Is cefixime (a third-generation cephalosporin antibiotic) a reasonable option for treating purulent penile discharge in children?

Cefixime for Treating Purulent Penile Discharge in Children

Cefixime is not recommended for treating purulent penile discharge (likely gonococcal infection) in children due to inadequate evaluation of its safety and effectiveness in pediatric gonococcal infections. 1

Recommended Treatment for Suspected Gonococcal Infections in Children

First-line Treatment

• For children weighing <45 kg with uncomplicated gonococcal infections:
  • Ceftriaxone 125 mg IM in a single dose 1

Alternative Treatment

• Spectinomycin 40 mg/kg (maximum dose: 2 g) IM in a single dose
  • Note: This is unreliable for pharyngeal infections 1
  • Requires follow-up culture to ensure treatment effectiveness 1

Why Not Cefixime?

1. Lack of pediatric evaluation: Oral cephalosporins, including cefixime, have not been adequately evaluated for treating gonococcal infections in children 1

2. Pharmacokinetic concerns: The pharmacokinetic activity of oral cephalosporins in adults cannot be extrapolated to children 1

3. Official recommendations: CDC guidelines explicitly state that only parenteral cephalosporins are recommended for gonococcal infections in children 1

4. FDA approval status: Ceftriaxone is approved for all gonococcal indications in children, while cefotaxime is approved only for gonococcal ophthalmia 1

Important Clinical Considerations

Diagnostic Requirements

• Due to legal implications of diagnosing gonorrhea in children:
  • Only standard culture procedures should be used 1
  • Specimens from urethra should be streaked onto selective media 1
  • All presumptive isolates must be confirmed by at least two tests using different principles 1
  • Isolates should be preserved for potential additional testing 1

Additional Management

• All children with gonococcal infections should be evaluated for coinfection with:

  • Syphilis
  • Chlamydia trachomatis 1

• Sexual abuse evaluation is necessary, as it is the most frequent cause of gonococcal infection in pre-adolescent children 1

Expert Opinion on Cefixime

While the FDA has approved cefixime for uncomplicated gonorrhea in patients six months of age or older 2, and some specialists do use cefixime in children because it can be administered orally 1, the CDC guidelines consistently recommend against this practice due to insufficient safety and effectiveness data.

The guidelines note: "Some specialists use cefixime to treat gonococcal infections in children because it can be administered orally; however, no reports have been published concerning the safety or effectiveness of cefixime used for this purpose." 1

Potential Pitfalls

1. Assuming adult treatments apply to children: Although cefixime is effective for gonorrhea in adults 3, 4, pediatric pharmacokinetics differ significantly

2. Oral vs. injectable preference: Despite the convenience of oral medication, injectable ceftriaxone remains the standard of care for children with suspected gonococcal infections

3. Antimicrobial resistance concerns: Even in adults, cefixime treatment failures have been documented with increasing minimum inhibitory concentrations 5, making the more potent ceftriaxone preferable for reliable treatment