What is the recommended cefixime dosage for acute bacterial tonsillitis in adults and children, and how should it be adjusted in patients with impaired renal function?

Cefixime Dosing for Acute Tonsillitis

Cefixime is not a first-line agent for acute bacterial tonsillitis, but when used, the FDA-approved dose is 400 mg daily for adults and 8 mg/kg/day (maximum 400 mg) for children aged 6 months or older, administered for at least 10 days when treating Streptococcus pyogenes infections. 1

First-Line Treatment Considerations

• Amoxicillin or penicillin V should be used as first-line therapy for acute bacterial tonsillitis caused by Group A Streptococcus, not cefixime. 2
• Cefixime has limited gram-positive coverage and is primarily indicated based on its activity against H. influenzae and M. catarrhalis, not S. pyogenes. 3
• The addition of cefixime to treatment regimens is only recommended in combination therapy for moderate disease or treatment failures in sinusitis guidelines, not as monotherapy for tonsillitis. 3

When Cefixime May Be Appropriate

• Cefixime can be considered for patients with non-Type I penicillin hypersensitivity (such as rash, not anaphylaxis) who cannot tolerate first-line agents. 4
• In combination therapy for treatment failures, cefixime may be paired with high-dose amoxicillin or clindamycin to provide adequate gram-negative coverage. 3

Adult Dosing

• The FDA-approved dose for adults is 400 mg once daily, which may be administered without regard to food. 1
• For infections caused by Streptococcus pyogenes (the primary pathogen in bacterial tonsillitis), treatment must continue for at least 10 days to prevent complications including rheumatic fever. 1, 2

Pediatric Dosing (6 months or older)

• The recommended pediatric dose is 8 mg/kg/day of oral suspension, administered either as a single daily dose or divided into two doses of 4 mg/kg every 12 hours. 1
• The maximum daily dose should not exceed 400 mg regardless of weight. 1
• Children weighing more than 45 kg or older than 12 years should receive the adult dose of 400 mg daily. 1
• Treatment duration must be at least 10 days for Streptococcus pyogenes infections. 1

Pediatric Dosing Table (from FDA Label)

• 5-7.5 kg: 50 mg/day (2.5 mL of 100 mg/5 mL suspension) 1
• 7.6-10 kg: 80 mg/day (4 mL of 100 mg/5 mL or 2 mL of 200 mg/5 mL suspension) 1
• 10.1-12.5 kg: 100 mg/day (5 mL of 100 mg/5 mL or 2.5 mL of 200 mg/5 mL suspension) 1
• 12.6-20.5 kg: 150 mg/day (7.5 mL of 100 mg/5 mL or 4 mL of 200 mg/5 mL suspension) 1
• 20.6-28 kg: 200 mg/day (10 mL of 100 mg/5 mL or 5 mL of 200 mg/5 mL suspension) 1
• 28.1-33 kg: 250 mg/day (12.5 mL of 100 mg/5 mL or 6 mL of 200 mg/5 mL suspension) 1
• 33.1-40 kg: 300 mg/day (15 mL of 100 mg/5 mL or 7.5 mL of 200 mg/5 mL suspension) 1
• 40.1-45 kg: 350 mg/day (17.5 mL of 100 mg/5 mL or 9 mL of 200 mg/5 mL suspension) 1

• 45 kg: 400 mg/day (adult dose) 1

Renal Impairment Dosing Adjustments

• Patients with creatinine clearance ≥60 mL/min require no dose adjustment. 1
• For creatinine clearance 21-59 mL/min: reduce dose to 260 mg daily (13 mL of 100 mg/5 mL suspension or 6.5 mL of 200 mg/5 mL suspension). 1
• For creatinine clearance ≤20 mL/min or patients on hemodialysis or continuous peritoneal dialysis: reduce dose to 172 mg daily (8.6 mL of 100 mg/5 mL suspension or 4.4 mL of 200 mg/5 mL suspension). 1
• Neither hemodialysis nor peritoneal dialysis removes significant amounts of cefixime from the body. 1

Clinical Evidence for Tonsillitis

• Comparative trials in children demonstrated that cefixime 8 mg/kg daily for 5 days achieved bacteriologic eradication rates of 82.6-82.7% and clinical cure rates of 86.7%, comparable to 10 days of penicillin V. 5, 6, 7
• However, these studies showed slightly lower eradication rates compared to penicillin V (88.2%), and the FDA label mandates 10-day treatment for S. pyogenes infections. 1, 6

Critical Clinical Pitfalls

• Do not use cefixime as first-line therapy for acute tonsillitis—amoxicillin or penicillin V remain the gold standard. 2
• Always prescribe orders in milliliters with a specified concentration (100 mg/5 mL or 200 mg/5 mL) to prevent dosing errors, as cefixime suspension is available in two different concentrations. 1
• Do not substitute capsules for suspension in pediatric patients, as bioavailability differs between formulations. 1
• Distinguish between Type I hypersensitivity reactions (anaphylaxis, angioedema) and non-serious reactions (rash)—cefixime is only appropriate for the latter. 4, 2
• Reconstituted suspension remains stable for only 14 days at room temperature or refrigerated; instruct patients to discard unused portions after this period. 1
• If no clinical improvement occurs after 72 hours, reassess the diagnosis and consider switching to high-dose amoxicillin-clavulanate or ceftriaxone rather than continuing cefixime. 4