Cefuroxime vs Cefixime: Clinical Recommendation
For gonorrhea treatment, cefixime and cefuroxime are equivalent options, but for respiratory tract infections, cefuroxime is superior due to better staphylococcal coverage and fewer gastrointestinal side effects, though cefixime has advantages for Haemophilus influenzae coverage.
Gonorrhea Treatment: Equivalent Efficacy
- Both cefixime 400 mg orally and cefuroxime (parenteral form) are listed as recommended regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum 1
- Cefixime cured 97.4% of uncomplicated urogenital and anorectal gonococcal infections in clinical trials, while ceftriaxone (same class as cefuroxime) cured 98.9% 1
- For gonorrhea specifically, choose cefixime 400 mg orally as a single dose—it provides equivalent efficacy to parenteral cefuroxime with the convenience of oral administration 1
Respiratory Tract Infections: Cefuroxime Preferred Overall
Antimicrobial Spectrum Considerations
- Cefuroxime provides superior coverage against Staphylococcus aureus, which is critical for respiratory infections 2, 3
- Cefixime has little to no activity against S. aureus, making it unsuitable when staphylococcal infection is possible 4
- For Streptococcus pneumoniae, both agents achieve approximately 75-85% coverage with equivalent activity 5
- Neither agent has clinically significant activity against drug-resistant S. pneumoniae (DRSP)—avoid both if DRSP is suspected 2, 5
Haemophilus influenzae Coverage: The Key Differentiator
- Cefixime demonstrates markedly superior activity against H. influenzae compared to cefuroxime, particularly against beta-lactamase producing strains 5, 4
- Cefuroxime achieves 70-85% coverage of H. influenzae while cefixime provides broader coverage 2
- If H. influenzae is the primary suspected pathogen, cefixime is the better choice 5
Clinical Trial Evidence in Acute Bronchitis
- A direct head-to-head trial in 465 patients with acute bronchitis showed cefuroxime axetil 250 mg twice daily achieved 88% satisfactory clinical outcomes versus 91% for cefixime 400 mg once daily (not statistically significant, p=0.36) 6
- Bacteriologic eradication rates were 89% for cefuroxime versus 91% for cefixime (p=0.75) 6
- Cefuroxime produced significantly fewer gastrointestinal adverse events than cefixime (10% vs 18%, p=0.01), with notably less diarrhea (5% vs 15%, p=0.001) 6
Practical Algorithm for Selection
Choose cefuroxime when:
- Staphylococcus aureus is a possible pathogen (skin/soft tissue involvement, post-viral complications) 2, 3
- Patient has history of antibiotic-associated diarrhea 6
- Mixed respiratory infection with both gram-positive and gram-negative organisms 2
Choose cefixime when:
- H. influenzae is the primary suspected pathogen (chronic bronchitis, COPD exacerbation) 5, 4
- Gonorrhea treatment is needed 1
- Once-daily dosing is critical for adherence 4, 7
Avoid both agents when:
- Drug-resistant S. pneumoniae is suspected—both have inadequate activity 2, 5
- Pseudomonas aeruginosa coverage is needed—both are inactive 2, 4
- Anaerobic coverage is required (e.g., aspiration pneumonia)—both have limited activity 2
Common Pitfalls
- Do not use cefixime for suspected staphylococcal infections—it lacks clinically meaningful activity against S. aureus 4, 3
- Do not assume either agent covers DRSP—this is a critical gap in coverage that leads to treatment failure 2, 5
- Cefuroxime axetil suspension is notably unpalatable in pediatric patients, which significantly limits adherence 5
- Cefixime's longer half-life (3 hours) permits once or twice daily dosing, but this pharmacokinetic advantage does not translate to superior clinical outcomes in most respiratory infections 4, 6