Effectiveness of Cefixime in Clinical Practice
Cefixime is an effective oral cephalosporin antibiotic with demonstrated efficacy of 97.4% for uncomplicated urogenital and anorectal gonococcal infections, though it is no longer recommended as first-line therapy for gonorrhea due to increasing antimicrobial resistance.
Efficacy by Infection Type
Gonorrhea Treatment
- Cefixime 400 mg orally has historically shown high efficacy (97.4%) for uncomplicated urogenital and anorectal gonococcal infections 1
- However, CDC guidelines have evolved over time regarding cefixime's role in gonorrhea treatment:
- In 1998, cefixime 400 mg was a first-line recommended regimen 1
- By 2012, CDC no longer recommended cefixime as first-line therapy due to declining susceptibility among N. gonorrhoeae isolates 1
- Current recommendation is combination therapy with ceftriaxone 250 mg IM plus either azithromycin 1g orally or doxycycline 100 mg orally twice daily for 7 days 1
Anatomical Site-Specific Efficacy
- Recent meta-analysis (2023) shows variable effectiveness by anatomical site 2:
- Urogenital infections: 97% cure rate (95% CI, 96%-98%)
- Rectal infections: 97% cure rate (95% CI, 84%-100%)
- Pharyngeal infections: only 89% cure rate (95% CI, 76%-96%)
Other FDA-Approved Indications
Cefixime is also effective for 3:
- Uncomplicated urinary tract infections (E. coli and P. mirabilis)
- Otitis media (H. influenzae, M. catarrhalis, S. pyogenes)
- Pharyngitis and tonsillitis (S. pyogenes)
- Acute exacerbations of chronic bronchitis (S. pneumoniae and H. influenzae)
Current Treatment Guidelines
Gonorrhea Treatment Algorithm
- First-line therapy: Ceftriaxone 250 mg IM plus either azithromycin 1g orally or doxycycline 100 mg orally twice daily for 7 days 1
- If injectable therapy not possible: Cefixime 400 mg orally can be considered as an alternative, but patient should return in 1 week for test-of-cure 1
- If cephalosporins contraindicated: Consider spectinomycin (if available) or consult infectious disease specialist 1
Enteric Fever Considerations
- For suspected enteric fever in travelers returned from Asia, ceftriaxone is preferred due to increasing fluoroquinolone resistance 1
- If oral therapy is required, azithromycin is preferred over cefixime due to cefixime treatment failure rates of 4-37.6% 1
Important Clinical Considerations
Antimicrobial Resistance Concerns
- Declining susceptibility to cefixime has been observed in N. gonorrhoeae isolates, particularly in the western United States and among men who have sex with men (MSM) 1
- This pattern mirrors the earlier emergence of fluoroquinolone resistance, suggesting potential for widespread resistance 1
Dosing and Administration
- Standard adult dose: 400 mg daily, can be given as a single dose 3
- For uncomplicated gonorrhea: 400 mg as a single oral dose 3
- For streptococcal infections: treatment should continue for at least 10 days 3
- Can be administered without regard to food 3
Common Side Effects
- Most common adverse reactions are gastrointestinal: diarrhea (16%), nausea (7%), loose stools (6%), abdominal pain (3%), dyspepsia (3%), and vomiting 3
- Dividing the daily dose (200 mg twice daily) may reduce gastrointestinal side effects compared to once-daily dosing 4
Conclusion for Clinical Practice
When considering cefixime for treatment:
- For gonorrhea: Use only when ceftriaxone is not available, and ensure follow-up testing
- For urinary tract infections: Effective for uncomplicated cases caused by susceptible organisms
- For respiratory infections: Effective alternative to other oral antibiotics for indicated conditions
- Always consider local resistance patterns before prescribing