What is the recommended dose of cefuroxime for a typical adult patient with normal renal function and a mild to moderate bacterial infection, considering age, weight, and potential allergies to cephalosporins or penicillins?

Cefuroxime Dosing for Adult Bacterial Infections

For typical adult patients with normal renal function and mild to moderate bacterial infections, cefuroxime should be dosed at 750 mg every 8 hours intravenously or intramuscularly for 5-10 days, or 500 mg twice daily orally (as cefuroxime axetil) for 10-21 days depending on the infection type. 1, 2

Standard Dosing by Route and Severity

Parenteral (IV/IM) Cefuroxime

• Mild to moderate infections: 750 mg every 8 hours is the standard dose for uncomplicated urinary tract infections, skin and soft tissue infections, disseminated gonococcal infections, and uncomplicated pneumonia 1

• Severe or complicated infections: 1.5 grams every 8 hours is recommended for more serious presentations 1

• Life-threatening infections or less susceptible organisms: 1.5 grams every 6 hours may be required 1

• Bone and joint infections: 1.5 grams every 8 hours, with surgical intervention performed when indicated as adjunct therapy 1

Oral Cefuroxime Axetil

• Most infections: 250 mg twice daily is appropriate for the majority of community-acquired infections 2, 3

• Urinary tract infections: 125 mg twice daily has proven effective for uncomplicated cases 2

• Lower respiratory tract infections: 500 mg twice daily should be used when pneumonia is suspected or for more severe presentations 2, 3

• Lyme disease (erythema migrans): 500 mg twice daily for 14-21 days 4

Infection-Specific Dosing Algorithms

Respiratory Tract Infections

For acute bacterial rhinosinusitis in adults:

• Initial therapy: Cefuroxime axetil 500 mg twice daily for 14 days 4, 5
• Important caveat: Cefuroxime showed significantly higher clinical relapse rates compared to amoxicillin-clavulanate at 2-4 weeks follow-up, with slower symptom improvement at days 3-5 and more persistent purulent discharge 5
• Switch therapy if no improvement after 72 hours: Consider gatifloxacin, levofloxacin, moxifloxacin, or high-dose amoxicillin-clavulanate (4g/250mg daily) 4

For community-acquired pneumonia:

• Oral: 500 mg twice daily for 5-10 days 2, 3
• Sequential IV-to-oral therapy: IV cefuroxime 750 mg 2-3 times daily for 2-5 days, followed by oral cefuroxime axetil 500 mg twice daily for 3-8 days 3

Lyme Disease

For early localized or disseminated Lyme disease with erythema migrans:

• Cefuroxime axetil 500 mg twice daily for 14 days (range 14-21 days) 4
• Pediatric dosing: 30 mg/kg per day in 2 divided doses (maximum 500 mg per dose) 4
• Critical distinction: First-generation cephalosporins like cephalexin are inactive against Borrelia burgdorferi and ineffective clinically; only second-generation (cefuroxime) and certain third-generation cephalosporins are appropriate 4

Skin and Soft Tissue Infections

• Standard dosing: 750 mg IV/IM every 8 hours for 5-10 days 1
• Oral alternative: 250 mg twice daily for mild infections 2
• Peak serum concentrations after 750 mg IM reach 16-25 mcg/mL at 1 hour, with levels dropping below 4 mcg/mL after 8 hours in patients with normal renal function 6

Penicillin Allergy Considerations

For patients with penicillin allergy:

• Cefuroxime can be used in patients with non-immediate (Type I) hypersensitivity reactions to beta-lactams 4
• Absolute contraindication: Known serious hypersensitivity reactions to cephalosporins, including anaphylaxis and Stevens-Johnson syndrome 4
• For immediate Type I hypersensitivity to beta-lactams, alternative agents (trimethoprim-sulfamethoxazole, azithromycin, clarithromycin, or doxycycline) should be used instead, though these have limited effectiveness against major respiratory pathogens 4

Renal Dose Adjustments

Dosing must be reduced when renal function is impaired: 1

• Creatinine clearance >20 mL/min: 750 mg to 1.5 grams every 8 hours (standard dosing) 1
• Creatinine clearance 10-20 mL/min: 750 mg every 12 hours 1
• Creatinine clearance <10 mL/min: 750 mg every 24 hours 1
• Hemodialysis patients: Give an additional dose at the end of dialysis 1

Pharmacokinetic and Pharmacodynamic Considerations

Bioavailability and absorption:

• Oral cefuroxime axetil has 68% absolute bioavailability (range 63-73%) after 500 mg administration with food 2
• Maximum plasma concentrations after oral administration of 250 mg and 500 mg are 4.6 mg/L and 7.9 mg/L respectively 2
• Protein binding is 33% ± 5.7% 2

Target attainment concerns:

• For beta-lactams like cefuroxime, time above MIC (T>MIC) is the most important pharmacodynamic parameter 7
• With a target of T>MIC >50%, cefuroxime 750 mg every 12 hours achieves >99% probability of target attainment for Streptococcus pneumoniae 8
• Critical limitation: Even with 1500 mg every 6 hours, probability of target attainment remains <90% for E. coli and K. pneumoniae 8
• For Staphylococcus aureus, 1500 mg every 8 hours provides >97% probability of target attainment 8

Common Pitfalls and Caveats

Resistance patterns:

• Cefuroxime is not appropriate for infections caused by Pseudomonas aeruginosa, Acinetobacter species, Enterococcus species, or organisms with MIC >2 mcg/mL 7
• First-generation cephalosporins are completely ineffective for Lyme disease 4
• Cefuroxime shows inferior outcomes compared to amoxicillin-clavulanate for chronic rhinosinusitis 5

Duration of therapy:

• Minimum 48-72 hours after patient becomes asymptomatic or bacterial eradication is documented 1
• Minimum 10 days for Streptococcus pyogenes infections to prevent rheumatic fever or glomerulonephritis 1
• Persistent infections may require several weeks of treatment 1

Adverse effects:

• Generally mild and transient, primarily gastrointestinal disturbances (diarrhea, nausea, vomiting) 2, 3
• Serious adverse events are rare 3
• Well tolerated in both adult and pediatric populations 3