Cefixime use in children: When and why

PHARMACOLOGY Gas tro in tes ti nal ab sorp tion is in com plete (about 40 to 50% is ab sorbed). The oral sus pen sion is more rap idly and com pletely ab sorbed than the tab lets. The elimi na tion halflife is about 3 h (1). The drug is not ap pre cia bly me tabo lized, and 25 to 50% of the dose is ex creted in the urine within 24 h. The rec om mended dos age for chil dren is 8 mg/kg/day orally, once daily or in two di vided doses.


CLINICAL TRIALS IN CHILDREN
Clini cal tri als have shown that ce fixime is com pa ra ble with amox icil lin and ce fa clor for the treat ment of acute oti tis me dia in chil dren two months to 13 years of age (2)(3)(4)(5)(6). S pneu mo niae was the most com mon patho gen, fol lowed by non type able H in flu en zae and M ca tar rhalis. Ce fixime was very ef fec tive in treat ing cases due to H in flu en zae and M ca tar rhalis (75 to 100% cure or im prove ment), which was com pa ra ble with or bet ter than ei ther amox icil lin or ce fa clor (2,3,5). Ce fixime had a slightly lower ef fi cacy in cases caused by S pneu mo niae com pared with amox icil lin (2,3). In one study, a number of cefixime fail ures were due to S pneu mo niae (2), per haps support ing an ex peri men tal ob ser va tion that ce fixime re quired a longer du ra tion (up to 10 days) com pared with amox icil lin to eradi cate pneu mo coc cus from the mid dle ear (6).
One study of strep to coc cal pha ryn gi tis in chil dren four to 12 years of age re ported that ce fixime was bet ter at both eradi cat ing and pre vent ing re cur rences of group A strep toccus com pared with peni cil lin V (7). The rea sons for this are not un der stood.
Stud ies have shown ce fixime to be ef fec tive for the treatment of uri nary tract in fec tion (with suc cess rate com pa ra ble with that of trimethoprim-sulfamethoxazole [8]), Sal mo nella ty phi in fec tion (9) and mul tire sis tant Shigella spe cies gas troen teri tis (10) in chil dren. Oral ce fixime was as ef fec tive as intra mus cu lar cef tri ax one in the treat ment of un com pli cated gon or rhea in teen ag ers and young adults (11).

ADVERSE EFFECTS
The ad verse ef fects of ce fixime are gen er ally mild and tran sient. In con trolled tri als com par ing ce fixime with amoxicil lin, the most no ta ble ef fect was di ar rhea, oc cur ring in about 15% of chil dren on ce fixime and about 8% on amox icil lin (1). Di ar rhea was usu ally mild, de vel oped within four days of treat ment and re solved on dis con tinua tion of ce fixime (12). Se vere di ar rhea and/or pseu do mem bra nous co li tis were reported in fewer than 2% of pa tients. Drug hy per sen si tiv ity reac tions also oc curred rarely.

CEFIXIME USE IN CHILDREN
Al though ce fixime is an ef fec tive an ti bi otic in many situations, less ex pen sive and equally ef fec tive al ter na tives are fre quently avail able. The fol low ing are guide lines on the use of ce fixime in chil dren: • For otitis media, since S pneumoniae is the most common bacterial pathogen, cefixime does not offer any advantages over less expensive agents such as amoxicillin, trimethoprim-sulfamethoxazole and erythromycin-sulfisoxazole. While beta-lactamase producing H influenzae and M catarrhalis are also common pathogens in otitis media, amoxicillin has been found to be effective even in many of these cases.
• For streptococcal pharyngitis, penicillin V remains the treatment of choice. Only penicillin has been studied and reported effective in preventing rheumatic fever. However, suitable antibiotic alternatives include erythromycin and cephalosporins. Cefixime and other less expensive first-and second-generation cephalosporins are effective in treating streptococcal sore throat.
• There are as yet insufficient published controlled studies that show cefixime to be effective for the treatment of children with sinusitis, 'bronchitis' or pneumonia. However, its antimicrobial spectrum does include the bacterial pathogens that commonly cause sinusitis and pneumonia in children.
• For urinary tract infection, cefixime offers little advantage over less expensive agents such as amoxicillin, trimethoprim-sulfamethoxazole and nitrofurantoin. However, cefixime can be used to treat urinary pathogens that are resistant to those antibiotics, but susceptible to cefixime.
• Single-dose cefixime is effective in treating uncomplicated gonorrhea infections, while longer duration is required to treat pelvic inflammatory disease caused partly by N gonorrhoeae. However, it is controversial whether cefixime is effective in treating pharyngeal gonorrhea.
• Cefixime is effective for treatment of young children (where quinolone antibiotics are contra-indicated) with gastroenteritis caused by Salmonella and Shigella species that are resistant to traditional antibiotics such as amoxicillin and trimethoprim-sulfamethoxazole. However, it is not known whether resistance will eventually develop in these pathogens with the increasing use of cefixime.
• Preliminary evidence suggests that switching to oral cefixime may be an effective alternative (after initial parenteral antibiotic therapy) in preventing the occurrence of serious Gram-negative infections in oncology patients recovering from febrile neutro-penia (13). However, controlled studies are awaited.