Cephalosporin

Aka: Cephalosporin

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II. General

  1. Spectrum changes from first to third generation
    1. First Generation: Better Gram Positive Cocci coverage
    2. Third Generation: Better Gram Negative Rod coverage

III. Contraindications

  1. Drug allergy to other Cephalosporin
  2. Type I Hypersensitivity Reaction to a Penicillin
    1. Less than 10% of those who report Penicillin Allergy actually have a Penicillin Allergy
    2. Cross reactivity was originally over-estimated as high as 10% in the 1960s
      1. Attributed to cross contamination from co-production of Cephalosporins and Penicillins in the same factory
    3. Penicillin Allergy has only an overall 1-2% risk of cross-reactivity with Cephalosporins
      1. Herbert (2000) West J Med 172(5): 341 [PubMed]
    4. Penicillin Anaphylaxis confers a 0.001% risk of Anaphylaxis to Cephalosporins
      1. Apter (2006) Am J Med 119(4):354.e11-9 [PubMed]
    5. Cross reactivity appears primarily limited to First Generation Cephalosporins and Penicillins
      1. Third Generation Cephalosporins have minimal to no allergy cross reactivity
      2. Campagna (2012) J Emerg Med 42(5): 612-20 [PubMed]
    6. Aminopenicillins (Amoxicillin and Ampicillin) allergy and allergy to first and Second Generation Cephalosporins: High
      1. R1-side chain of Aminopenicillins are similar to first and Second Generation Cephalosporins (esp. Cefprozil, Cefadroxil)
      2. Reaction rate is as high as 27% for Cefadroxil
      3. Campagna (2012) J Emerg Med 42(5): 612-20 [PubMed]

IV. Class: First Generation Cephalosporins

  1. Oral Agents
    1. Cephalexin (Keflex)
    2. Cephradine (Velosef)
    3. Cefadroxil (Duricef)
  2. Parenteral Agents
    1. Cefazolin (Ancef)
  3. Organisms covered
    1. Gram Positive Cocci (Streptococcus and MSSA)
    2. EKP Gram Negative Bacteria

V. Class: Second Generation Cephalosporins

  1. Second Generation Broad-spectrum Cephalosporins
    1. Oral Agents
      1. Loracarbef (Lorabid)
      2. Cefprozil (Cefzil)
      3. Cefuroxime (Ceftin, Zinacef)
      4. Cefaclor (Ceclor)
    2. Organisms Covered
      1. Gram Positive Cocci
      2. EKP Gram Negative Bacteria
      3. Gram Negative Coccobacilli (e.g. HaemophilusInfluenzae)
  2. Second Generation Anti-anaerobe Cephalosporins
    1. Parenteral Agents
      1. Cefoxitin
      2. Cefotetan
      3. Cefamandole
    2. Organisms Covered (growing Anaerobe resistance)
      1. Bacteroides fragilis

VI. Class: Third Generation Cephalosporins

  1. Third Generation Broad-Spectrum Cephalosporins
    1. Oral agents
      1. Cefixime (Suprax)
        1. Only indication is for Gonorrhea
      2. Cefpodoxime (Vantin)
        1. Does not cover Enterobacter or Pseudomonas
      3. Cefdinir (Omnicef)
    2. Parenteral agents
      1. Cefotaxime (Claforan)
      2. Ceftizoxime (Cefizox)
      3. Ceftriaxone (Rocephin)
    3. Organisms Covered
      1. Gram Positive Cocci
      2. EKP Gram Negative Bacteria
      3. ESP Gram Negative Bacteria
      4. No Pseudomonas activity
  2. Third Generation Anti-Pseudomonal Cephalosporins
    1. Parenteral Agents
      1. Ceftazidime (Fortaz)
    2. Organisms Covered
      1. Pseudomonas
      2. EKP Gram Negative Bacteria
      3. ESP Gram Negative Bacteria
      4. Poor Gram Positive Cocci coverage
      5. No Coccobacilli coverage

VII. Class: Fourth Generation Cephalosporins

  1. Parenteral Agents
    1. Cefepime (Maxipime)
  2. Organisms Covered
    1. Broad spectrum Gram-positive and Gram-negative organisms building on third generation coverage
    2. Beta-Lactamase resistant organisms
    3. Pseudomonas coverage

VIII. Class: Fifth Generation Cephalosporins

  1. Parenteral Agents
    1. Ceftaroline
    2. Ceftolozane and Tazobactam (Zerbaxa)
    3. Ceftazidime and Avibactam (Avycaz)
  2. Organisms Covered
    1. Broad spectrum Gram-positive and Gram-negative organisms building on third generation coverage
    2. Pseudomonas coverage
    3. Methicillin Resistant Staphylococcus Aureus (MRSA)

IX. Dosing: Adults

  1. Almost all Cephalosporins
    1. Typical Dose: 1-2 grams IV q8h
  2. Exceptions
    1. Ceftriaxone 1-2 grams IV q24 hours
    2. Cefotetan 1-2 grams IV q12 hours

X. Dosing: Children

  1. Almost all Cephalosporins
    1. Typical dose: 100-200 mg/kg/day divided q8 hours
  2. Exceptions
    1. Ceftriaxone 75-100 mg/kg/day q24 hours

XI. Prevention: Reducing Adverse Effects

  1. Least Diarrhea
    1. Loracarbef (Lorabid)
    2. Cefprozil (Cefzil)
  2. Best taste
    1. Loracarbef (Lorabid)
    2. Cefixime (Suprax)
    3. Cefpodoxime (Vantin, taste applies to under age 2 years)

XII. References

  1. Pensa and Hayes in Swadron (2022) EM:Rap 22(9): 6-8

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