What is the recommended dose and treatment duration of cefoxitin (a broad-spectrum antibiotic) for a patient with a urinary tract infection (UTI)?

Cefoxitin for UTI: Dosing and Duration

Cefoxitin is not a recommended agent for urinary tract infections and should not be used as first-line or even second-line therapy for UTI treatment. 1

Why Cefoxitin is Inappropriate for UTI

Guideline Recommendations Do Not Support Cefoxitin Use

• Current evidence-based guidelines from 2024 do not list cefoxitin among recommended empirical or targeted therapies for any category of UTI (uncomplicated cystitis, pyelonephritis, complicated UTI, or catheter-associated UTI). 1

• The 2024 JAMA guidelines specify first-generation cephalosporins or ceftriaxone (third-generation) for patients requiring parenteral therapy, but cefoxitin (a second-generation cephamycin) is notably absent from treatment algorithms. 1

• The 2024 European Association of Urology guidelines recommend second-generation cephalosporins combined with aminoglycosides for complicated UTI, but do not specifically endorse cefoxitin monotherapy. 1

Preferred Alternatives Based on Current Guidelines

For uncomplicated cystitis:

• Nitrofurantoin 100 mg twice daily for 5 days (first-line) 1
• Fosfomycin 3 g single dose (first-line) 1
• Trimethoprim-sulfamethoxazole 160/800 mg twice daily for 3 days (first-line if local resistance <20%) 1

For pyelonephritis requiring IV therapy:

• Ceftriaxone is the recommended empirical choice for patients requiring intravenous therapy, with 7 days of β-lactam treatment demonstrating clear efficacy. 1
• First-generation cephalosporins or TMP-SMX are reasonable first-line agents for oral therapy, dependent on local resistance patterns. 1

For complicated UTI with systemic symptoms:

• Amoxicillin plus aminoglycoside, or third-generation cephalosporin IV (not cefoxitin specifically). 1
• Treatment duration of 7-14 days is generally recommended. 1

If Cefoxitin Must Be Used (FDA Labeling Information)

Dosing from FDA Label

• Adults: 1-2 grams IV every 6-8 hours for uncomplicated infections. 2
• Pediatric patients ≥3 months: 80-160 mg/kg/day divided into 4-6 equal doses (maximum 12 grams/day). 2

Critical Limitations

• The FDA label lists "uncomplicated urinary tract infection" as an indication but provides no specific duration guidance for UTI treatment. 2
• Cefoxitin requires IV administration, making it impractical for typical outpatient UTI management. 2
• The pharmacy bulk package formulation is only for 1-gram doses and cannot be used for patients requiring different dosing. 2

Renal Dose Adjustment Required

• In renal impairment (CrCl 30-50 mL/min): 1-2 grams every 8-12 hours. 2
• In moderate impairment (CrCl 10-29 mL/min): 1-2 grams every 12-24 hours. 2
• In severe impairment (CrCl 5-9 mL/min): 0.5-1 gram every 12-24 hours. 2

Clinical Bottom Line

Choose evidence-based first-line agents instead of cefoxitin. The absence of cefoxitin from contemporary UTI guidelines reflects superior alternatives with better oral bioavailability, proven efficacy in randomized trials, and established treatment durations. 1 If a parenteral second-generation cephalosporin is truly needed for complicated UTI, it should be combined with an aminoglycoside per guideline recommendations, not used as monotherapy. 1