Cefuroxime: Comprehensive Dosing and Clinical Guidelines
Adult Dosing
For most adult infections, cefuroxime is dosed at 250-500 mg orally twice daily or 750 mg IV every 8 hours, with higher doses (1.5 g IV every 8 hours) reserved for severe infections. 1, 2
Standard Adult Regimens
Oral (Cefuroxime Axetil):
- Mild to moderate infections: 250 mg twice daily 1, 2
- Respiratory tract infections (pneumonia, severe bronchitis): 500 mg twice daily 1, 2, 3
- Uncomplicated gonorrhea: Single 1 g dose 3
- Early Lyme disease (erythema migrans): 500 mg twice daily for 14-21 days 2
- Animal bites: 500 mg twice daily for 14 days 2
- Maximum daily dose: 4000 mg/day 2
Intravenous:
- Standard infections: 750 mg every 8 hours 2
- Severe infections/bacteremia: 1.5 g every 8 hours 2
- Surgical prophylaxis: 1.5 g IV single dose pre-incision, with 750 mg re-injection every 2 hours if procedure exceeds 2 hours 1, 4
Critical administration note: Cefuroxime axetil must be taken with food to increase absorption 2
Pediatric Dosing
For children, cefuroxime IV is dosed at 100-200 mg/kg/day divided every 6-8 hours (maximum 1500 mg per dose), while oral cefuroxime axetil is dosed at 20-50 mg/kg/day divided twice daily (maximum 500 mg per dose). 5, 2
Age-Specific IV Dosing
- Neonates <7 days: 30 mg/kg IV every 12 hours 5
- Neonates >7 days: 30 mg/kg IV every 8 hours 5
- Infants >1 month: 100-150 mg/kg/day divided every 6-8 hours 5
- Complicated intra-abdominal infections: 150 mg/kg/day divided every 6-8 hours 5
- Bacterial meningitis: 200-240 mg/kg/day divided every 6-8 hours (though third-generation cephalosporins are preferred) 5
Oral Dosing (Cefuroxime Axetil)
- Children 1-24 months: 125 mg twice daily 5, 2
- Children 2-12 years: 250 mg twice daily 5, 2
- Children ≥8 years (Lyme disease): 30 mg/kg/day divided twice daily (maximum 500 mg per dose) 2
- General pediatric dosing: 20-50 mg/kg/day divided every 12 hours, with higher doses (50 mg/kg/day) for severe infections 2
Renal Dose Adjustments
While specific renal dosing tables were not provided in the evidence, standard practice requires dose reduction in renal impairment. For patients with significant renal dysfunction, extend dosing intervals or reduce individual doses based on creatinine clearance, as cefuroxime is renally eliminated. 3, 6
Spectrum of Activity and Target Organisms
Cefuroxime provides excellent coverage against common respiratory pathogens including Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and methicillin-sensitive Staphylococcus aureus, as well as many Enterobacteriaceae. 3, 7, 8
Susceptible Organisms
- Gram-positive: S. pneumoniae (including penicillin-intermediate strains), S. pyogenes, methicillin-sensitive S. aureus, S. epidermidis 1, 3, 8
- Gram-negative: H. influenzae (including beta-lactamase producers), M. catarrhalis (including beta-lactamase producers), E. coli, Klebsiella pneumoniae, Proteus mirabilis 1, 3, 8
- Other: Borrelia burgdorferi (Lyme disease) 2, 7
Important Resistance Patterns
First-generation cephalosporins like cephalexin are ineffective against H. influenzae and Borrelia burgdorferi and should never be substituted for cefuroxime in these infections. 1, 2
Cefuroxime has NO activity against:
- Methicillin-resistant S. aureus (MRSA) - requires vancomycin or clindamycin 5
- Group D streptococci (enterococci) 3
- Pseudomonas aeruginosa 6
Contraindications and Precautions
Absolute contraindication: Known hypersensitivity to cefuroxime or other cephalosporins 3, 7
Relative contraindications and cautions:
- Penicillin allergy: Exercise caution due to 5-10% cross-reactivity; for documented severe beta-lactam allergy, use clindamycin 900 mg IV plus gentamicin 5 mg/kg/day instead 1, 4
- Renal impairment: Requires dose adjustment 3
- History of antibiotic-associated colitis: Use with caution 7
Adverse Effects
Cefuroxime is generally well tolerated, with gastrointestinal disturbances being the most common adverse effects, occurring in a minority of patients and typically mild to moderate in severity. 3, 7, 8
Common Adverse Effects
- Gastrointestinal: Diarrhea, nausea, vomiting (most frequent) 3, 7, 8
- Mild and transient in nature, reversible upon discontinuation 3, 7
Serious Adverse Effects (Rare)
- Hypersensitivity reactions (including anaphylaxis in beta-lactam allergic patients) 7
- Clostridioides difficile-associated diarrhea 7
- Hematologic abnormalities (rare with cephalosporins) 7
Drug Interactions
Cefuroxime has minimal clinically significant drug interactions, though probenecid increases cefuroxime serum levels by blocking renal tubular secretion. 3
Notable Interactions
- Probenecid: Increases cefuroxime serum concentrations and prolongs half-life 3
- Aminoglycosides: Can be used in combination (e.g., gentamicin for beta-lactam allergy coverage) without significant interaction 1, 4
- Metronidazole: Commonly combined for anaerobic coverage in surgical prophylaxis without interaction 1, 2
Alternative Therapies
When cefuroxime is contraindicated or inappropriate, alternatives depend on the infection type and patient factors. 1, 2
For Respiratory Tract Infections
- Amoxicillin/clavulanate: 500-875 mg twice daily (adults) or 45 mg/kg twice daily (pediatrics) - often preferred for sinusitis due to faster symptom improvement 1, 2
- Azithromycin: 500 mg day 1, then 250 mg daily for 4 days 1
- Clarithromycin: 500 mg twice daily 1
- Levofloxacin: 500 mg daily (adults only, avoid in children) 1
For Beta-Lactam Allergy
- Clindamycin 900 mg IV plus gentamicin 5 mg/kg/day for surgical prophylaxis or severe infections 1, 4
- Fluoroquinolones (levofloxacin, ciprofloxacin) for adults with respiratory or urinary infections 1
- Azithromycin or clarithromycin for respiratory infections 1, 7
For MRSA Coverage
- Vancomycin or clindamycin must be added when MRSA is suspected, as cefuroxime has no MRSA activity 5
For Lyme Disease
- Doxycycline 100 mg twice daily for 14-21 days is first-line; amoxicillin 500 mg three times daily is an alternative 2
Clinical Pearls and Common Pitfalls
Avoid these critical errors:
Do NOT use cefuroxime for MRSA infections - it has zero activity and will lead to treatment failure 5
Do NOT substitute first-generation cephalosporins (cephalexin, cefadroxil) for cefuroxime in respiratory infections - they lack H. influenzae coverage 1, 2
Do NOT use cefuroxime for Lyme disease in children <8 years - use amoxicillin instead, as doxycycline is contraindicated 2
Ensure oral cefuroxime axetil is taken WITH FOOD - absorption is significantly reduced on an empty stomach 2
For serious infections requiring consistent serum levels, dose IV cefuroxime every 8 hours, NOT every 12 hours - the shorter half-life necessitates more frequent dosing for severe infections 2, 6
In surgical prophylaxis, re-dose every 2 hours intraoperatively if the procedure exceeds 2 hours to maintain adequate tissue concentrations 1, 4
For chronic rhinosinusitis, amoxicillin-clavulanate demonstrates faster symptom improvement than cefuroxime despite similar overall cure rates 2