Cefixime

[curious30]

---

Members do not see this ad.

Would anybody prescribe cefixime to a 10 week old with a UTI?

 

[GiardiaLOOMBlia]

Would anybody prescribe cefixime to a 10 week old with a UTI?

There are not very many studies that have investigated the safety and efficacy of cefixime in infants under 6 months of age as far as I know. I'm not sure why you would want to use cefixime when bactrim and nitrofurantoin have proved to be safe and effective in treating UTIs in infants. Additionally cefixime won't provide ample coverage for gram negatives when compared to the other two although it's gram negative coverage is better than first gen cepaholsporins. For bactrim you shouldn't use it under 2 months of age and nitrofurantoin not under 1 month of age so for a 10 week old you should be fine using one or the other.

 

[Stitch]

It depends on your local resistance patterns, but it's not an unreasonable choice. I've been using omnicef lately for outpatient treatments as we've got some resistance to Bactrim floating around.

My main concern here would be the patient's age. Are they vaccinated? If not then I'd probably pull the trigger and do a full sepsis eval. Even if they have gotten their first set of shots, I'd probably admit this kid for IV antibiotics (probably cefotaxime, maybe ampicillin). At this age, there's a high incidence of pyelonephritis, plus the kid will need a renal ultrasound and follow up VCUG by the PCP once the infection has been treated.

There is some hospitalist data that suggests we should send these kids home after a dose of ceftriaxone as long as you can guarentee close follow up with a PCP, but our renal guys keep us on the conservative side, and I agree.

 

[BigRedBeta]

It depends on your local resistance patterns, but it's not an unreasonable choice. I've been using omnicef lately for outpatient treatments as we've got some resistance to Bactrim floating around.

My main concern here would be the patient's age. Are they vaccinated? If not then I'd probably pull the trigger and do a full sepsis eval. Even if they have gotten their first set of shots, I'd probably admit this kid for IV antibiotics (probably cefotaxime, maybe ampicillin). At this age, there's a high incidence of pyelonephritis, plus the kid will need a renal ultrasound and follow up VCUG by the PCP once the infection has been treated.

There is some hospitalist data that suggests we should send these kids home after a dose of ceftriaxone as long as you can guarentee close follow up with a PCP, but our renal guys keep us on the conservative side, and I agree.

Of course, the recent study that came out in PEDIATRICS this year (maybe late last year, I believe it was done by a national EM group) suggested that we're over-admitting these kids (Study was with 29 to 60 day olds, so 10 weeks seems applicable), and that an overwhelming majority will have no significant morbidity at home. At 10 weeks, if anything, I'd be even less likely to admit them if they looked good/were feeding well while in the ED. I agree though that reading the parents and getting these kids their follow-up is crucial. It's worthwhile to admit for their renal ultrasound and VCUG if the parents seem sketchy.

As for the drug of choice...would not be what I reached for by any stretch. If I admitted them, would probably start with cefotaxime, wait for my susceptibilities and switch to whatever oral agent was appropriate. Outpatient, omnicef until I had culture results and close followup.

 

[curious30]

The patient was admitted to the hospital. We always get RUS and VCUG for all infants with UTI. A blood culture was drawn to evaluate for bacteremia. However we did not complete a full septic work up because of the very very remote possibility this patient would have a meningitis. He looked very well and was admitted to an observation unit (30 hours max.) Unfortunately, because of the timing of the cultures it would take well over 30 hours for results, including sensitivities. Additionally, the patient looked well and clinically responded to rocephin. The gram stain reveal GNRs. A biogram of our facility shows 50% resistance to amoxil and bactrim and 25% resistance to macrodantin. However 3rd generations are quite effective against E. coli and the patient responded clinically to rocephin.
I realize that cefixime in a 10 week old would be considered an off label use given that it is not well studied in infants. However there was a study in Pediatrics in 1999 where several infant in this age range were treated with cefixime (some PO only) and seemed to do well. I would not use this medication in an infant less than 1 month given the rare incidence of apnea a/w the sodium benzoate in PO cefixime solution.
I polled the group that I worked with and multiple people have said that they would use it. Simply stated, my question was just that, given this senario, would you use cefixime in this patient?

 

[Stitch]

I would not use this medication in an infant less than 1 month given the rare incidence of apnea a/w the sodium benzoate in PO cefixime solution.

I hope you wouldn't treat any infant less than one month with oral antibiotics period. They need the whole deal!

We always get RUS and VCUG for all infants with UTI.

Just curious, how others are doing things. At what age do you stop admitting them and doing the work up as an inpatient? As BigRedBeta points out, there's decent evidence that many of these kids do well as outpatients with close follow up, but part of it depends on the institution, the local PCPs and the renal guys.