I would point out to you that the Physician’s Desk Reference does explain how to mix this product with a local anesthetic for injection to cut down on the IM pain. So if you have patients who are going to be doing this or if you are administering this in your office, you may want to refer to that if pain has been a problem with the product and it very often is. Be aware that some of the cephalosporins do have those instructions in the PDR now.

Cefoperazone is a product that used to be used for Pseudomonas. It still is available but it causes bleeding and Antabuse-like reactions and so we prefer to use newer products such as ceftazidime.

Ceftazidime is a drug that while it has a very broad Gram negative spectrum, it is principally used in treating Pseudomonas. Remember when we are treating Pseudomonas we would use at least two different agents because Pseudomonas tends to become resistant to any single agent used alone. This says it’s the best cephalosporin in treating Pseudomonas and I would say it is that currently but it is not the most effective.

Cefepime is probably the most effective cephalosporin. This is Maxipime. This was marketed about 18 months ago. It is given twice a day. They consider it fourth generation cephalosporin because it has greater Gram negative coverage. It is more effective against Pseudomonas than is ceftazidime. Yet we would prefer for initial therapy to use ceftazidime and then if they become resistant or fail ceftazidime, switch to cefepime. We’re using a fair amount of cefepime now in some of our older patients who have cystic fibrosis who have become resistant to ceftazidime. Its expense is similar to the IV third generation cephalosporins so it is no more expensive but they all are reasonably expensive.

Cefixime is Suprax. This is given orally as a tablet or suspension. It has increased Gram negative activity and may be useful in gonorrhea but be aware that this product has no coverage of anaerobes, Staph or Pseudomonas and doesn’t have very good pneumococcal coverage either. Diarrhea is common with this product – about 1 in 3 patients will develop loose stools, very often at about the second day. Usually that will spontaneously subside by the fourth day. Dividing it into two doses a day may reduce the GI upset or the diarrhea which suggests that this is more chemical irritation than it is actually an overgrowth. Like all of the third generation agents it is somewhat expensive.

Ceftibuten is the next product we are going to talk about. This is Cedax. It is given once a day. It is good against H. flu and M. cat but it has poor pneumococcal coverage. So if you were considering using this for many common pediatric soft tissue infections, for otitis media, it may not be the best choice.

Cefpodoxime is Vantin. This particular product is just about as good as cefuroxime against common soft tissue infections. It is considered one of the cephalosporins of choice for treating acute otitis media. Again, like cefuroxime, it has a bitter aftertaste and may be problematic in kids over three. But under three, many kids will take this without any objections. Most otitis is seen in kids under three so it may very well be a reasonable drug to try if you want to use a cephalosporin for acute otitis.

Loracarbef is not truly a cephalosporin but it is darn close. Actually what it is is Ceclor that’s had a sulfur taken out of the ring nucleus and substituted with a carbon. It’s called a carbacephem but for all intensive purposes it behaves like a cephalosporin. In doing that, it’s gotten around the high incidence of serum sickness that we see with cefaclor and it may be a reasonable alternative drug to consider if you want to treat soft tissue infections with a cephalosporin type drug.

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