Can I prescribe cefixime for an uncomplicated urinary tract infection in a non‑pregnant adult woman with no β‑lactam allergy and normal renal function?

Can Cefixime Be Used for Uncomplicated UTI?

Yes, cefixime is FDA-approved and can be prescribed for uncomplicated urinary tract infections in non-pregnant adult women, though it is not a first-line agent and should be reserved for situations where preferred antibiotics cannot be used. 1

FDA-Approved Indication

• Cefixime is specifically FDA-approved for uncomplicated urinary tract infections caused by E. coli and Proteus mirabilis 1
• The standard dosing is 400 mg once daily, though dividing this into 200 mg twice daily may reduce gastrointestinal side effects 2

Position in Treatment Algorithm

First-Line Agents (Use These First)

• Nitrofurantoin (5 days), fosfomycin (single 3g dose), or pivmecillinam (5 days) are the recommended first-line options for acute uncomplicated cystitis 3
• Trimethoprim-sulfamethoxazole (3 days) can be used if local resistance is <20% and the patient has not had recent antibiotic exposure 4

When to Consider Cefixime

• Cefixime is a second-line option when first-line agents are contraindicated, not tolerated, or when there is documented resistance 3
• It can be used when fluoroquinolone resistance exceeds 10% and other preferred agents cannot be used 4
• Consider cefixime when β-lactam allergy excludes penicillins but cephalosporins are tolerated 3

Clinical Efficacy Evidence

For Uncomplicated Cystitis

• Clinical efficacy rates of 96.2% have been reported for uncomplicated cystitis 5
• One study showed cefixime had higher clinical and microbiological efficacy than ciprofloxacin in acute uncomplicated cystitis 6
• Multiple controlled trials demonstrated good efficacy comparable to amoxicillin and co-trimoxazole 2

Important Limitation for Pyelonephritis

• Oral β-lactams (including cefixime) are less effective than fluoroquinolones for pyelonephritis 4
• If cefixime must be used for pyelonephritis, an initial IV dose of ceftriaxone 1g or aminoglycoside should be given first 4
• The 2024 EAU guidelines list only cefpodoxime and ceftibuten (not cefixime) as recommended oral cephalosporins for uncomplicated pyelonephritis 4

Critical Caveats

Spectrum Limitations

• Cefixime has excellent activity against Enterobacteriaceae but treatment should not be initiated without sensitivity testing in complicated UTI where gram-positive organisms and non-fermenting bacteria may be present 2
• It is resistant to many β-lactamases, making it useful for some ESBL-producing organisms, though this is not its primary indication 7, 3

Common Pitfall

• Do not use cefixime as empiric first-line therapy when nitrofurantoin, fosfomycin, or pivmecillinam are available and appropriate 3
• The once-daily 400 mg dosing has higher gastrointestinal side effects than divided dosing; consider 200 mg twice daily for better tolerability 2

Practical Prescribing Approach

For uncomplicated cystitis in your patient:

1. First, attempt nitrofurantoin, fosfomycin, or pivmecillinam 3
2. If these are contraindicated or unavailable, cefixime 400 mg once daily (or 200 mg twice daily) for 3-5 days is appropriate 1, 2
3. Obtain urine culture if treatment fails or symptoms recur 4

Avoid cefixime for:

• Empiric treatment of pyelonephritis without an initial IV dose 4
• Complicated UTI without documented susceptibility 2
• When first-line agents are available and appropriate 3