Chronic obstructive pulmonary disease, acute exacerbation: Note: Avoid use in patients with risk factors for Pseudomonas infection or poor outcomes (eg, ≥65 years of age with major comorbidities, FEV1 <50% predicted, frequent exacerbations) (Sethi 2022).
Oral: 200 mg twice daily for 5 to 7 days (GOLD 2022; Phillips 1993).
Odontogenic soft tissue infection, pyogenic (initial therapy for mild infection or step-down therapy after parenteral treatment) (alternative agent) (off-label use):
Note: For patients unable to take penicillin (Chow 2022).
Oral: 400 mg twice daily in combination with metronidazole; continue until clinical resolution, typically for 7 to 14 days. Use in addition to appropriate surgical management (eg, drainage and/or extraction) (Chow 2022).
Otitis media, acute (alternative agent for patients with penicillin allergy that does not preclude cephalosporin use): Oral: 200 mg twice daily. Duration is 5 to 7 days for mild to moderate infection and 10 days for severe infection (Limb 2021).
Pneumonia, community-acquired, outpatient empiric therapy (alternative agent): Oral: 200 mg twice daily as part of an appropriate combination regimen. Duration of therapy is for a minimum of 5 days; patients should be clinically stable with normal vital signs before therapy is discontinued (ATS/IDSA [Metlay 2019]).
Rhinosinusitis, acute bacterial (alternative agent for patients with penicillin allergy who are able to tolerate cephalosporins):
Note: In uncomplicated acute bacterial rhinosinusitis, initial observation and symptom management without antibiotic therapy is appropriate in most patients. Reserve antibiotic therapy for poor follow-up or lack of improvement over the observation period (AAO-HNSF [Rosenfeld 2015]; ACP/CDC [Harris 2016]).
Oral: 200 mg twice daily (von Sydow 1995) with clindamycin for 5 to 7 days (IDSA [Chow 2012]); some experts use as monotherapy when the risk of drug-resistant S. pneumoniae is low (eg, <65 years of age, low endemic resistance, few comorbidities, no recent hospitalization or antibiotic use) (Hadley 2007; Patel 2021).
Skin and soft tissue infection (alternative agent): Oral: 400 mg every 12 hours (Stevens 1993) for 7 to 14 days (IDSA [Stevens 2014]; Stevens 1993).
Streptococcal pharyngitis, group A (alternative agent for mild, nonanaphylactic penicillin allergy):
Note: Cephalosporin selection depends on the type of hypersensitivity reaction to penicillin. To avoid the development of resistance, narrower spectrum cephalosporins (eg, cephalexin or cefadroxil) are preferred when possible (IDSA [Shulman 2012]; Pichichero 2021).
Oral: 100 mg twice daily for 5 to 10 days (Pichichero 2007; Pichichero 2021).
Urinary tract infection (alternative agent): Note: Use only when first-line agents cannot be used; limited evidence suggests inferior efficacy of oral beta-lactams (Gupta 2021a; Gupta 2021b; IDSA/ESCMID [Gupta 2011]).
Cystitis, acute uncomplicated or acute simple cystitis (infection limited to the bladder without signs/symptoms of upper tract, prostate, or systemic infection): Oral: 100 mg twice daily for 5 to 7 days (Gupta 2021a; Hooton 2012; Gupta 2021b; IDSA/ESCMID [Gupta 2011]; Kavatha 2003).
Urinary tract infection, complicated (including pyelonephritis) (off-label use): Oral: 200 mg twice daily for 10 to 14 days (Hooton 2021a; IDSA/ESCMID [Gupta 2011]; Johnson 2018). Note: Oral beta-lactam therapy should generally follow appropriate parenteral therapy (Hooton 2021a; IDSA/ESCMID [Gupta 2011]).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function:
CrCl ≥30 mL/minute: No dosage adjustment necessary.
CrCl <30 mL/minute: Administer usual recommended dose every 24 hours.
Hemodialysis, intermittent (thrice weekly): Dialyzable (~50%) (Borin 1992; Höffler 1990): 100 to 200 mg every 24 hours; when scheduled dose falls on a dialysis day, administer after hemodialysis (Höffler 1990; expert opinion).
Peritoneal dialysis: Negligible clearance (Johnson 1993): 100 to 200 mg every 24 hours (Johnson 1993; expert opinion).
CRRT:
Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour), unless otherwise noted. Close monitoring of response and adverse reactions due to drug accumulation is important.
Dose as for CrCl ≥30 mL/minute, although use of an IV antimicrobial agent is generally preferred (expert opinion).
PIRRT (eg, sustained, low-efficiency diafiltration):
Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection) and consideration of initial loading doses. Close monitoring of response and adverse reactions due to drug accumulation is important.
Dose as for CrCl ≥30 mL/minute, although use of an IV antimicrobial agent is generally preferred. Administer one of the twice-daily doses after PIRRT on PIRRT treatment days when possible (expert opinion).
Cirrhosis (with or without ascites): No dosage adjustment necessary.
(For additional information see "Cefpodoxime: Pediatric drug information")
General dosing: Infants, Children, and Adolescents: Oral: 5 mg/kg/dose every 12 hours; usual maximum dose: 200 mg/dose (Bradley 2021; Red Book [AAP 2021]).
Bronchitis, bacterial exacerbation of chronic: Children ≥12 years and Adolescents: Oral: 200 mg every 12 hours for 10 days.
Irinotecan-associated diarrhea, prophylaxis: Limited data available: Children ≥2 years and Adolescents: Oral: 5 mg/kg/dose every 12 hours; maximum dose: 200 mg/dose; begin 1 to 2 days before each treatment cycle and continue until 2 days following the last irinotecan dose (McGregor 2012; McNall-Knapp 2010).
Otitis media, acute (AOM) (alternative agent for nonanaphylactic penicillin allergy):
Infants ≥2 months and Children: Oral: 5 mg/kg/dose every 12 hours; maximum dose: 200 mg/dose (AAP [Lieberthal 2013]; manufacturer's labeling). For patients with severe or recurrent AOM, tympanic membrane perforation, or who are <2 years of age, treat for 10 days; for patients ≥2 years of age with mild to moderate, nonrecurrent disease without tympanic membrane perforation, shorter durations of 5 to 7 days may be sufficient (AAP [Lieberthal 2013]; Hoberman 2016; Kozyrskyj 2010; Marchisio 2019; NICE 2018).
Pneumonia, community-acquired (alternative agent): Note: Cefpodoxime is not active against most strains of penicillin-resistant Streptococcus pneumoniae, and activity against penicillin-intermediate strains is variable (Fenoll 2008a; Fenoll 2008b; manufacturer's labeling).
Infants >3 months and Children <12 years: Limited data available: Oral: 5 mg/kg/dose every 12 hours; maximum dose: 200 mg/dose (Klein 1995; Sengupta 2004). Note: The usual total duration of therapy for uncomplicated pneumonia is 5 to 10 days (IDSA [Bradley 2011]; Pernica 2021; Same 2021).
Children ≥12 years and Adolescents: Oral: 200 mg every 12 hours (van Zyl 2002; manufacturer's labeling). Note: Although the manufacturer recommends treatment duration of 14 days, the usual total duration of therapy for uncomplicated pneumonia is 5 to 10 days (IDSA [Bradley 2011]; Pernica 2021; Same 2021).
Rhinosinusitis, acute bacterial (alternative agent for patients with penicillin allergy): Note: The role of cefpodoxime in the management of acute bacterial sinusitis is limited; other options may be preferred (IDSA [Chow 2012]).
Infants ≥2 months and Children <12 years: Oral: 5 mg/kg/dose every 12 hours for 10 days; maximum dose: 200 mg/dose (IDSA [Chow 2012]; manufacturer's labeling).
Children ≥12 years and Adolescents: Oral: 200 mg every 12 hours for 10 days.
Skin and soft tissue infection: Note: Cefpodoxime is not currently recommended in IDSA guidelines for treatment of skin and soft tissue infection; alternate agents are preferred (eg, first-generation cephalosporins). Additionally, durations shorter than 7 days (eg, 5 days) may be appropriate for uncomplicated infections (IDSA [Stevens 2014]).
Children ≥12 years and Adolescents: Oral: 400 mg every 12 hours for 7 to 14 days (manufacturer's labeling).
Streptococcus, group A; pharyngitis/tonsillitis (alternative agent for nonanaphylactic penicillin allergy): Note: Narrow-spectrum cephalosporins (eg, cephalexin) are preferred over broad-spectrum cephalosporins such as cefpodoxime (IDSA [Shulman 2012]).
Infants ≥2 months, Children, and Adolescents: Oral: 5 mg/kg/dose every 12 hours; maximum dose: 100 mg/dose (Dajani 1993; Pichichero 1994; manufacturer's labeling). Preferred treatment duration is 10 days (IDSA [Shulman 2012]), although 5 days may be adequate (Pichichero 1994; manufacturer's labeling).
Urinary tract infection: Note: Duration of therapy should be individualized based on patient age, severity/extent of infection, and clinical response; typical duration is 7 to 14 days, though it may be as short as 5 days (eg, for uncomplicated cystitis in patients ≥2 years of age) (Afolabi 2020; Balighian 2018; Stein 2015).
Infants and Children <12 years: Limited data available: Oral: 4 to 5 mg/kg/dose every 12 hours; maximum dose: 200 mg/dose (Stein 2015).
Children ≥12 years and Adolescents: Oral: 100 to 200 mg every 12 hours (Stein 2015; manufacturer's labeling).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Altered kidney function: Infants ≥2 months, Children, and Adolescents: Oral:
CrCl ≥30 mL/minute/1.73 m2: No dosage adjustment necessary.
CrCl <30 mL/minute/1.73 m2: Administer usual recommended dose every 24 hours.
Hemodialysis: Dialyzable based on adult data (~50%) (Borin 1992; Höffler 1990).
Infants, Children, and Adolescents: Oral: The manufacturer recommends administration of dose 3 times weekly after hemodialysis.
Cirrhosis (with or without ascites): Infants ≥2 months, Children, and Adolescents: No dosage adjustment necessary.
Refer to adult dosing.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Suspension Reconstituted, Oral:
Generic: 50 mg/5 mL (50 mL, 100 mL); 100 mg/5 mL (50 mL, 100 mL)
Tablet, Oral:
Generic: 100 mg, 200 mg
Yes
Oral: Administer around-the-clock to promote less variation in peak and trough serum levels. Administer tablets with food; suspension may be administered without regard to food. Shake suspension well before using.
Oral:
Suspension: May administer with or without food; shake suspension well before use.
Tablet: Administer with food.
Chronic obstructive pulmonary disease, acute exacerbation: Treatment of acute bacterial exacerbation of chronic obstructive pulmonary disease caused by Streptococcus pneumoniae, Haemophilus influenzae (non-beta-lactamase-producing strains only), or Moraxella catarrhalis.
Cystitis, acute uncomplicated: Treatment of acute uncomplicated cystitis caused by Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, or Staphylococcus saprophyticus.
Otitis media, acute: Treatment of acute otitis media caused by S. pneumoniae (excluding penicillin-resistant strains), Streptococcus pyogenes, H. influenzae (including beta-lactamase-producing strains), or M. catarrhalis (including beta-lactamase-producing strains).
Pneumonia, community-acquired: Treatment of community-acquired pneumonia caused by S. pneumoniae or H. influenzae (including beta-lactamase-producing strains).
Rhinosinusitis, acute bacterial: Treatment of acute bacterial rhinosinusitis caused by H. influenzae (including beta-lactamase-producing strains), S. pneumoniae, and M. catarrhalis. Note: According to the Infectious Diseases Society of America guidelines for acute bacterial rhinosinusitis, cefpodoxime is recommended in combination with clindamycin due to concern for pneumococcal resistance (IDSA [Chow 2012]).
Skin and soft tissue infection: Treatment of uncomplicated skin and soft tissue infection caused by Staphylococcus aureus (including penicillinase-producing strains) or S. pyogenes.
Streptococcal pharyngitis, group A : Treatment of pharyngitis or tonsillitis caused by S. pyogenes.
Odontogenic soft tissue infection, pyogenic; Urinary tract infection, complicated (including pyelonephritis)
Vantin may be confused with Ventolin
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
>10%:
Dermatologic: Diaper rash (12%)
Gastrointestinal: Diarrhea (infants and toddlers 15%)
1% to 10%:
Central nervous system: Headache (1%)
Dermatologic: Skin rash (1%)
Gastrointestinal: Diarrhea (7%), nausea (4%), abdominal pain (2%), vomiting (1% to 2%)
Genitourinary: Vaginal infection (3%)
<1%: Anaphylaxis, anxiety, chest pain, cough, decreased appetite, dizziness, dysgeusia, epistaxis, eye pruritus, fatigue, fever, flatulence, flushing, fungal skin infection, hypotension, insomnia, malaise, nightmares, pruritus, pseudomembranous colitis, purpuric nephritis, tinnitus, vulvovaginal candidiasis, weakness, xerostomia
Hypersensitivity to cefpodoxime, any component of the formulation, or other cephalosporins.
Documentation of allergenic cross-reactivity for beta-lactams (eg, penicillins and cephalosporins) is limited. However, because of similarities in chemical structure and/or pharmacologic actions, the possibility of cross-sensitivity cannot be ruled out with certainty.
Concerns related to adverse effects:
• Beta-lactam allergy: Use with caution in patients with a history of beta-lactam allergy, especially IgE-mediated reactions (eg, anaphylaxis, angioedema, urticaria).
• 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:
• Renal impairment: Use with caution in patients with renal impairment; modify dosage in severe impairment.
Dosage form specific issues:
• Benzyl alcohol and derivatives: Some dosage forms may contain sodium benzoate/benzoic acid; benzoic acid (benzoate) is a metabolite of benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension, and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol derivative with caution in neonates. See manufacturer’s labeling.
Substrate of OAT1/3
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.
Aminoglycosides: Cephalosporins may enhance the nephrotoxic effect of Aminoglycosides. Cephalosporins may decrease the serum concentration of Aminoglycosides. Risk C: Monitor therapy
Antacids: May decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy
Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification
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
Furosemide: May enhance the nephrotoxic effect of Cephalosporins. Risk C: Monitor therapy
Histamine H2 Receptor Antagonists: May decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy
Immune Checkpoint Inhibitors: Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors. Risk C: Monitor therapy
Inhibitors of the Proton Pump (PPIs and PCABs): May decrease the serum concentration of Cefpodoxime. Risk C: Monitor therapy
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
Food increases extent of absorption and peak concentration of tablets. Management: Take tablets with food.
Adverse events were not observed in animal reproduction studies.
Cefpodoxime is present in breast milk.
Due to the potential for serious adverse reactions in the breastfed infant, the manufacturer recommends a decision be made to discontinue breastfeeding or to discontinue the drug, taking into account the importance of treatment to the mother.
In general, antibiotics that are present in breast milk may cause non-dose-related modification of bowel flora (WHO 2002).
Take tablets with food.
Monitor renal function. Observe for signs and symptoms of anaphylaxis during first dose.
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.
Absorption: Rapid and well absorbed (50%); tablet AUC increased 21% to 33% with food.
Distribution: Good tissue penetration, including lung and tonsils; penetrates into pleural fluid.
Vd:
Children <5 years: 1.52 ± 0.56 L/kg (Kearns 1994).
Children ≥5 years and Adolescents: 0.89 ± 0.3 L/kg (Kearns 1994).
Protein binding: Serum: 22% to 33%; Plasma: 21% to 29%.
Metabolism: De-esterified in GI tract to active metabolite, cefpodoxime.
Bioavailability: Oral: 50%.
Half-life elimination:
Children: 1.7 to 3.3 hours (Fulton 2001).
Adults: 2.09 to 2.84 hours; prolonged with renal impairment (~10 hours for CrCl <30 mL/minute).
Time to peak: Tablets: Within 2 to 3 hours; Oral suspension: Within 2 to 3 hours; slower in presence of food, 48% increase in Tmax.
Excretion: Urine (~29% to 33% as unchanged drug in 12 hours).
Altered kidney function: Elimination is reduced in those with CrCl <50 mL/minute.
Pediatric: Although only 29% to 33% of the drug is excreted unchanged in the urine at 12 hours, in children 6 to 10 years, a single dose of 10 mg/kg results in urine concentrations at 4 hours ranging from 220 to 340 mg/L and at 8 hours ranging from 130 to 180 mg/L (Casellas 1993).
Older adult: The half-life is increased to ~4.2 hours.
Anti-infective considerations:
Parameters associated with efficacy:
Time-dependent; associated with time free drug concentration (fT) > minimum inhibitory concentration (MIC):
Enterobacterales: Goal: 30% to 40% fT > MIC (bacteriostatic), 60% to 70% fT > MIC (bactericidal) (Craig 1998; Turnidge 1998).
Streptococcus spp. and H. influenzae: Goal: >40% fT > MIC (Craig 1998; Turnidge 1998).
Expected drug concentration in normal renal function:
Infants >8 months of age and children ≤12 years of age, Cmax (peak):
5 mg/kg, oral suspension, single dose: 2.1 mg/L.
Adults, Cmax (peak):
100 mg, oral suspension, single dose: 1.5 mg/L (range: 1.1 to 2.1 mg/L).
100 mg, oral tablet, steady state: 1.19 ± 0.41 mg/L (Borin 1991).
200 mg, oral tablet, steady state: 2.3 ± 0.71 mg/L (Borin 1991).
400 mg, oral tablet, steady state: 3.62 ± 0.62 mg/L (Borin 1991).
Postantibiotic effect: Generally <1 hour; varies based on organism (Craig 1991; Craig 1998).
Suspension (reconstituted) (Cefpodoxime Proxetil Oral)
50 mg/5 mL (per mL): $0.86 - $0.91
100 mg/5 mL (per mL): $1.72
Tablets (Cefpodoxime Proxetil Oral)
100 mg (per each): $6.74
200 mg (per each): $8.43 - $8.46
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