Is cefuroxime (Cefuroxime) safe to use in a patient with a levofloxacin (Levofloxacin) allergy?

From the Guidelines

Yes, cefuroxime can generally be used in patients with a levofloxacin allergy, as these medications belong to different antibiotic classes and do not typically exhibit cross-reactivity. Cefuroxime is a second-generation cephalosporin, while levofloxacin is a fluoroquinolone, and the risk of cross-reactivity between these classes is low 1. According to the Dutch Working Party on Antibiotic Policy (SWAB) guideline, there is no evidence to suggest that a levofloxacin allergy would increase the risk of an allergic reaction to cefuroxime 1.

When considering the use of cefuroxime in a patient with a levofloxacin allergy, it's essential to note that the patient's allergy history should be carefully evaluated. If the patient has a history of severe allergic reactions to antibiotics, they should be monitored closely when starting cefuroxime. The standard adult dose of cefuroxime is typically 250-500 mg twice daily for most infections, with higher doses (750 mg to 1.5 g twice daily) used for more severe infections. Treatment duration generally ranges from 5-14 days depending on the infection being treated.

It's also important to consider the mechanism of action of cefuroxime, which inhibits bacterial cell wall synthesis, differing from levofloxacin's mechanism of action that targets bacterial DNA gyrase. If a patient has a history of anaphylaxis or other severe allergic reactions to any medication, they should inform their healthcare provider before starting cefuroxime and report any new symptoms such as rash, itching, or difficulty breathing immediately. The American Academy of Pediatrics also suggests that cefuroxime is a suitable alternative for patients with a penicillin allergy, with a low risk of cross-reactivity 1.

In terms of specific guidance, the SWAB guideline recommends that patients with a suspected non-severe, delayed-type allergy to a cephalosporin can receive cephalosporins with a dissimilar side chain, irrespective of time since the index reaction 1. This suggests that cefuroxime can be used in patients with a levofloxacin allergy, as long as the patient's allergy history is carefully evaluated and they are monitored closely for any signs of an allergic reaction.

Key points to consider:

• Cefuroxime and levofloxacin belong to different antibiotic classes and do not typically exhibit cross-reactivity
• Patients with a history of severe allergic reactions to antibiotics should be monitored closely when starting cefuroxime
• The standard adult dose of cefuroxime is typically 250-500 mg twice daily for most infections
• Treatment duration generally ranges from 5-14 days depending on the infection being treated
• Patients with a history of anaphylaxis or other severe allergic reactions to any medication should inform their healthcare provider before starting cefuroxime and report any new symptoms immediately.

From the FDA Drug Label

WARNINGS BEFORE THERAPY WITH CEFUROXIME FOR INJECTION IS INSTITUTED, CAREFUL INQUIRY SHOULD BE MADE TO DETERMINE WHETHER THE PATIENT HAS HAD PREVIOUS HYPERSENSITIVITY REACTIONS TO CEPHALOSPORINS, PENICILLINS, OR OTHER DRUGS. The FDA drug label does not answer the question.

From the Research

Cefuroxime and Levofloxacin Allergy Considerations

• There is no direct evidence in the provided studies that addresses the use of cefuroxime in patients with a levofloxacin allergy.
• However, studies 2 and 3 discuss the safety considerations of fluoroquinolones, including levofloxacin, in the elderly population, highlighting potential adverse effects such as gastrointestinal reactions, hypersensitivity reactions, and CNS effects.
• Study 4 reviews the use of cephalosporins in penicillin-allergic patients, noting that the cross-reactivity between penicillins and cephalosporins is lower than previously reported, with an overall cross-reactivity rate of approximately 1% when using first-generation cephalosporins or cephalosporins with similar R1 side chains.
• Cefuroxime is a second-generation cephalosporin, and according to study 4, the cross-reactivity between penicillins and second-generation cephalosporins is negligible (odds ratio 1.1; confidence interval 0.6-2.1).
• Study 5 reviews the antimicrobial spectrum and potency of orally administered cephalosporins, including cefuroxime axetil, and notes that cefuroxime is highly active against penicillin-susceptible Streptococcus pneumoniae and retains some activity against penicillin-intermediate strains.

Potential for Cross-Reactivity

• While there is no direct evidence of cross-reactivity between levofloxacin and cefuroxime, the provided studies suggest that the risk of cross-reactivity between different classes of antibiotics is generally low.
• However, it is essential to consider the individual patient's medical history and potential allergies before administering any antibiotic, including cefuroxime, especially if they have a known allergy to levofloxacin or other fluoroquinolones 2, 3.