Cefuroxime axetil (oral)

Cefuroxime axetil (oral)
Adult Indications & Dosage
Pediatric Indications & Dosage
Contraindications
Warnings & Precautions
Adverse Reactions
Drug Interactions
Use in Specific Populations
Administration & Monitoring
Overdosage
Pharmacology
Clinical Studies
How Supplied
Images
Patient Counseling Information
Precautions with Alcohol
Brand Names
Look-Alike Names

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Adeel Jamil, M.D. [2]

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Overview

Cefuroxime axetil (oral) is a Cefuroxime Axetil that is FDA approved for the treatment of acute bacterial exacerbation of chronic bronchitis, acute otitis media, acute bronchitis - secondary bacterial infection, uncomplicated gonorrhea, impetigo, infection of skin and subcutaneous tissue, uncomplicated lyme disease, pharyngitis, tonsillitis, uncompliated urinary tract infectious disease. Common adverse reactions include diarrhea, nausea and vomiting, vaginitis.

Adult Indications and Dosage

FDA-Labeled Indications and Dosage (Adult)

• 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.

CEFTIN Tablets

• CEFTIN Tablets are indicated for the treatment of patients with mild to moderate infections caused by susceptible strains of the designated microorganisms in the conditions listed below:

Pharyngitis/Tonsillitis

• Caused by Streptococcus pyogenes

• NOTE: The usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever, is penicillin given by the intramuscular route. CEFTIN Tablets are generally effective in the eradication of streptococci from the nasopharynx; however, substantial data establishing the efficacy of cefuroxime in the subsequent prevention of rheumatic fever are not available. Please also note that in all clinical trials, all isolates had to be sensitive to both penicillin and cefuroxime. There are no data from adequate and well‑controlled trials to demonstrate the effectiveness of cefuroxime in the treatment of penicillin‑resistant strains of Streptococcus pyogenes.

Acute Bacterial Otitis Media

• Caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase−producing strains), Moraxella catarrhalis (including beta-lactamase−producing strains), or Streptococcus pyogenes.

Acute Bacterial Maxillary Sinusitis

• Caused by Streptococcus pneumoniae or Haemophilus influenzae (non-beta-lactamase−producing strains only).

• NOTE: In view of the insufficient numbers of isolates of beta -lactamase–producing strains of Haemophilus influenzae and Moraxella catarrhalis that were obtained from clinical trials with Ceftin Tablets for patients with acute bacterial maxillary sinusitis, it was not possible to adequately evaluate the effectiveness of Ceftin Tablets for sinus infections known, suspected, or considered potentially to be caused by beta -lactamase–producing Haemophilus influenzae or Moraxella catarrhalis.

Acute Bacterial Exacerbations of Chronic Bronchitis and Secondary Bacterial Infections of Acute Bronchitis

• Caused by Streptococcus pneumoniae, Haemophilus influenzae (beta-lactamase negative strains), or Haemophilus parainfluenzae (beta‑lactamase negative strains).

Uncomplicated Skin and Skin‑ Structure Infections

• Caused by Staphylococcus aureus (including beta-lactamase‑producing strains) or Streptococcus pyogenes.

Uncomplicated Urinary Tract Infections

• Caused by Escherichia coli or Klebsiella pneumoniae.

Uncomplicated Gonorrhea, urethral and endocervical

• Caused by penicillinase-producing and non-penicillinase‑producing strains of Neisseria gonorrhoeae and uncomplicated gonorrhea, rectal, in females, caused by non-penicillinase−producing strains of Neisseria gonorrhoeae.

Early Lyme Disease (erythema migrans)

• Caused by Borrelia burgdorferi

Dosing Information

NOTE: CEFTIN Tablets and ceftin for oral suspension are not bioequivalent and are not substitutable on a milligram‑per‑milligram basis.

This image is provided by the National Library of Medicine.

Patients with Renal Impairment

• Because cefuroxime is eliminated primarily by the kidney, a dosage interval adjustment is required for patients whose creatinine clearance is <30 mL/min.

This image is provided by the National Library of Medicine.

Off-Label Use and Dosage (Adult)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Cefuroxime axetil (oral) in adult patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Cefuroxime axetil (oral) in adult patients.

Pediatric Indications and Dosage

FDA-Labeled Indications and Dosage (Pediatric)

CEFTIN for Oral Suspension

• CEFTIN for Oral Suspension is indicated for the treatment of pediatric patients 3 months to 12 years of age with mild to moderate infections caused by susceptible strains of the designated microorganisms in the conditions listed below. The safety and effectiveness of CEFTIN for Oral Suspension in the treatment of infections other than those specifically listed below have not been established either by adequate and well‑controlled trials or by pharmacokinetic data with which to determine an effective and safe dosing regimen.

Pharyngitis/Tonsillitis caused by Streptococcus pyogenes

• NOTE: The usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever, is penicillin given by the intramuscular route. CEFTIN for Oral Suspension is generally effective in the eradication of streptococci from the nasopharynx; however, substantial data establishing the efficacy of cefuroxime in the subsequent prevention of rheumatic fever are not available. Please also note that in all clinical trials, all isolates had to be sensitive to both penicillin and cefuroxime. There are no data from adequate and well‑controlled trials to demonstrate the effectiveness of cefuroxime in the treatment of penicillin‑resistant strains of Streptococcus pyogenes.

Acute Bacterial Otitis Media

• Caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase−producing strains), Moraxella catarrhalis (including beta-lactamase−producing strains), or Streptococcus pyogenes.

Impetigo

• Caused by Staphylococcus aureus (including beta-lactamase−producing strains) or Streptococcus pyogenes.

Dosing Information

CEFTIN for Oral Suspension

• CEFTIN for Oral Suspension may be administered to pediatric patients ranging in age from 3 months to 12 years, according to dosages in the table given below:

This image is provided by the National Library of Medicine.

Directions for Mixing CEFTIN for Oral Suspension

• Prepare a suspension at the time of dispensing as follows:

• Shake the bottle to loosen the powder.
• Remove the cap.
• Add the total amount of water for reconstitution (see Table 12) and replace the cap.
• Invert the bottle and vigorously rock the bottle from side to side so that water rises through the powder.
• Once the sound of the powder against the bottle disappears, turn the bottle upright and vigorously shake it in a diagonal direction.

This image is provided by the National Library of Medicine.

• NOTE: Shake the oral suspension well before each use. Replace cap securely after each opening. Store the reconstituted suspension between 2° and 8°C (36° and 46°F) (in a refrigerator). Discard after 10 days.

Off-Label Use and Dosage (Pediatric)

Guideline-Supported Use

There is limited information regarding Off-Label Guideline-Supported Use of Cefuroxime axetil (oral) in pediatric patients.

Non–Guideline-Supported Use

There is limited information regarding Off-Label Non–Guideline-Supported Use of Cefuroxime axetil (oral) in pediatric patients.

Contraindications

• Cefuroxime axetil products are contraindicated in patients with known allergy to the cephalosporin group of antibiotics.

Warnings

• CEFTIN tablets and ceftin for oral suspension are not bioequivalent and are therefore not substitutable on a milligram‑per‑milligram basis.

• Before therapy with CEFTIN products is instituted, careful inquiry should be made to determine whether the patient has had previous hypersensitivity reactions to ceftin products, other cephalosporins, penicillins, or other drugs. If this product is to be given to penicillin‑sensitive patients, caution should be exercised because cross‑hypersensitivity among beta‑lactam antibiotics has been clearly documented and may occur in up to 10% of patients with a history of penicillin allergy. If a clinically significant allergic reaction to ceftin products occurs, discontinue the drug and institute appropriate therapy. Serious acute hypersensitivity reactions may require treatment with epinephrine and other emergency measures, including oxygen, intravenous fluids, intravenous antihistamines, corticosteroids, pressor amines, and airway management, as clinically indicated.

• 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. Hypertoxin producing 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.

PRECAUTIONS

General

• As with other broad‑spectrum antibiotics, prolonged administration of cefuroxime axetil may result in overgrowth of nonsusceptible microorganisms. If superinfection occurs during therapy, appropriate measures should be taken.

• Cephalosporins, including cefuroxime axetil, should be given with caution to patients receiving concurrent treatment with potent diuretics because these diuretics are suspected of adversely affecting renal function.

• Cefuroxime axetil, as with other broad‑spectrum antibiotics, should be prescribed with caution in individuals with a history of colitis. The safety and effectiveness of cefuroxime axetil have not been established in patients with gastrointestinal malabsorption. Patients with gastrointestinal malabsorption were excluded from participating in clinical trials of cefuroxime axetil.

• Cephalosporins may be associated with a fall in prothrombin activity. Those at risk include patients with renal or hepatic impairment or poor nutritional state, as well as patients receiving a protracted course of antimicrobial therapy, and patients previously stabilized on anticoagulant therapy. Prothrombin time should be monitored in patients at risk and exogenous Vitamin K administered as indicated.

• Prescribing CEFTIN 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.

• Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, 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 the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.

Adverse Reactions

Clinical Trials Experience

Multiple-Dose Dosing Regimens

7 to 10 Days Dosing

• Using multiple doses of cefuroxime axetil tablets, 912 patients were treated with cefuroxime axetil (125 to 500 mg twice daily). There were no deaths or permanent disabilities thought related to drug toxicity. Twenty (2.2%) patients discontinued medication due to adverse events thought by the investigators to be possibly, probably, or almost certainly related to drug toxicity. Seventeen (85%) of the 20 patients who discontinued therapy did so because of gastrointestinal disturbances, including diarrhea, nausea, vomiting, and abdominal pain. The percentage of cefuroxime axetil tablet‑treated patients who discontinued study drug because of adverse events was very 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 events increased with the higher recommended doses.

• The following adverse events were thought by the investigators to be possibly, probably, or almost certainly related to cefuroxime axetil tablets in multiple‑dose clinical trials (n = 912 cefuroxime axetil‑treated patients).

• Table Adverse Reactions‑CEFTIN Tablets:

This image is provided by the National Library of Medicine.

This image is provided by the National Library of Medicine.

5 Day Experience

• In clinical trials using CEFTIN in a dose of 250 mg twice daily in the treatment of secondary bacterial infections of acute bronchitis, 399 patients were treated for 5 days and 402 patients were treated for 10 days. No difference in the occurrence of adverse events was found between the 2 regimens.

In Clinical Trials for Early Lyme Disease With 20 Days Dosing

• Two multicenter trials assessed cefuroxime axetil tablets 500 mg twice a day for 20 days. The most common drug‑related adverse experiences were diarrhea (10.6% of patients), 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.

=Single Dose Regimen for Uncomplicated Gonorrhea

• In clinical trials using a single dose of cefuroxime axetil tablets, 1,061 patients were treated with the recommended dosage of cefuroxime axetil (1,000 mg) for the treatment of uncomplicated gonorrhea. There were no deaths or permanent disabilities thought related to drug toxicity in these studies.

• The following adverse events were thought by the investigators to be possibly, probably, or almost certainly related to cefuroxime axetil in 1,000‑mg single‑dose clinical trials of cefuroxime axetil tablets in the treatment of uncomplicated gonorrhea conducted in the United States.

• Table Adverse Reactions‑CEFTIN Tablets

This image is provided by the National Library of Medicine.

CEFTIN FOR ORAL SUSPENSION IN CLINICAL TRIALS

• In clinical trials using multiple doses of cefuroxime axetil powder for oral suspension, pediatric patients (96.7% of whom were younger than 12 years of age) were treated with the recommended dosages of cefuroxime axetil (20 to 30 mg/kg/day divided twice a day up to a maximum dose of 500 or 1,000 mg/day, respectively). There were no deaths or permanent disabilities in any of the patients in these studies. Eleven US patients (1.2%) discontinued medication due to adverse events thought by the investigators to be possibly, probably, or almost certainly related to drug toxicity. The discontinuations were primarily for gastrointestinal disturbances, usually diarrhea or vomiting. During clinical trials, discontinuation of therapy due to the taste and/or problems with administering this drug occurred in 13 (1.4%) pediatric patients enrolled at centers in the United States.

• The following adverse events were thought by the investigators to be possibly, probably, or almost certainly related to cefuroxime axetil for oral suspension in multiple‑dose clinical trials (n = 931 cefuroxime axetil‑treated US patients).

• Table Adverse Reactions—CEFTIN for Oral Suspension:

This image is provided by the National Library of Medicine.

CEPHALOSPORIN CLASS ADVERSE REACTIONS

• In addition to the adverse reactions listed above that have been observed in patients treated with cefuroxime axetil, the following adverse reactions and altered laboratory tests have been reported for cephalosporin‑class antibiotics: Toxic nephropathy, aplastic anemia, hemorrhage, increased BUN, increased creatinine, false‑positive test for urinary glucose, increased alkaline phosphatase, neutropenia, elevated bilirubin, and agranulocytosis.

• Several cephalosporins have been implicated in triggering seizures, particularly in patients with renal impairment when the dosage was not reduced (see DOSAGE AND ADMINISTRATION and OVERDOSAGE). If seizures associated with drug therapy occur, the drug should be discontinued.

• Anticonvulsant therapy can be given if clinically indicated.

Postmarketing Experience

POSTMARKETING EXPERIENCE WITH CEFTIN PRODUCTS

• In addition to adverse events reported during clinical trials, the following events have been identified during clinical practice in patients treated with CEFTIN Tablets or with CEFTIN for Oral Suspension and were reported spontaneously. Data are generally insufficient to allow an estimate of incidence or to establish causation.

General

• The following hypersensitivity reactions have been reported: Anaphylaxis, angioedema, pruritus, rash, serum sickness‑like reaction, urticaria.

Gastrointestinal

• Pseudomembranous colitis

Hematologic

• Hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia, and increased prothrombin time.

Hepatic

• Hepatic impairment including hepatitis and cholestasis, jaundice.

Neurologic

• Seizure, encephalopathy.

Skin

• Erythema multiforme, Stevens‑Johnson syndrome, toxic epidermal necrolysis.

Urologic

• Renal dysfunction

Drug Interactions

Drug/Laboratory Test Interactions A false-positive reaction for glucose in the urine may occur with copper reduction tests (Benedict’s or Fehling’s solution or with CLINITEST® tablets), but not with enzyme-based tests for glycosuria (e.g., CLINISTIX®). 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.

Drug/Drug Interactions Concomitant administration of probenecid with cefuroxime axetil tablets increases the area under the serum concentration versus time curve by 50%. The peak serum cefuroxime concentration after a 1.5 g single dose is greater when taken with 1 g of probenecid (mean = 14.8 mcg/mL) than without probenecid (mean = 12.2 mcg/mL).

Drugs that reduce gastric acidity may result in a lower bioavailability of cefuroxime axetil compared with that of fasting state and tend to cancel the effect of postprandial absorption.

In common with other antibiotics, cefuroxime axetil may affect the gut flora, leading to lower estrogen reabsorption and reduced efficacy of combined oral estrogen/progesterone contraceptives.

Use in Specific Populations

Pregnancy

Pregnancy Category (FDA): B Pregnancy Category B. 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 mg/m2) and in rats at doses up to 1,000 mg/kg/day (9 times the recommended maximum human dose based on mg/m2) and have revealed no evidence of impaired fertility or harm to the fetus due to cefuroxime axetil. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
Pregnancy Category (AUS):

• Australian Drug Evaluation Committee (ADEC) Pregnancy Category

There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Cefuroxime axetil (oral) in women who are pregnant.

Labor and Delivery

There is no FDA guidance on use of Cefuroxime axetil (oral) during labor and delivery.

Nursing Mothers

Because cefuroxime is excreted in human milk, consideration should be given to discontinuing nursing temporarily during treatment with cefuroxime axetil.

Pediatric Use

The safety and effectiveness of cefuroxime axetil 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 cefuroxime axetil 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 studies 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 CLINICAL PHARMACOLOGY, INDICATIONS AND USAGE, ADVERSE REACTIONS, DOSAGE AND ADMINISTRATION, and CLINICAL STUDIES).

Geriatic Use

Of the total number of subjects who received cefuroxime axetil in 20 clinical studies of cefuroxime axetil, 375 were 65 and over while 151 were 75 and over. No overall differences in safety or effectiveness were observed between these subjects and younger adult subjects. The geriatric patients reported somewhat fewer gastrointestinal events and less frequent vaginal candidiasis compared with patients aged 12 to 64 years old; however, no clinically significant differences were reported between the elderly and younger adult patients. Other reported clinical experience has not identified differences in responses between the elderly and younger adult patients.

Gender

There is no FDA guidance on the use of Cefuroxime axetil (oral) with respect to specific gender populations.

Race

There is no FDA guidance on the use of Cefuroxime axetil (oral) with respect to specific racial populations.

Renal Impairment

There is no FDA guidance on the use of Cefuroxime axetil (oral) in patients with renal impairment.

Hepatic Impairment

There is no FDA guidance on the use of Cefuroxime axetil (oral) in patients with hepatic impairment.

Females of Reproductive Potential and Males

There is no FDA guidance on the use of Cefuroxime axetil (oral) in women of reproductive potentials and males.

Immunocompromised Patients

There is no FDA guidance one the use of Cefuroxime axetil (oral) in patients who are immunocompromised.

Administration and Monitoring

Administration

• Oral

• Intravenous

Monitoring

There is limited information regarding Monitoring of Cefuroxime axetil (oral) in the drug label.

• Description

IV Compatibility

There is limited information regarding IV Compatibility of Cefuroxime axetil (oral) in the drug label.

Overdosage

Overdosage of cephalosporins can cause cerebral irritation leading to convulsions. Serum levels of cefuroxime can be reduced by hemodialysis and peritoneal dialysis.

Pharmacology

There is limited information regarding Cefuroxime axetil (oral) Pharmacology in the drug label.

Mechanism of Action

Structure

• Cefuroxime axetil tablets contain cefuroxime as cefuroxime axetil. Cefuroxime axetil is a semisynthetic, broad-spectrum cephalosporin antibiotic for oral administration.

Chemically, cefuroxime axetil, the 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:

File:Cefuroxime axetil (oral)01.png

This image is provided by the National Library of Medicine.

Pharmacodynamics

Microbiology The in vivo bactericidal activity of cefuroxime axetil is due to cefuroxime’s binding to essential target proteins and the resultant inhibition of cell-wall synthesis.

Cefuroxime has bactericidal activity against a wide range of common pathogens, including many beta-lactamase–producing strains. Cefuroxime is stable to many bacterial beta-lactamases, especially plasmid-mediated enzymes that are commonly found in enterobacteriaceae.

Cefuroxime has been demonstrated to be active against most strains of the following microorganisms both in vitro and in clinical infections as described in the INDICATIONS AND USAGE section (see INDICATIONS AND USAGE section).

Aerobic Gram-Positive Microorganisms

Staphylococcus aureus (including beta-lactamase–producing strains) Streptococcus pneumoniae Streptococcus pyogenes

Aerobic Gram-Negative Microorganisms

Escherichia coli Haemophilus influenzae (including beta-lactamase–producing strains) Haemophilus parainfluenzae Klebsiella pneumoniae Moraxella catarrhalis (including beta-lactamase–producing strains) Neisseria gonorrhoeae (including beta-lactamase–producing strains)

Spirochetes

Borrelia burgdorferi

Cefuroxime has been shown to be active in vitro against most strains of the following microorganisms; however, the clinical significance of these findings is unknown.

Cefuroxime exhibits in vitro minimum inhibitory concentrations (MICs) of 4 mcg/mL or less (systemic susceptible breakpoint) against most (≥90%) strains of the following microorganisms; however, the safety and effectiveness of cefuroxime in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled trials.

Aerobic Gram-Positive Microorganisms

Staphylococcus epidermidis Staphylococcus saprophyticus Streptococcus agalactiae

NOTE: Listeria monocytogenes and certain strains of enterococci, e.g., Enterococcus faecalis (formerly Streptococcus faecalis), are resistant to cefuroxime. Methicillin-resistant staphylococci are resistant to cefuroxime.

Aerobic Gram-Negative Microorganisms

Morganella morganii Proteus inconstans Proteus mirabilis Providencia rettgeri

NOTE: Pseudomonas spp., Campylobacter spp., Acinetobacter calcoaceticus, Legionella spp., and most strains of Serratia spp. and Proteus vulgaris are resistant to most first- and second-generation cephalosporins. Some strains of Morganella morganii, Enterobacter cloacae, and Citrobacter spp. have been shown by in vitro tests to be resistant to cefuroxime and other cephalosporins.

Anaerobic Microorganisms

Peptococcus niger

NOTE: Most strains of Clostridium difficile and Bacteroides fragilis are resistant to cefuroxime.

Susceptibility Tests Dilution Techniques

Quantitative methods that are used to determine MICs provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure uses a standardized dilution method1 (broth, agar, or microdilution) or equivalent with cefuroxime powder. The MIC values obtained should be interpreted according to the following criteria:

tabel

A report of “Susceptible” indicates that the pathogen, if in the blood, is likely to be inhibited by usually achievable concentrations of the antimicrobial compound in blood. A report of “Intermediate” indicates that inhibitory concentrations of the antibiotic may be achieved if high dosage is used or if the infection is confined to tissues or fluids in which high antibiotic concentrations are attained. 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 usually achievable concentrations of the antimicrobial compound in the blood are unlikely to be inhibitory and that other therapy should be selected.

Standardized susceptibility test procedures require the use of laboratory control microorganisms. Standard cefuroxime powder should give the following MIC values:

tabel

Diffusion Techniques

Quantitative methods that require measurement of zone diameters provide estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure2 that has been recommended (for use with disks) to test the susceptibility of microorganisms to cefuroxime uses the 30 mcg cefuroxime disk. Interpretation involves correlation of the diameter obtained in the disk test with the MIC for cefuroxime.

Reports from the laboratory providing results of the standard single-disk susceptibility test with a 30 mcg cefuroxime disk should be interpreted according to the following criteria:

tabel

Interpretation should be as stated above for results using dilution techniques.

As with standard dilution techniques, diffusion methods require the use of laboratory control microorganisms. The 30 mcg cefuroxime disk provides the following zone diameters in these laboratory test quality control strains:

tabel

Pharmacokinetics

Absorption and Metabolism 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. Cefuroxime is subsequently distributed throughout the extracellular fluids. The axetil moiety is metabolized to acetaldehyde and acetic acid.

Pharmacokinetics Approximately 50% of serum cefuroxime is bound to protein. Serum pharmacokinetic parameters for cefuroxime axetil tablets are shown in Table 1.

tabel

Comparative Pharmacokinetic Properties: Cefuroxime axetil for oral suspension was not bioequiv­alent to cefuroxime axetil tablets when tested in healthy adults. The tablet and powder for oral suspension formulations are NOT substitutable on a milligram-per-milligram 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 had to be established in separate clinical trials.

Food Effect on Pharmacokinetics Absorption of the tablet is greater when taken after food (absolute bioavailability of cefuroxime axetil tablets increases from 37% to 52%). Despite this difference in absorption, the clinical and bacteriologic responses of patients were independent of food intake at the time of tablet administration in 2 studies where this was assessed.

Renal Excretion 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 the urine of pediatric patients have not been studied at this time. Until further data are available, the renal pharmacokinetic properties of cefuroxime axetil established in adults should not be extrapolated to pediatric patients.

Because cefuroxime is renally excreted, the serum half-life is prolonged in patients with reduced renal function. In a study of 20 elderly patients (mean age = 83.9 years) having a mean creatinine clearance of 34.9 mL/min, the mean serum elimination half-life was 3.5 hours. Despite the lower elimination of cefuroxime in geriatric patients, dosage adjustment based on age is not necessary

Nonclinical Toxicology

There is limited information regarding Nonclinical Toxicology of Cefuroxime axetil (oral) in the drug label.

Clinical Studies

CLINICAL STUDIES Cefuroxime Axetil Tablets Acute Bacterial Maxillary Sinusitis

One adequate and well-controlled study was performed in patients with acute bacterial maxillary sinusitis. In this study each patient had a maxillary sinus aspirate collected by sinus puncture before treatment was initiated for presumptive acute bacterial sinusitis. All patients had to have radiographic and clinical evidence of acute maxillary sinusitis. As shown in the following summary of the study, the general clinical effectiveness of cefuroxime axetil tablets was comparable to an oral antimicrobial agent that contained a specific betalactamase inhibitor in treating acute maxillary sinusitis. However, sufficient microbiology data were obtained to demonstrate the effectiveness of cefuroxime axetil tablets in treating acute bacterial maxillary sinusitis due only to Streptococcus pneumoniae or non-beta-lactamase–producing Haemophilus influenzae. An insufficient number of beta-lactamase–producing Haemophilus influenzae and Moraxella catarrhalis isolates were obtained in this trial to adequately evaluate the effectiveness of cefuroxime axetil tablets in the treatment of acute bacterial maxillary sinusitis due to these 2 organisms.

This study enrolled 317 adult patients, 132 patients in the United States and 185 patients in South America. Patients were randomized in a 1:1 ratio to cefuroxime axetil 250 mg twice daily or an oral antimicrobial agent that contained a specific beta-lactamase inhibitor. An intent-to-treat analysis of the submitted clinical data yielded the following results:

tabel

In this trial and in a supporting maxillary puncture trial, 15 evaluable patients had non-beta-lactamase–producing Haemophilus influenzae as the identified pathogen. Ten (10) of these 15 patients (67%) had their pathogen (non-beta-lactamase-producing Haemophilus influenzae) eradicated. Eighteen (18) evaluable patients had Streptococcus pneumoniae as the identified pathogen. Fifteen (15) of these 18 patients (83%) had their pathogen (Streptococcus pneumoniae) eradicated.

Safety

The incidence of drug-related gastrointestinal adverse events was statistically significantly higher in the control arm (an oral antimicrobial agent that contained a specific beta-lactamase inhibitor) versus the cefuroxime axetil arm (12% versus 1%, respectively; P<.001), particularly drug-related diarrhea (8% versus 1%, respectively; P = .001).

Early Lyme Disease

Two adequate and well-controlled studies were performed in patients with early Lyme disease. In these studies all patients had to present with physician-documented erythema migrans, with or without systemic manifestations of infection. Patients were randomized in a 1:1 ratio to a 20-day course of treatment with cefuroxime axetil 500 mg twice daily or doxycycline 100 mg 3 times daily. Patients 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 patients (181 treated with cefuroxime axetil and 174 treated with doxycycline) were enrolled in the 2 studies. In order to objectively validate the clinical diagnosis of early Lyme disease in these patients, 2 approaches were used: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. By these procedures, it was possible to confirm the physician diagnosis of early Lyme disease in 281 (79%) of the 355 study patients. The efficacy data summarized below are specific to this “validated” patient subset, while the safety data summarized below reflect the entire patient population for the 2 studies.

Analysis of the submitted clinical data for evaluable patients in the “validated” patient subset yielded the following results:

tabel

Cefuroxime axetil and doxycycline were effective in prevention of the development of sequelae of late Lyme disease.

Safety

Drug-related adverse events affecting the skin were reported significantly more frequently by patients treated with doxycycline than by patients treated with cefuroxime axetil (12% versus 3%, respectively; P = .002), primarily reflecting the statistically significantly higher incidence of drug-related photosensitivity reactions in the doxycycline arm versus the cefuroxime axetil arm (9% versus 0%, respectively; P<.001). While the incidence of drug-related gastrointestinal adverse events was similar in the 2 treatment groups (cefuroxime axetil - 13%; doxycycline - 11%), the incidence of drug-related diarrhea was statistically significantly higher in the cefuroxime axetil arm versus the doxycycline arm (11% versus 3%, respectively; P = .005).

Secondary Bacterial Infections of Acute Bronchitis

Four randomized, controlled clinical studies were performed comparing 5 days versus 10 days of cefuroxime axetil for the treatment of patients with secondary bacterial infections of acute bronchitis. These studies enrolled a total of 1,253 patients (CAE-516 n = 360; CAE-517 n = 177; CAEA4001 n = 362; CAEA4002 n = 354). The protocols for CAE-516 and CAE-517 were identical and compared cefuroxime axetil 250 mg twice daily for 5 days, cefuroxime axetil 250 mg twice daily for 10 days, and AUGMENTIN® 500 mg 3 times daily for 10 days. These 2 studies were conducted simultaneously. CAEA4001 and CAEA4002 compared cefuroxime axetil 250 mg twice daily for 5 days, cefuroxime axetil 250 mg twice daily for 10 days, and CECLOR® 250 mg 3 times daily for 10 days. They were otherwise identical to CAE-516 and CAE-517 and were conducted over the following 2 years. Patients were required to have polymorphonuclear cells present on the Gram stain of their screening sputum specimen, but isolation of a bacterial pathogen from the sputum culture was not required for inclusion. The following table demonstrates the results of the clinical outcome analysis of the pooled studies CAE-516/CAE-517 and CAEA4001/CAEA4002, respectively:

tabel

The response rates for patients who were both clinically and bacteriologically evaluable were consistent with those reported for the clinically evaluable patients.

Safety

In these clinical trials, 399 patients were treated with cefuroxime axetil for 5 days and 402 patients with cefuroxime axetil for 10 days. No difference in the occurrence of adverse events was observed between the 2 regimens.

Carcinogenesis, Mutagenesis, Impairment of Fertility 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 mg/m2) have revealed no impairment of fertility.

How Supplied

Cefuroxime Axetil Tablets, USP 250 mg of cefuroxime (as cefuroxime axetil), are white to off-white, uncoated, capsule-shaped tablets with “A33” debossed on one side and plain on the other side.

       20 Tablets/Bottle                                 NDC 52343-046-20 
       60 Tablets/Bottle                                 NDC 52343-046-60 

Cefuroxime Axetil Tablets, USP 500 mg of cefuroxime (as cefuroxime axetil), are white to off-white, uncoated, capsule-shaped tablets with “A34” debossed on one side and plain on the other side.

       20 Tablets/Bottle                                 NDC 52343-047-20 
       60 Tablets/Bottle                                 NDC 52343-047-60 

Store at 20° to 25°C (68° to 77°F); excursions permitted to 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Replace cap securely after each opening.

Storage

• Before reconstitution, store dry powder between 2° and 30°C (36° and 86°F).

• After reconstitution, immediately store suspension between 2° and 8°C (36° and 46°F), in a refrigerator. Discard after 10 days.

Images

Drug Images

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Package and Label Display Panel

NDC 0173-0387-00 Ceftin® Tablets (cefuroxime axetil tablets) 250 mg 20 Tablets Rx only See package insert for Dosage and Administration. Store between 15o and 30oC (59o and 86oF). Replace cap securely after each opening. GlaxoSmithKline Research Triangle Park, NC 27709 Made in England 4142817 Rev. 2/02

This image is provided by the National Library of Medicine.

NDC 0173-0394-00 Ceftin® Tablets (cefuroxime axetil tablets) 500 mg Rx only 20 Tablets Each tablet contains cefuroxime axetil equivalent to 500 mg of cefuroxime. See package insert for Dosage and Administration. Store between 15o and 30oC (59o and 86oF). Replace cap securely after each opening. GlaxoSmithKline Research Triangle Park, NC 27709 Made in England 4141667 Rev. 12/01

This image is provided by the National Library of Medicine.

NDC 0173-0740-00 Ceftin® for Oral Suspension (cefuroxime axetil powder for oral suspension) For Oral Use Only 125 mg per 5 mL 100 mL (when reconstituted) Rx only Contains 3.0 g cefuroxime axetil equivalent to 2.5 g of cefuroxime. Phenylketonurics: Contains Phenylalanine 11.8 mg per 5 mL (1 teaspoonful) constituted suspension. See package insert for Dosage and Administration. Directions for Mixing Oral Suspension: Prepare the suspension at time of dispensing. Shake the bottle to loosen the powder. Remove the cap. Add 37 mL of water for reconstitution and replace the cap. Invert bottle and vigorously rock it from side to side so that water rises through the powder. Once the sound of powder against the bottle disappears, turn the bottle upright and vigorously shake it in a diagonal direction.

Before reconstitution, store dry powder between 2o and 30oC (36o and 86oF).

After reconstitution, store suspension between 2o and 8oC (36o and 46oF), in a refrigerator. SHAKE WELL BEFORE EACH USE. Replace cap securely after each opening. Discard after 10 days.

GlaxoSmithKline Research Triangle Park, NC 27709 Made in England 10000000022540 Rev. 12/05

This image is provided by the National Library of Medicine.

NDC 0173-0741-10 Ceftin® for Oral Suspension (cefuroxime axetil powder for oral suspension) For Oral Use Only 250 mg per 5 mL 50 mL (when reconstituted) Contains 3.6 g cefuroxime axetil equivalent to 3 g of cefuroxime. Phenylketonurics: Contains Phenylalanine 25.2 mg per 5 mL (1 teaspoonful) constituted suspension.

See package insert for Dosage and Administration.

Directions for Mixing Oral Suspension: Prepare the suspension at time of dispensing. Shake the bottle to loosen the powder. Remove the cap. Add 19 mL of water for reconstitution and replace the cap. Invert bottle and vigorously rock it from side to side so that water rises through the powder. Once the sound of powder against the bottle disappears, turn the bottle upright and vigorously shake it in a diagonal direction.

Before reconstitution, store dry powder between 2o and 30oC (36o and 86oF).

After reconstitution, store suspension between 2o and 8oC (36o and 46oF), in a refrigerator. SHAKE WELL BEFORE EACH USE. Replace cap securely after each opening. Discard after 10 days.

GlaxoSmithKline

Research Triangle Park, NC 27709

Made in England

10000000022489 Rev. 12/05

This image is provided by the National Library of Medicine.

This image is provided by the National Library of Medicine.

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Patient Counseling Information

During clinical trials, the tablet was tolerated by pediatric patients old enough to swallow the cefuroxime axetil tablet whole. The crushed tablet has a strong, persistent, bitter taste and should not be administered to pediatric patients in this manner. Pediatric patients who cannot swallow the tablet whole should receive the oral suspension. Patients should be counseled that antibacterial drugs, including cefuroxime axetil, should only be used to treat bacterial infections. They do not treat viral infections (e.g., the common cold). When cefuroxime axetil is prescribed to treat a bacterial infection, patients should be told 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 cefuroxime axetil or other antibacterial drugs in the future.

Precautions with Alcohol

• Alcohol-Cefuroxime axetil (oral) interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

Brand Names

• Ceftin®

Look-Alike Drug Names

• A® — B®

Drug Shortage Status

Price

References

The contents of this FDA label are provided by the National Library of Medicine.

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