Cefotaxime. An update of its pharmacology and therapeutic use

Towards Antibiotic Synthesis in Continuous-Flow Processes

Continuous-flow chemistry has become a mainstream process and a notable trend among emerging technologies for drug synthesis. It is routinely used in academic and industrial laboratories to generate a wide variety of molecules and building blocks. The advantages it provides, in terms of safety, speed, cost efficiency and small-equipment footprint compared to analog batch processes, have been known for some time. What has become even more important in recent years is its compliance with the quality objectives that are required by drug-development protocols that integrate inline analysis and purification tools. There can be no doubt that worldwide government agencies have strongly encouraged the study and implementation of this innovative, sustainable and environmentally friendly technology. In this brief review, we list and evaluate the development and applications of continuous-flow processes for antibiotic synthesis. This work spans the period of 2012-2022 and highlights the main cases in which either active ingredients or their intermediates were produced under continuous flow. We hope that this manuscript will provide an overview of the field and a starting point for a deeper understanding of the impact of flow chemistry on the broad panorama of antibiotic synthesis.

Population pharmacokinetics of cefotaxime in intensive care patients

PURPOSE

To characterise the pharmacokinetics and associated variability of cefotaxime in adult intensive care unit (ICU) patients and to assess the impact of patient covariates.

METHODS

This work was based on data from cefotaxime-treated patients included in the ACCIS (Antibiotic Concentrations in Critical Ill ICU Patients in Sweden) study. Clinical data from 51 patients at seven different ICUs in Sweden, given cefotaxime (1000-3000 mg given 2-6 times daily), were collected from the first day of treatment for up to three consecutive days. In total, 263 cefotaxime samples were included in the population pharmacokinetic analysis.

RESULTS

A two-compartment model with linear elimination, proportional residual error and inter-individual variability (IIV) on clearance and central volume of distribution best described the data. The typical individual was 64 years, with body weight at ICU admission of 92 kg and estimated creatinine clearance of 94 mL/min. The resulting typical value of clearance was 11.1 L/h, central volume of distribution 5.1 L, peripheral volume of distribution 18.2 L and inter-compartmental clearance 14.5 L/h. The estimated creatinine clearance proved to be a significant covariate on clearance (p < 0.001), reducing IIV from 68 to 49%.

CONCLUSION

A population pharmacokinetic model was developed to describe cefotaxime pharmacokinetics and associated variability in adult ICU patients. The estimated creatinine clearance partly explained the IIV in cefotaxime clearance. However, the remaining unexplained IIV is high and suggests a need for dose individualisation using therapeutic drug monitoring where the developed model, after evaluation of predictive performance, may provide support.

Validation of an HPLC method for estimation of cefotaxime from dried blood spot: alternative to plasma-based PK evaluation in neonates

Aim: Pharmacokinetic evaluation of cefotaxime in neonates is currently a challenge due to the large volume requirement of blood for its analysis by existing methods. A dried blood spot (DBS) based method is the best alternative. Materials & methods: We validated an HPLC method for estimation of cefotaxime from DBS and plasma. Extraction employed a simple procedure using acetonitrile and buffer. Selective separation of cefotaxime was achieved on a C8 column using gradient programming. Results & conclusion: The linearity of the method ranged from 2 to 200 μg/ml with acceptable precision and accuracy for both plasma and DBS. Hematocrit was not affecting the assay accuracy. A strong correlation and interchangeability observed with the plasma method proves its clinical validity for application to PK evaluations.

Cefotaxime induced generalized bullous fixed drug eruption - A case report

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Based on the characteristics of the antimicrobial spectrum of Cefotaxime, low incidence of allergy, and lack of adverse effects, Cefotaxime has been used successfully for prophylaxis of a number of infectious diseases.

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Drug reactions like FDE are very frequently seen by dermatologists in the day to day practice. FDE to Cefotaxime is not usual.

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Healthcare professionals should have a high index of suspicion should aware of the possibility of reactions to Cephalosporin.

Fixed drug eruption (FDE) is the most common cutaneous adverse drug reaction. Cefotaxime, a broad-spectrum third-generation cephalosporin, appeared to be a safe and effective therapy in greater than 90% of infections including cellulitis, abscesses and necrotizing ulcers of the skin and subcutaneous tissues but here we report a rare case of 36 years old female patient developed generalized bullous FDE after intravenous administration of Cefotaxime.

Evaluation of efficacy and tolerability of cefotaxime and sulbactam versus cefepime and tazobactam in patients of urinary tract infection-a prospective comparative study

OBJECTIVE

Urinary tract infection (UTI) is the third most common infection experienced by humans after respiratory and gastro-intestinal infections. Cephalosporins are now widely been used in UTI, but emerging resistance is a problem to that. Our study aims at evaluating efficacy and safety of third generation cephalosporin combined with beta lactamase inhibitors compared with fourth generation cephalosporin.

MATERIALS AND METHODS

The present, open, randomised, parallel group comparative study includes 60 patients of urinary tract infection. Group A patient were put on treatment regimen of cefotaxime and sulbactam (0.5-2 gms IV/IM BD) and Group B patients were prescribed cefepime and tazobactam (0.5-1 gm IV/IM BD) depending upon urine culture and sensitivity pattern of causative agent and condition of the patient. Bacteriological cure rate, clinical cure rate will be assessed for efficacy and adverse drug reaction (ADR) recorded for evaluating safety.

RESULTS

The study showed a male predominance with 37 males (61.6%) and 23 (38.4%) females out of the total 60 patients with a maximum number within the age group of 50-70., and the most common organism isolated was E coli (73.3%), in rest of the patients Klebsiella (13.33%), Proteus (6.66%), and Staphylococcus (6.66%) were isolated. The overall bacteriological cure rate, in the present study, with cefotaxime/sulbactam and cefepime/tazobactam was 86.5%±6.5 and 93.3%±6.7 respectively. The clinical cure rate post five days of therapay, in goup A1 was 79.03%±2.82 and the same in group B1 was 87% ± 2.11. The clinical cure rate post ten days of therapy in group A2 98.57±0.03 and the same in group B2was 100%. Overall success rate as evaluated by our data in the present study in group A i.e those treated with cefotaxime/sulbactam was 89.28±9.1% and in group B i.e. those treated with cefepime/ tazobactam and 94.49±5.06%.

CONCLUSION

From the present study, those drugs in both generations of cephalosporins combined with beta lactamase inhibitors cefotaxime/sulbactam and cefepime/tazobactam were equally effective and well tolerated in the treatment of UTI. However the cost effectiveness and safety parameters are the important deciding factors for prescribing the same.

Continuous vs. intermittent cefotaxime administration in patients with chronic obstructive pulmonary disease and respiratory tract infections: pharmacokinetics/pharmacodynamics, bacterial susceptibility and clinical efficacy

AIM

To compare the pharmacokinetics/pharmacodynamics, antibiotic resistance and clinical efficacy of continuous (CA) vs. intermittent administration (IA) of cefotaxime in patients with obstructive pulmonary disease and respiratory infections.

METHODS

A randomized controlled prospective nonblinded study was performed in 93 consecutive hospitalized patients requiring antibiotics for acute exacerbations of chronic obstructive pulmonary disease. Forty-seven patients received 2 g of cefotaxime intravenously over 24 h plus a loading dose of 1 g, and 46 patients were given the drug intermittently (1 g three times daily).

RESULTS

Similar pathogens were identified in both groups, being mostly Haemophilus influenzae (51%), Streptococcus pneumoniae (21%) and Moraxella catharralis (18%). Mean minimal inhibitory concentration (MIC) values were also similar before and after treatment in both groups. Clinical cure was achieved in 37/40 (93%) (CA) vs. 40/43 (93%) (IA) of patients (P = 0.93). In microbiologically evaluable patients, criteria such as 70% of treatment time with antibiotic concentrations > or = MIC (CA 100%vs. IA 60% of patients) and/or > or = 5 x MIC (CA 100%vs. IA 55% of patients) were significantly better following continuous administration (P < 0.01). Samples with suboptimal antibiotic concentrations were found in 0% of CA vs. 65% of IA patients (P < 0.01).

CONCLUSIONS

Although clinical cure rates were comparable, continuous cefotaxime administration led to significantly greater proportions of concentrations > MIC and > 5 x MIC compared with intermittent dosing. Continuous administration of cefotaxime at a lower dose [2 g (CA) vs. 3 g (CI)] is equally effective pharmacodynamically and microbiologically, may be more cost-effective and offers at least the same clinical efficacy. Based on these observations, we recommend continuous administration of cefotaxime as the preferred mode of administration.

Brain Abscess

Optimal treatment of a brain abscess requires early clinical suspicion, and the diagnosis is usually made by identification of the abscess on contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI). The immediate first step is to reduce the potentially life-threatening brain mass (abscess and surrounding cerebral edema) and secure the diagnosis with culture specimens. This is usually accomplished by reducing the increased intracranial pressure (ICP) through surgical aspiration with or without drainage of the abscess pus. The surgical procedure chosen depends on several factors, including the location and type of abscess, multiplicity, and the medical condition of the patient. In addition, dexamethasone and hyperventilation may be required if brain herniation is imminent. The dexamethasone dose should be reduced as soon as the ICP is reduced because steroid administration may retard abscess capsule formation and decrease antibiotic concentrations within the abscess cavity. Antibiotic therapy should be started as soon as the diagnosis is made. Penicillin G or third-generation cephalosporins plus metronidazole are commonly given to treat both anaerobic and aerobic bacteria. The initial choice of antibiotic will vary on the basis of the suspected source of the brain organisms, which is most often either contiguous spread from a sinus or mastoid infection or hematogenous spread from a pulmonary, gastrointestinal, cardiac, or dental infection. Isolation and determination of the antibiotic sensitivities of the organism from abscess pus allow definitive antibiotic therapy. Patients should be managed in an intensive care unit. Phenytoin is often given to prevent seizures, which could further elevate the ICP. The duration of antimicrobial treatment is 4 to 8 weeks, during which time the patient should be monitored clinically and with repeated neuroimaging studies to ensure abscess resolution.

Clinical and pharmacological evaluation of a modified cefotaxime bid regimen versus traditional tid in pediatric lower respiratory tract infections

It is generally accepted that the treatment of community-acquired pneumonia, either in adults or in pediatric patients, is mainly empirical. Thus, the treatment selection must fulfill both the epidemiological requirements, according to the most frequently described pathogens, and the pharmacological criteria to ensure adequate and prolonged drug concentrations at the infection site, to reach clinical efficacy. Cefotaxime has proven to be effective in this indication when traditionally administered three times daily and, more recently, twice daily, as a result of a re-evaluation of its pharmacokinetic/pharmacodynamic features. To gain further evidence using this updated dosing schedule, 258 pediatric patients with lower respiratory tract infections were treated with cefotaxime 100 mg/kg/day, administered as a twice daily or three times daily regimen. In the cefotaxime 50 mg/kg twice-daily group (n = 130), a complete resolution of clinical signs and symptoms were observed in 88.5% of patients. Similarly, in the cefotaxime 33.3 mg/kg group (n = 128), 93.6% of patients had a complete resolution of clinical signs and symptoms. Both drug schedules were well tolerated. Pharmacokinetic parameters determined for the two cefotaxime dosing schedules showed comparability. The serum half-life of desacetylcefotaxime was marginally longer than for cefotaxime in both dosage groups (1.64 and 1.36 h for desacetylcefotaxime versus 1.2 and 0.85 h for cefotaxime after 50 mg/kg or 33.3 mg/kg doses, respectively). Results from this study support the use of twice-daily cefotaxime administration for the treatment of lower respiratory tract infections in pediatric patients.

Determination of third-generation cephalosporins by high-performance liquid chromatography in connection with pharmacokinetic studies

The third-generation cephalosporins are semisynthetic beta-lactam antibiotics, including several oral and parental agents with extended activity against Gram-negative pathogens. They are generally determined either by microbiological techniques or by high-performance liquid chromatography (HPLC). The major drawback or bioassays is the lack of specificity, especially when a biotransformation of the cephalosporin molecule leads to active metabolites, or when the antibacterial therapy is based on association with drugs. Thus, for many years, numerous reversed-phase HPLC procedures have been proposed to overcome these difficulties. This review presents different HPLC methods proposed for the quantification in biological fluids of fourteen third-generation cephalosporins, ranged between parenteral and oral compounds. The sensitivity and specificity of these chromatographic procedures are discussed with regard to the pharmacokinetic properties of the antibiotics studied.

Cefotaxime. A reappraisal of its antibacterial activity and pharmacokinetic properties, and a review of its therapeutic efficacy when administered twice daily for the treatment of mild to moderate infections

Cefotaxime is well established as an effective and well tolerated antibacterial drug for 3 times daily parenteral treatment of a variety of moderate to severe infections in hospitalised patients. Its frequency of administration has recently been reassessed with a 12-hourly regimen. Comparative studies in hospitalised patients with nosocomial or community-acquired lower respiratory tract infections, demonstrate the similar clinical and bacteriological efficacy of twice daily cefotaxime 1 or 2 g and the same daily dose of ceftriaxone, usually administered once daily. Cefotaxime 2 g twice daily was also similar in efficacy to ceftriaxone 2 g once daily. Retrospective and post-marketing studies also reveal the similar efficacy of cefotaxime administered twice and 3 times daily, and pharmacoeconomic studies suggest that total direct costs of treatment with cefotaxime compared is similar to that with other third generation cephalosporins in currently used dosage regimens. When administered twice daily, cefotaxime is, thus, an effective antibacterial agent for the treatment of hospitalised patients outside the intensive care unit with a variety of mild to moderate non-CNS infections caused by susceptible organisms. When appropriately administered twice daily there is potential to lower the cost of antibacterial treatment without compromising efficacy.

Relationship of MICs to efficacy of cefotaxime in treatment of Streptococcus pneumoniae infections

In June 1993, the National Committee for Clinical Laboratory Standards (NCCLS) recommended stringent new interpretive guidelines for antibiotics indicated for Streptococcus pneumoniae meningitis. To assess the predictive values of the recommended breakpoints, retrospective data were collected from patients who had S. pneumoniae infections and were treated with cefotaxime monotherapy. Susceptibilities based on the NCCLS interpretative categories were compared with clinical and bacteriologic outcomes. In 76 evaluable patients, the most common infections were bacteremia-septicemia (n = 49), meningitis (n = 37), and lower respiratory tract infection (n = 14). Under the NCCLS breakpoints proposed in 1993, 55 isolates would have been classed as susceptible to cefotaxime (MIC, < or = 0.25 microgram/ml), 18 would have been classed as intermediate (MIC, 0.5 to 1.0 microgram/ml), and 2 would have been classed as resistant (MIC, > or = 2 micrograms/ml). Of 75 cefotaxime-treated patients for whom cefotaxime MICs were recorded, 73 were clinically cured or improved (37 of 37 with meningitis and 36 of 38 with other infections). One case of bacteremia and one case of bone-and-joint infection were scored as therapeutic failures because initial monotherapy had to be modified because of an adverse drug reaction. Excluding these patients, there were 18 patients infected with S. pneumoniae that would have been classed as not fully susceptible (i.e., MICs > or = 0.5 microgram/ml); all of these patients were cured or improved. The results of this analysis demonstrate that successful treatment with cefotaxime did not correlate well with the guidelines for the susceptibility of pneumococcal isolates to either penicillin or cefotaxime established by the 1993 NCCLS breakpoint recommendations. Because of this study and other similar findings, the NCCLS adopted more clinically relevant guidelines in 1994.

Pharmacokinetics of cefotaxime and desacetylcefotaxime in the young

Available information on the pharmacokinetics of cefotaxime (CTX) and desacetylcefotaxime (dCTX) indicates that their disposition depends on development, with the greatest changes occurring during the 1st year of life. To a great extent, these changes reside with the acquisition of renal function (e.g., both glomerular filtration and active tubular secretion) during the 1st year of life. When the impact of development on CTX and dCTX disposition is considered, it is apparent that age-appropriate pharmacokinetic data can be used to individualize CTX dosing regimens according to age. Also, alternative dosing regimens that have been proven to be both safe and effective can be justified.

Experience with cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis

Spontaneous bacterial peritonitis (SBP) is a severe infectious complication in cirrhotic patients, and initial antibiotic therapy must be empirical. An initial study published in 1985 found that cefotaxime administered at a dose of 2 g every 4 h was more effective and safer than the combination of tobramycin-ampicillin. Since then, cefotaxime has been considered the agent of choice in the empiric therapy of SBP. Subsequent publications showed that a dosage of 2 g every 6 h was also adequate in this infection. More recent studies have demonstrated that the high efficacy of cefotaxime in SBP can be maintained by using lower dosages than those used in initial investigations. In one of these studies, a dose of 2 g every 8 h for 5 days was found to be as effective as the same dose for 10 days. Finally, a prospective, randomized multicenter trial aimed at comparing the efficacy of two different dosages of cefotaxime, 2 g every 6 h versus 2 g every 12 in a large series of cirrhotic patients with SBP, showed that both dosages resulted in similar rates of resolution of infection and survival. Despite the reasonably adequate rate of infection resolution in SBP patients, the in-hospital mortality rate remains high as a result of complications such as renal failure. Further studies should therefore be addressed to reducing the incidence of these complications and thus improving survival.

Cefotaxime and desacetylcefotaxime antimicrobial interactions. The clinical relevance of enhanced activity: a review

This presentation reviews 15 years of in vitro, pharmacokinetic, and clinical data concerning the active metabolite of cefotaxime sodium, desacetylcefotaxime. This principle metabolite maintains an antimicrobial activity and spectrum superior to so-called "second-generation" cephalosporins, plus it has an extended serum elimination half-life. Furthermore, it penetrates well into various important body compartments. The metabolite enhances cefotaxime potency by additive or synergistic antimicrobial interactions that can significantly reduce cefotaxime minimum inhibitory concentrations (MICs) among oxacillin-susceptible staphylococci, Streptococcus species including pneumococci resistant to penicillin, anaerobes, enteric bacilli, Pseudomonas aeruginosa, and when tested in human serum, some enterococci. The high activity of cefotaxime alone and the contributions of desacetylcefotaxime to the drug's total antimicrobial value must be considered in reestablishing correct dosing of this "third-generation" cephalosporin. Physicians should use cefotaxime susceptibility tests to direct appropriate, cost-effective dosing and the selection of co-drugs when needed. Moreover, empiric cefotaxime regimen doses should also be reduced for some infections at sites where expected pathogen MICs remain low (< or = 2 micrograms/ml).

Retrospective analysis of the clinical and economic outcomes of twice-daily dosing of cefotaxime in a Canadian tertiary care institution

A retrospective analysis of the clinical and economic outcome of a regimen of cefotaxime 1 g given every 12 h was conducted following the introduction of an institutional policy recommending this new dosing strategy. Patients were identified from a log order entry in the pharmacy, and the medical records were reviewed using a standardized data collection form. Explicit criteria were applied for the indications for antimicrobial therapy, presence of infection, and outcome parameters. A total of 60 patients with a mean (+/- SD) age of 56.2 (+/- 17.8) years and a mean (+/- SD) length of stay of 20.75 (+/- 18.1) days were identified. Of these, 48 (80%) were found to have a clinically or microbiologically documented infection, and of the 42 patients who could be assessed accordingly to the criteria chosen, 37 (88%) had a favorable clinical response; 21 patients (35%) received cefotaxime alone. The costs for administration of cefotaxime have decreased by approximately 30% since the introduction of this new dosing regimen.

Two different dosages of cefotaxime in the treatment of spontaneous bacterial peritonitis in cirrhosis: results of a prospective, randomized, multicenter study

Cefotaxime (CTX) is considered one of the first-choice antibiotics in the therapy of spontaneous bacterial peritonitis (SBP) in cirrhosis. Because CTX is largely metabolized in the liver, this drug may also be effective in SBP by administering lower doses than those habitually used. To investigate this possibility, a prospective, randomized, multicenter study was performed to compare the therapeutic efficacy of two different dosages of CTX in 143 patients with SBP: 71 (group I) were allocated to receive a high dose (2 g every 6 hours, which is one of the most frequently recommended doses in this infection), and 72 (group II) were allocated to receive a low dose (2 g every 12 hours). At inclusion, both groups were similar in relation to clinical and laboratory data, with the exception of a higher incidence of positive ascitic fluid culture in group I than in group II (59% vs. 40%; P = .029). The rate of infection resolution was similar for both groups (77% vs. 79%). Hospital survival was also similar in both groups (69% vs. 79%). No difference was observed between patients with positive or negative ascitic fluid cultures with regard to infection resolution and patient survival. The duration of antibiotic therapy was similar in both groups (9.0 +/- 3.3 days in group I vs. 8.8 +/- 3.1 days in group II). In a subset of 13 patients from group I and 11 patients from group II CTX levels were determined in serum (peak and trough) and ascitic fluid (concomitantly with trough serum). Peak serum levels were similar in patients from both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of bone and joint infections utilizing a third-generation cephalosporin with an outpatient drug delivery device. HIAT Study Group

The purpose of this study was to determine the efficacy, safety, and cost effectiveness of a third-generation cephalosporin, cefotaxime, administered via an ambulatory delivery system (ADS) in the treatment of bone and joint infections (BJI). A total of 27 BJI patients enrolled as a subgroup of a multicenter, prospective, open-label trial were administered 1-2 g of cefotaxime every 8 hours using ADS. Of these patients, 18 were evaluable, with the causative organisms identified and susceptible to cefotaxime. The evaluable group comprised 7 primary and 11 postsurgical BJI patients. Inpatient treatment followed by outpatient treatment with cefotaxime/ADS achieved a clinical success rate of 83.3%; however, the mean length of hospital stay for these patients was not substantially reduced. Administration via ADS permitted administration of several daily doses with minimal intervention by the patient. Both the drug and the delivery system were well tolerated. In conclusion, an intravenous antibiotic regimen such as cefotaxime administered via an ADS is an appropriate management option for patients with BJI. It is efficacious, well tolerated, and user friendly.

Reducing costs and hospital stay for pneumonia with home intravenous cefotaxime treatment: results with a computerized ambulatory drug delivery system

Studies have documented the efficacy and safety of antibiotic infusion in the home as a cost-effective alternative to in-hospital infusion. The present analysis focuses on home treatment of pneumonia with cefotaxime delivered via an ambulatory infusion pump and the potential of this therapy to reduce the length of hospital stay. Data presented here and in previously published studies of a variety of serious infections show that admitting patients into home intravenous antibiotic therapy programs can significantly reduce, and sometimes eliminate, hospital stay, while providing efficacy and safety comparable to that expected from hospital treatment. Analysis of hospitalization patterns for pneumonia patients placed on cefotaxime therapy delivered via portable infusion pump revealed that length of stay was only 10% of that for the reference diagnosis-related group. Despite the great potential cost savings, there are reimbursement barriers to the use of home infusion antibiotics. However, healthcare reform may promote greater acceptance, use, and support of home infusion technology.

Treatment of serious infections with cefotaxime utilizing an outpatient drug delivery device: global analysis of a large-scale, multicenter trial. HIAT Study Group

The primary objective of this multicenter, prospective trial was to determine the safety, efficacy, and cost effectiveness of cefotaxime delivered via an ambulatory delivery system (ADS) in the treatment of patients with a variety of bacterial infections. The secondary objective was to determine the safety and efficacy of cefotaxime/ADS treatment of infections in a diabetic subgroup. A total of 238 patients (> or = 18 years) in five infection categories were enrolled from 10 sites. All patients received cefotaxime/ADS. Both global analysis and analysis of a subpopulation with diabetes mellitus were performed. Of the 211 patients who completed the study, 201 patients (95.3%) exhibited a satisfactory or improved clinical response following cefotaxime/ADS. Bacteriologic response, evaluable in 134 of 211 patients, was satisfactory in 125 of these patients (93.3%). Within the diabetes mellitus subpopulation, a satisfactory or improved clinical response was identified in 30 of 32 patients (93.8%). In conclusion, administration of cefotaxime via ADS is a well-tolerated, safe, and clinically effective treatment of serious infection and may be less expensive than inpatient intravenous antibiotic therapy.

Outpatient antibiotic therapy for elderly patients. HIAT Study Group

The purpose of this study was to determine the safety and efficacy of outpatient intravenous (IV) therapy with a third-generation cephalosporin, cefotaxime, in patients > or = 60 years of age and to determine its effect on length of hospital stay. Subset analysis was performed with 62 patients with various infections who had been enrolled in a prospective, multicenter, open-label trial of IV cefotaxime delivered through a computerized ambulatory delivery system (ADS). Initial treatment was given in hospital if required, followed by home therapy. The overall clinical response rate among evaluable patients was 98%, and the overall bacteriologic response rate was 93%. The mean duration of inpatient therapy was 3.6 days less than the mean of 8.2 days allowed under diagnosis-related group (DRG) allotments. Outpatient therapy with cefotaxime via infusion pump is safe and effective and may reduce hospitalization requirements.

Treatment of skin and soft-tissue infections utilizing an outpatient parenteral drug delivery device: a multicenter trial. HIAT Study Group

The purpose of this study was to examine the safety and efficacy of outpatient intravenous antibiotic therapy for skin and soft-tissue infections and determine its effect on length of hospital stay. In this open-label, multicenter, prospective study, 130 adult patients with skin and soft-tissue infections requiring parenteral antibiotic therapy were enrolled as a subgroup. Initial therapy was delivered to hospital inpatients or in outpatient treatment centers, followed by home infusion therapy. Cefotaxime was delivered intravenously using a programmable ambulatory infusion pump. The clinical response rate was 97.5% (n = 118), while the bacteriologic response rate was 94.0% (n = 83). Only 32.2% of patients required hospitalization, and the mean duration of inpatient care for all evaluable patients was only 1.5 days. The mean duration of hospitalization for patients receiving inpatient care was 4.7 days. In conclusion, home intravenous cefotaxime therapy is safe, effective, and may reduce healthcare costs for many patients with skin and soft-tissue infections.

Pharmacological properties of cephalosporins

The cephalosporins differ in the substituents attached at the 3 and/or 7 positions of the molecule. Very schematically, substitution at C3 mainly modifies the overall pharmacokinetic properties whereas substitution at position 7 influences the antibacterial characteristics. When using the more common "generation" system for classification, three generations can be distinguished on the basis of their antibacterial spectrum, potency, and their stability to beta-lactamases. The first generation cephalosporins have similar antibacterial and pharmacokinetic characteristics. C3-esterified cephalosporins (e.g. cephalothin and cephapirin) are significantly metabolized. The so-called second generation cephalosporins exhibit only minor differences with respect to the pharmacokinetic properties in contrast to the third generation cephalosporins. The apparent volumes of distribution of most cephalosporins range between seven and 20 1, indicating that they mainly stay in the extracellular space. Plasma protein binding is variable from compound to compound. Generally, the major route of elimination of most cephalosporins is via the kidney except for cefoperazone and ceftriaxone which are both excreted to a large extent by the biliary route. With the exception of cefonicid, cefotetan and cefriaxone, which have longer elimination half-lives (i.e. 4.5, 3.5 and around eight hours), all other cephalosporins have a half-life ranging from 0.5 to 2.5 hours. The pattern of adverse reactions is comparable for all the cephalosporins although there are slight differences in both the incidence and the type of reactions. The major categories of adverse reactions are gastrointestinal, dermatologic, hypersensitivity, haematologic, hepatic, renal as well as CNS effects. Alcohol intolerance (antabus-like effect) can occur when cephalosporins containing the NMTT moiety are administered concomitantly.(ABSTRACT TRUNCATED AT 250 WORDS)

Nosocomial pneumonia: comparative multicentre trial between monotherapy with cefotaxime and treatment with antibiotic combinations

In a multicentre clinical trial involving 32 hospitals, 588 adult patients diagnosed with nosocomial pneumonia and not receiving mechanical ventilation were treated randomly with monotherapy with cefotaxime or the antibiotic combination routinely used in each particular hospital. Both groups of patients were similar regarding demographic data, concurrent diseases, additional therapies and causative organism. Protocol violations were recorded in 40 patients, and these patients were excluded from the evaluation of treatment efficacy. The cure rate was 79% in the cefotaxime group and 71% in the group receiving antibiotic combinations; this difference is statistically significant (p = 0.03, Fisher's two-tailed test). In the patients receiving combinations of cephalosporins having activity predominantly against gram-positive organisms plus aminoglycosides, the cure rate obtained was very low. The frequency of serious adverse reactions was significantly higher in the group treated with antibiotic combinations. It is concluded that monotherapy with cefotaxime is the regimen that offers better results for the empirical treatment of nosocomial pneumonia.