Cefotaxime in children: efficacy, tolerance and effect on the intestinal bacterial flora

Serious pediatric infections

Third-generation cephalosporins are important additions to the range of antibiotics available for treating children with serious bacterial infections. They are highly active against the common pathogens, which cause bacterial meningitis in children. Strains of Haemophilus influenzae type b resistant to both ampicillin and chloramphenicol, and Streptococcus pneumoniae relatively resistant to penicillin remain susceptible to cefotaxime and ceftriaxone. Escherichia coli, Klebsiella pneumoniae, Citrobacter diversus, as well as the other more common gram-negative bacilli isolated from neonates and children are susceptible to these agents. However, Listeria monocytogenes is not cephalosporin-sensitive. Ceftazidime is the only third-generation cephalosporin useful for treating serious infections due to Pseudomonas aeruginosa in children. As with other beta-lactam antibiotics, the clearance of cephalosporins is prolonged in neonates, particularly premature babies. Cefotaxime and ceftriaxone are equivalent to ampicillin and chloramphenicol for the treatment of bacterial meningitis in children over two to three months of age with respect to neurologic outcome and safety, despite the in vitro activity of cefotaxime and ceftriaxone being much greater than the standard antibiotics for the meningeal pathogens. Cefotaxime and ceftriaxone are effective in the treatment of serious gram-negative infections in children. In many instances, ceftriaxone can be administered once daily, which allows for more convenient therapy, particularly on an outpatient basis. Although controversial, ceftazidime has been used as single-agent therapy for empiric treatment of neutropenic immunocompromised children with fever.

Epidemiology of intestinal colonization by members of the family Enterobacteriaceae resistant to cefotaxime in a hematology-oncology unit

Intestinal colonization by members of the family Enterobacteriaceae resistant to cefotaxime was surveyed for 3 years in a hematology-oncology unit. Of 416 patients, 66 (15.9%) were colonized, each with a different strain. The incidence of intestinal carriage was not correlated with cefotaxime consumption in the ward but was strongly associated with individual exposure to cefotaxime.

The effect of antimicrobial agents on fecal flora of children

Influences of antibiotics on the fecal flora in children were studied for oral ampicillin, penicillin V, erythromycin, cefaclor, and gentamicin and for intravenous ampicillin, methicillin, cefpiramide, and ceftazidime. All antibiotics affected the normal flora, although the quality and quantity of the changes were variable. No substantial differences were noted between the oral and intravenous use of ampicillin with regard to its effect on the flora. Three penicillins, ampicillin, penicillin V, and methicillin, caused remarkable changes. The characteristic pattern observed was the considerable suppression of Bifidobacterium, Streptococcus, and Lactobacillus species. Although enterobacteria did not significantly change in number, Klebsiella spp. frequently replaced Escherichia coli. In patients given erythromycin and cefaclor, the reduction in the number of Bifidobacterium spp. was 1 log10 and that of members of the family Enterobacteriaceae was 3 log10. Gentamicin administered orally caused a drastic change, including a remarkable decline of E. coli to less than 2 log10/g of feces. Cefpiramide, a parenteral expanded-spectrum cephalosporin, suppressed normal flora so markedly that almost all species of organisms were eradicated, and the active growth of yeasts was promoted (2.6 log10 increase). Ceftazidime caused similar changes as cefpiramide, but the changes were less extensive. Yeasts increased after treatment with most antibiotic groups. This increase was particularly prominent in patients given oral penicillins and expanded-spectrum cephalosporins.

Evaluation of cefotaxime in bacterial infections

Cefotaxime, a third generation cephalosporin antibiotic, was evaluated in 26 infants and children for the treatment of documented or suspected bacterial infections, including pneumonia (10 cases), soft tissue skin infection (13 cases), and urinary tract infection (3 cases). An average daily dose of 60 mg/kg in 3 to 4 divided doses was administered parenterally for an average of 7 days. In 14 of the cases, primary pathogens, including Haemophilus influenzae b (resistant to ampicillin), Staphylococcus aureus, Staphylococcus pyogenes, Streptococcus pneumoniae and Escherichia coli, were eradicated. Clinical recovery occurred in each case. Blood levels at different time intervals and biological half-life were similar to those reported for adults. Mild and transient side effects observed were elevation of SGOT in two cases, alkaline phosphatase in one, and eosinophilia in one case.

Mechanism of action, antimicrobial activity, pharmacology, adverse effects, and clinical efficacy of cefotaxime

Cefotaxime sodium, a parenteral cephalosporin antibiotic, exerts its bactericidal action through inhibition of bacterial cell wall synthesis. Chemical structure modifications have enabled this compound to be resistant to the action of Richmond I, III, IV, and V beta-lactamase enzymes. Excellent activity against many gram-negative bacilli, especially Enterobacteriaceae, has been demonstrated. Antipseudomonal activity is generally poor, however. Activity against gram-positive cocci, with the notable exception of Streptococcus fecalis, is adequate. Anaerobic activity is variable, particularly against Clostridia and Bacteroides species. Acute, subacute, and chronic toxicity studies in animals were generally unremarkable. No mutagenic effects or reproductive toxicity have been noted in animals. In man, cefotaxime is desacetylated to a microbiologically active metabolite. Urinary excretion is approximately 50-60% and 15-20% of a dose for the parent compound and desacetyl metabolite, respectively. The elimination half-life of cefotaxime is about one hour, with the total body clearance being approximately twice that of the renal clearance. Severe renal dysfunction causes a prolongation of the elimination half-life of cefotaxime and particularly desacetyl cefotaxime. A relatively low degree of protein binding in part attributes to a wide bodily distribution of cefotaxime. Cefotaxime is effective in a variety of infectious processes caused by susceptible organisms. Local reactions at the injection site and hypersensitivity phenomena are the most common adverse effects. Comparative trials attesting to cefotaxime's clinical utility over other parenteral cephalosporins or amino-glycosides are very limited. Based on the available evidence, cefotaxime should be most useful in combating serious gram-negative infections, because of its excellent activity against most of these organisms and its low toxicity profile.