maxillary sinusitis. In the trial, the clinical effectiveness of CEFTIN in treating acute maxillary sinusitis was comparable to an oral antimicrobial agent containing a specific β-lactamase inhibitor. However, microbiology data demonstrated CEFTIN to be effective in treating acute bacterial maxillary sinusitis due only to Streptococcus pneumoniae or non-β-lactamase-producing Haemophilus influenzae. Insufficient numbers of β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis isolates were obtained in this trial to adequately evaluate the effectiveness of CEFTIN in treating acute bacterial maxillary sinusitis due to these 2 organisms.
This trial randomized 317 adult subjects, 132 subjects in the U.S. and 185 subjects in South America. Table 12 shows the results of the intent-to-treat analysis.
Table 12: Clinical Effectiveness of CEFTIN Tablets in
the Treatment of Acute Bacterial Maxillary Sinusitis
| U.S. Subjectsa | South American Subjectsb | |||
| CEFTIN 250 mg Twice Daily (n = 49) |
Controlc (n = 43) |
CEFTIN 250 mg Twice Daily (n = 49) |
Controlc (n = 43) |
|
| Clinical success (cure + improvement) | 65% | 53% | 77% | 74% |
| Clinical cure | 53% | 44% | 72% | 64% |
| Clinical improvement | 12% | 9% | 5% | 10% |
| a 95% confidence interval around the success
difference [-0.08, +0.32]. b 95% confidence interval around the success difference [-0.10, +0.16]. c Control was an antibacterial drug containing a β-lactamase inhibitor. |
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In this trial and in a supporting maxillary puncture trial, 15 evaluable subjects had non- β-lactamase-producing Haemophilus influenzae as the identified pathogen. Of these, 67% (10/15) had this pathogen eradicated. Eighteen (18) evaluable subjects had Streptococcus pneumoniae as the identified pathogen. Of these, 83% (15/18) had this pathogen eradicated.
Two adequate and well-controlled trials were performed in subjects with early Lyme disease. All subjects presented with physician-documented erythema migrans, with or without systemic manifestations of infection. Subjects were assessed at 1 month posttreatment for success in treating early Lyme disease (Part I) and at 1 year posttreatment for success in preventing the progression to the sequelae of late Lyme disease (Part II).
A total of 355 adult subjects (181 treated with cefuroxime axetil and 174 treated with doxycycline) were randomized in the 2 trials, with diagnosis of early Lyme disease confirmed in 79% (281/355). The clinical diagnosis of early Lyme disease in these subjects was validated by 1) blinded expert reading of photographs, when available, of the pretreatment erythema migrans skin lesion, and 2) serologic confirmation (using enzyme-linked immunosorbent assay [ELISA] and immunoblot assay [“Western” blot]) of the presence of antibodies specific to Borrelia burgdorferi, the etiologic agent of Lyme disease. The efficacy data in Table 13 are specific to this “validated” patient subset, while the safety data below reflect the entire patient population for the 2 trials. Clinical data for evaluable subjects in the “validated” patient subset are shown in Table 13.
Table 13: Clinical Effectiveness of CEFTIN Tablets
Compared with Doxycycline in the Treatment of Early Lyme Disease
| Part I (1 Month after 20 Days of Treatment)a | Part II (1 Year after 20 Days of Treatment)b | |||
| CEFTIN 500 mg Twice Daily (n = 125) |
Doxycycline 100 mg 3 Times Daily (n = 108) |
CEFTIN 500 mg Twice Daily (n = 105c) |
Doxycycline 100 mg 3 Times Daily (n = 83c) |
|
| Satisfactory clinical outcomed | 91% | 93% | 84% | 87% |
| Clinical cure/success | 72% | 73% | 73% | 73% |
| Clinical improvement | 19% | 19% | 10% | 13% |
| a 95% confidence interval around the
satisfactory difference for Part I (-0.08, +0.05). b 95% confidence interval around the satisfactory difference for Part II (-0.13, +0.07). c n's include subjects assessed as unsatisfactory clinical outcomes (failure + recurrence) in Part I (CEFTIN - 11 [5 failure, 6 recurrence]; doxycycline - 8 [6 failure, 2 recurrence]). d Satisfactory clinical outcome includes cure + improvement (Part I) and success + improvement (Part II). |
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CEFTIN and doxycycline were effective in prevention of the development of sequelae of late Lyme disease.
While the incidence of drug-related gastrointestinal adverse reactions was similar in the 2 treatment groups (cefuroxime axetil - 13%; doxycycline - 11%), the incidence of drug-related diarrhea was higher in the cefuroxime axetil arm versus the doxycycline arm (11% versus 3%, respectively).
REFERENCES
1. Clinical and Laboratory Standards Institute (CLSI). Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically; Approved Standard - Tenth Edition. 2015. CLSI document M07-A10, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.
2. Clinical and Laboratory Standards Institute (CLSI). Methods for Antimicrobial Dilution and Disk Susceptibility Testing for Infrequently Isolated or Fastidious Bacteria: Approved Guidelines - Second Edition. 2010. CLSI document M45-A2, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.
3. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Susceptibility Testing; Twenty-fifth Informational Supplement. 2015. CLSI document M100- S25, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.
4. Clinical and Laboratory Standards Institute (CLSI). Performance Standards for Antimicrobial Disk Diffusion Susceptibility Tests; Approved Standard - Twelfth Edition. 2015. CLSI document M02-A12, Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, Pennsylvania 19087, USA.
Inform patients that CEFTIN is a cephalosporin that can cause allergic reactions in some individuals [see WARNINGS AND PRECAUTIONS].
Inform patients that diarrhea is a common problem caused by antibacterials, and it usually ends when the antibacterial is discontinued. Sometimes after starting treatment with antibacterials, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as 2 or more months after having taken their last dose of the antibacterial. If this occurs, advise patients to contact their physician as soon as possible.
Inform patients and caregivers that CEFTIN for oral suspension contains phenylalanine (a component of aspartame) [see WARNINGS AND PRECAUTIONS].
Instruct patients to swallow the tablet whole, without crushing the tablet. Patients who cannot swallow the tablet whole should receive the oral suspension.
Instruct patients to shake the oral suspension well before each use, store in the refrigerator, and discard after 10 days. The oral suspension should be taken with food.
Inform patients that antibacterial drugs, including CEFTIN, should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When CEFTIN is prescribed to treat a bacterial infection, inform patients that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may: (1) decrease the effectiveness of the immediate treatment, and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by CEFTIN or other antibacterial drugs in the future.
