What is the appropriate treatment and dosage of cefixime (cephalosporin antibiotic) for a child with a bacterial respiratory infection?

Cefixime for Respiratory Infections in Children

Critical Limitation: Cefixime is NOT Recommended for Most Pediatric Respiratory Infections

Cefixime should NOT be used as first-line therapy for bacterial respiratory infections in children because it has inadequate activity against Streptococcus pneumoniae, the most common bacterial respiratory pathogen, and has no clinically significant activity against drug-resistant S. pneumoniae (DRSP). 1

Why Cefixime Fails for Respiratory Infections

Inadequate Pneumococcal Coverage

• The American Academy of Otolaryngology explicitly states that cefixime has limited gram-positive coverage including S. pneumoniae, may occasionally fail against even penicillin-susceptible pneumococci, and has no activity against DRSP 1
• The Infectious Diseases Society of America specifically excludes cefixime from recommended alternatives for acute bacterial sinusitis, stating that third-generation cephalosporins like cefpodoxime-proxetil and cefotiam-hexetil are acceptable, but NOT cefixime 2
• Cefixime's predicted clinical efficacy in children with acute bacterial rhinosinusitis is only 82-87% (based on H. influenzae and M. catarrhalis coverage only), which is significantly lower than high-dose amoxicillin-clavulanate at 91-92% 1

When Cefixime Has Limited Role

• Cefixime has potent activity against H. influenzae but this narrow spectrum makes it unsuitable as monotherapy for respiratory infections where S. pneumoniae is the primary concern 1
• It may only be considered as part of combination therapy (e.g., high-dose amoxicillin or clindamycin plus cefixime) for moderate disease or treatment failures, but this approach lacks robust clinical trial evidence 1

Recommended First-Line Therapy Instead

For Mild Respiratory Infections in Children

• High-dose amoxicillin (90 mg/kg/day) is the preferred first-line agent for children who have not received antibiotics in the previous 4-6 weeks 1
• High-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) for children with recent antibiotic exposure or moderate disease 1
• Alternative second-generation/third-generation cephalosporins with adequate pneumococcal coverage: cefpodoxime proxetil, cefuroxime axetil, or cefdinir 1

For Community-Acquired Pneumonia in Children

• The Pediatric Infectious Diseases Society recommends ampicillin or penicillin G for hospitalized children who are fully immunized 1
• For outpatient pneumonia in children under 5 years: high-dose amoxicillin (90 mg/kg/day) 1
• Cefixime is not mentioned in the PIDS/IDSA pneumonia guidelines as an appropriate option 1

FDA-Approved Indications for Cefixime

What Cefixime IS Approved For

While cefixime is FDA-approved for certain respiratory conditions, this does not mean it is the optimal choice:

• Pharyngitis and tonsillitis caused by Streptococcus pyogenes (though penicillin remains the drug of choice) 3
• Acute exacerbations of chronic bronchitis caused by S. pneumoniae and H. influenzae 3
• Otitis media (though the suspension formulation is required, not tablets/capsules) 3

Dosing IF Cefixime is Used (Despite Limitations)

• Pediatric dose: 8 mg/kg/day as a single daily dose or divided into 4 mg/kg every 12 hours 3
• Maximum daily dose: 400 mg 3
• Duration: At least 10 days for S. pyogenes infections 3
• Must use suspension formulation for otitis media due to superior pharmacokinetics 3

Clinical Evidence Shows Limited Efficacy

Research Findings

• A 1995 post-marketing surveillance study showed 98% cure/improvement rates in children with respiratory infections, but this study lacked bacteriologic confirmation and included many viral infections 4
• A 1998 multinational study demonstrated 96-100% clinical success in acute sinusitis and otitis media, but microbiologic data showed all S. pneumoniae isolates were eradicated only because the study population had predominantly susceptible strains 5
• These older studies (1980s-1990s) predate the current era of widespread pneumococcal resistance 6, 7

Common Pitfalls to Avoid

Critical Errors in Prescribing

• Do not assume all cephalosporins are equivalent for respiratory infections—cefixime's spectrum is fundamentally different from cefuroxime, cefpodoxime, or cefdinir 1
• Do not use cefixime for suspected pneumococcal pneumonia—it lacks adequate coverage and may lead to treatment failure 1, 2
• Do not substitute tablets/capsules for suspension in otitis media—pharmacokinetics differ significantly 3

When to Reassess

• If no clinical improvement occurs after 72 hours of any antibiotic therapy, switch to an agent with broader pneumococcal coverage or consider hospitalization 1
• Therapeutic efficacy should be assessed by fever resolution (within 24 hours for pneumococcal infections) rather than cough resolution, which may persist longer 2

Bottom Line Algorithm

For pediatric bacterial respiratory infections:

1. First-line: High-dose amoxicillin (90 mg/kg/day) or high-dose amoxicillin-clavulanate (90 mg/6.4 mg per kg per day) 1
2. Second-line (if β-lactam allergy without anaphylaxis): Cefpodoxime, cefuroxime, or cefdinir 1
3. Cefixime: Reserve only for combination therapy in treatment failures or when specifically treating pharyngitis/tonsillitis with documented S. pyogenes 1, 3
4. Never use cefixime alone for suspected pneumococcal respiratory infections 1, 2