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Cefoxitin: Drug information

Cefoxitin: Drug information
(For additional information see "Cefoxitin: Patient drug information" and see "Cefoxitin: Pediatric drug information")

For abbreviations and symbols that may be used in Lexicomp (show table)
Pharmacologic Category
  • Antibiotic, Cephalosporin (Second Generation)
Dosing: Adult

Usual dosage range: IV: 1 to 2 g every 6 to 8 hours.

Bite wounds (animal) (off-label use): IV: 1 g every 6 to 8 hours (IDSA [Stevens 2014]).

Mycobacterial (nontuberculous, rapidly growing) infection (off-label use):

Patients without cystic fibrosis: 2 to 4 g two to three times daily or 200 mg/kg/day in 3 divided doses (maximum daily dosage: 12 g/day) as part of an appropriate combination regimen (ATS/ERS/ESCMID/IDSA [Daley 2020]; BTS [Haworth 2017]).

Patients with cystic fibrosis: 200 mg/kg/day in 3 divided doses (maximum daily dosage: 12 g/day) as part of an appropriate combination regimen (CFF/ECFS [Floto 2016]).

Duration of therapy: The optimal duration of therapy is unknown, but generally the duration of parenteral therapy is ≤12 weeks depending on severity of infection, tolerability, and other patient-specific factors, followed by long-term oral maintenance therapy; consult an infectious diseases specialist for specific recommendations (ATS/ERS/ESCMID/IDSA [Daley 2020]; BTS [Haworth 2017]; CFF/ECFS [Floto 2016]).

Pelvic inflammatory disease (CDC [Workowski 2015]):

Inpatients: IV: 2 g every 6 hours plus doxycycline for at least 24 to 48 hours after clinical improvement, followed by oral doxycycline to complete 14 days.

Outpatients: IM: 2 g as a single dose plus oral probenecid, followed by oral doxycycline (with or without concomitant metronidazole) for 14 days.

Surgical (perioperative) prophylaxis: IV: 2 g within 60 minutes prior to surgical incision. Doses may be repeated in 2 hours if procedure is lengthy or if there is excessive blood loss (Bratzler 2013).

Dosing: Renal Impairment: Adult

Loading dose: 1 to 2 g, followed by maintenance dosing according to CrCl.

Maintenance dosage:

CrCl 30 to 50 mL/minute: 1 to 2 g every 8 to 12 hours

CrCl 10 to 29 mL/minute: 1 to 2 g every 12 to 24 hours

CrCl 5 to 9 mL/minute: 0.5 to 1 g every 12 to 24 hours

CrCl <5 mL/minute: 0.5 to 1 g every 24 to 48 hours

Hemodialysis: Loading dose: 1 to 2 g after each hemodialysis; maintenance dose as noted above based on creatinine clearance

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Pediatric

(For additional information see "Cefoxitin: Pediatric drug information")

General dosing, susceptible infection (Red Book [AAP 2012]): Infants, Children, and Adolescents: IM, IV:

Mild to moderate infection: 80 mg/kg/day divided every 6 to 8 hours; maximum daily dose: 4,000 mg/day

Severe infection: 160 mg/kg/day divided every 6 hours; maximum daily dose: 12 g/day

Manufacturer's labeling: Infants ≥3 months, Children, and Adolescents: 80 to 160 mg/kg/day divided every 4 to 6 hours; maximum daily dose: 12 g/day

Intra-abdominal infections, complicated: Infants, Children, and Adolescents: IV: 160 mg/kg/day divided every 4 to 6 hours; maximum daily dose: 8 g/day (Solomkin 2010)

Peritonitis, prophylaxis for patients receiving peritoneal dialysis undergoing gastrointestinal or genitourinary procedures: Limited data available: Infants, Children, and Adolescents: IV: 30 to 40 mg/kg administered 30 to 60 minutes before procedure; maximum dose: 2,000 mg/dose (Warady [ISPD 2012])

Surgical prophylaxis: IV:

Manufacturer's labeling: Infants ≥3 months, Children, and Adolescents: 30 to 40 mg/kg 30 to 60 minutes prior to initial incision, followed by 30 to 40 mg/kg every 6 hours for up to 24 hours; maximum single dose: 2,000 mg

Alternate dosing (ASHP guidelines, endorsed by IDSA): Children and Adolescents: 40 mg/kg within 60 minutes prior to surgery; may repeat in 2 hours if procedure is lengthy or if there is excessive blood loss; maximum single dose: 2,000 mg (Bratzler 2013; Red Book [AAP 2012])

Dosing: Renal Impairment: Pediatric

Infants, Children, and Adolescents: The manufacturer's labeling suggests dosing modification consistent with the adult recommendations. Some clinicians have used the following guidelines (Aronoff 2007); Note: Renally adjusted dose recommendations are based on doses of 20 to 40 mg/kg/dose every 6 hours.

GFR >50 mL/minute/1.73 m2: No adjustment required.

GFR 30 to 50 mL/minute/1.73 m2: 20 to 40 mg/kg/dose every 8 hours

GFR 10 to 29 mL/minute/1.73 m2: 20 to 40 mg/kg/dose every 12 hours

GFR <10 mL/minute/1.73 m2: 20 to 40 mg/kg/dose every 24 hours

Intermittent hemodialysis: Moderately dialyzable (20% to 50%): 20 to 40 mg/kg/dose every 24 hours

Peritoneal dialysis (PD): 20 to 40 mg/kg/dose every 24 hours

Continuous renal replacement therapy (CRRT): 20 to 40 mg/kg/dose every 8 hours

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Geriatric

Refer to adult dosing.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Solution Reconstituted, Injection:

Generic: 10 g (1 ea [DSC])

Solution Reconstituted, Injection [preservative free]:

Generic: 10 g (1 ea)

Solution Reconstituted, Intravenous:

Generic: 2 g (1 ea)

Solution Reconstituted, Intravenous [preservative free]:

Generic: 1 g (1 ea); 2 g (1 ea)

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Injection:

Generic: 1 g (1 ea); 2 g (1 ea)

Solution Reconstituted, Intravenous:

Generic: 10 g (1 ea)

Administration: Adult

IM: Inject deep IM into large muscle mass. Note: IM injection is painful and this route of administration is not described in the prescribing information.

IV: Can be administered IVP over 3 to 5 minutes or by IV intermittent infusion over 10 to 60 minutes

Administration: Pediatric

Parenteral:

IV Push: Administer over 3 to 5 minutes

Intermittent IV infusion: Administer over 10 to 60 minutes

IM: Deep IM injection into a large muscle mass such as the upper outer quadrant of the gluteus maximus. Note: IM injection is painful and this route of administration is not described in the prescribing information.

Use: Labeled Indications

Bacteremia/sepsis: Treatment of bacteremia/sepsis caused by Streptococcus pneumoniae, Staphylococcus aureus (including penicillinase-producing strains), Escherichia coli, Klebsiella species, and Bacteroides species including B. fragilis.

Bone and joint infections: Treatment of bone and joint infections caused by S. aureus (including penicillinase-producing strains).

Gynecological infections: Treatment of endometritis, pelvic cellulitis, and pelvic inflammatory disease caused by E. coli, Neisseria gonorrhoeae (including penicillinase-producing strains), Bacteroides species including Bacteroides fragilis, Clostridium species, P. niger, Peptostreptococcus species, and Streptococcus agalactiae.

Limitations of use: Cefoxitin does not have activity against Chlamydia trachomatis. When cefoxitin is used to treat pelvic inflammatory disease, add appropriate antichlamydial coverage.

Lower respiratory tract infections: Treatment of pneumonia and lung abscess, caused by S. pneumoniae, other streptococci (excluding enterococci; eg, Enterococcus faecalis [formerly Streptococcus faecalis]), S. aureus (including penicillinase-producing strains), E. coli, Klebsiella species, Haemophilus influenzae, and Bacteroides species.

Septicemia: Treatment of septicemia caused by S. pneumoniae, S. aureus (including penicillinase-producing strains), E. coli, Klebsiella species, and Bacteroides species including B. fragilis.

Skin and skin structure infections: Treatment of skin and skin structure infections caused by S. aureus (including penicillinase-producing strains), Staphylococcus epidermidis, Streptococcus pyogenes and other streptococci (excluding enterococci [eg, E. faecalis] [formerly S. faecalis]), E. coli, Proteus mirabilis, Klebsiella species, Bacteroides species including B. fragilis, Clostridium species, P. niger, and Peptostreptococcus species.

Urinary tract infections: Treatment of UTIs caused by E. coli, Klebsiella species, P. mirabilis, Morganella morganii, Proteus vulgaris, and Providencia species (including Providencia rettgeri).

Use: Off-Label: Adult

Bite wounds (animal); Mycobacterial (nontuberculous, rapidly growing) infection

Medication Safety Issues
Sound-alike/look-alike issues:

CefOXitin may be confused with ceFAZolin, cefotaxime, cefoTEtan, cefTAZidime, cefTRIAXone, Cytoxan

Mefoxin may be confused with Lanoxin

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

1% to 10%: Gastrointestinal: Diarrhea

<1%: Anaphylaxis, angioedema, bone marrow depression, dyspnea, eosinophilia, exacerbation of myasthenia gravis, exfoliative dermatitis, fever, hemolytic anemia, hypotension, increased blood urea nitrogen, increased serum creatinine, increased serum transaminases, interstitial nephritis, jaundice, leukopenia, nausea, nephrotoxicity (increased; with aminoglycosides), phlebitis, prolonged prothrombin time, pruritus, pseudomembranous colitis, skin rash, thrombocytopenia, thrombophlebitis, toxic epidermal necrolysis, urticaria, vomiting

Contraindications

Hypersensitivity to cefoxitin, any component of the formulation, or other cephalosporins

Warnings/Precautions

Concerns related to adverse effects:

• Hypersensitivity: Use with caution in patients with a history of penicillin allergy, especially IgE-mediated hypersensitivity reactions (eg, anaphylaxis, angioedema, urticaria). If a hypersensitivity reaction occurs, discontinue immediately.

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• GI disease: Use with caution in patients with a history of gastrointestinal disease, particularly colitis.

• Renal impairment: Use with caution in patients with renal impairment; modify dosage in severe impairment.

• Seizure disorders: Use with caution in patients with a history of seizure disorder; high levels, particularly in the presence of renal impairment, may increase risk of seizures.

Special populations:

• Children: In pediatric patients ≥3 months of age, higher doses have been associated with an increased incidence of eosinophilia and elevated AST.

• Elderly: This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Elderly patients are more likely to have decreased renal function; use care in dose selection and monitor renal function.

Other warnings/precautions:

• Discontinuation of therapy: For group A beta-hemolytic streptococcal infections, antimicrobial therapy should be given for at least 10 days to guard against the risk of rheumatic fever or glomerulonephritis.

Metabolism/Transport Effects

None known.

Drug Interactions

Aminoglycosides: Cephalosporins may enhance the nephrotoxic effect of Aminoglycosides. Cephalosporins may decrease the serum concentration of Aminoglycosides. Risk C: Monitor therapy

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

Probenecid: May increase the serum concentration of Cephalosporins. Risk C: Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification

Vitamin K Antagonists (eg, warfarin): Cephalosporins may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy

Pregnancy Considerations

Cefoxitin crosses the placenta and reaches the cord serum and amniotic fluid.

An increased risk of major birth defects or other adverse fetal or maternal outcomes has generally not been observed following use of cephalosporin antibiotics, including cefoxitin, during pregnancy.

Cefoxitin is one of the antibiotics recommended for prophylactic use prior to cesarean delivery (ACOG 199 2018).

Breast-Feeding Considerations

Cefoxitin is present in breast milk.

The estimated dose to a breastfed infant would be <0.1% of the maternal dose. According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother. However, cephalosporins are generally considered acceptable for use in breastfeeding women (Ito 2000). In general, antibiotics that are present in breast milk may cause nondose-related modification of bowel flora. Monitor infants for GI disturbances, such as thrush or diarrhea (WHO 2002).

Dietary Considerations

Some products may contain sodium.

Monitoring Parameters

Monitor renal function periodically when used in combination with other nephrotoxic drugs; prothrombin time. Observe for signs and symptoms of anaphylaxis during first dose. CBC with prolonged use (ATS/ERS/ESCMID/IDSA [Daley 2020]).

Mechanism of Action

Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Pharmacodynamics and Pharmacokinetics

Distribution: Widely to body tissues and fluids including ascitic, pleural, synovial, bile; poorly penetrates into CSF even with inflammation of the meninges (Landesman 1981)

Protein binding: 65% to 79%

Half-life elimination: Neonates and Infants (PNA: 10-53 days): 1.4 hours (Regazzi 1983); Adults: 41-59 minutes; prolonged with renal impairment

Time to peak, serum: IM: Within 20-30 minutes

Excretion: Urine (85% as unchanged drug)

Pricing: US

Solution (reconstituted) (cefOXitin Sodium Injection)

10 g (per each): $60.00 - $112.25

Solution (reconstituted) (cefOXitin Sodium Intravenous)

1 g (per each): $3.60 - $11.94

2 g (per each): $7.20 - $23.94

Solution (reconstituted) (cefOXitin Sodium-Dextrose Intravenous)

1GM 4%(50ML) (per each): $19.58

2GM 2.2%(50ML) (per each): $35.07

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Aboxitin (BD);
  • Acifox (PH);
  • Advoxin (EG);
  • Cefmore (TW);
  • Cefovex (PH);
  • Cefoxitin Sodium (AU);
  • Cefoxivit (PH);
  • Cefxitin (TH);
  • Cenomycin (JP);
  • Daliding (CN);
  • Dintaxin (PH);
  • Foxitane (BD);
  • Foxitin (AE, JO, SA);
  • Irva (BD);
  • Jeitin (KR);
  • Lofatin (TW);
  • Mefoxil (GR);
  • Mefoxin (AE, AU, BB, BE, BF, BG, BJ, BM, BS, BZ, CI, CY, CZ, ET, FI, FR, GB, GH, GM, GN, GY, HN, HU, IE, IL, IQ, IR, IT, JM, JO, KE, KW, LB, LR, LU, LY, MA, ML, MR, MU, MW, NE, NG, NL, NZ, OM, PT, SA, SC, SD, SL, SN, SR, SY, TN, TT, TW, TZ, UG, YE, ZA, ZM, ZW);
  • Mefoxitin (AT, CH, DE, DK, NO, SE);
  • Merxin (JP);
  • Monodin (PH);
  • Monowel (PH);
  • Orfixitin (EG);
  • Pacetin (KR);
  • Panafox (PH);
  • Plucefox (EG);
  • Primafoxin (EG);
  • Sephros (MY);
  • Voxitin (AE, CY, IL, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Zepax (PH);
  • Zepotin (PH);
  • Zoxin (JO)


For country abbreviations used in Lexicomp (show table)

REFERENCES

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  3. American College of Obstetricians and Gynecologists (ACOG), Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin no. 199: Use of prophylactic antibiotics in labor and delivery [published correction appears in Obstet Gynecol. 2019;134(4):883-884]. Obstet Gynecol. 2018;132(3):e103‐e119. doi:10.1097/AOG.0000000000002833 [PubMed 30134425]
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  20. Mefoxin (cefoxitin) [prescribing information]. Rockford, IL: Mylan Institutional LLC; February 2017.
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  22. Roos R, von Hattingberg HM, Belohradsky BH, et al. Pharmacokinetics of cefoxitin in premature and newborn infants studied by continuous serum level monitoring during combination therapy with penicillin and amikacin. Infection. 1980;8(6):301-306.
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