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Oral Cephalosporin Antibiotics: an Overview of Clinical Pharmacology and Dermatologic Applications

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Oral Cephalosporin Antibiotics: an Overview of Clinical Pharmacology and Dermatologic Applications DRUG THERAPY TOPICS Oral Cephalosporin Antibiotics: An Overview of Clinical Pharmacology and Dermatologic Applications James Q. Del Rosso, DO ephalosporins are a diverse group of ␤-lactam The continued popularity and worldwide use of antibiotics with a broad range of antibacterial both parenteral and oral cephalosporins relate pre- C activity and clinical applications. Since dominantly to a proven track record of “broad- the initial discovery of the basic cephalosporin spectrum” antibacterial activity (against several moiety in the 1940s, several cephalosporin com- gram-positive and gram-negative pathogens) and pounds have been developed and approved for excellent safety during 30 years of cumulative clinical use.1,2 At present, 24 cephalosporin clinical experience.2,5 Specific cephalosporins offer compounds—more than half of the available unique bacterial coverage advantages not found ␤-lactam antibiotics—are available in the United with most other cephalosporins. Examples include States.2-5 Although all cephalosporins exhibit some single-dose intramuscular ceftriaxone for treatment structural similarity, modifications of the basic of uncomplicated gonorrhea or chancroid; par- cephalosporin nucleus have led to production of enteral cefoxitin or cefotetan for Bacteroides fragilis several unique cephalosporin compounds. Specific infection; and parenteral cefoperazone, cef- structure-activity relations account for clinically tazidime, or cefepime for Pseudomonas aeruginosa significant differences in pharmacokinetic profiles, infection.2-7 In dermatology, cephalosporin use is spectrum of antibacterial activity (organism “cover- primarily related to skin and soft-tissue infections age”), clinical applications, adverse reaction pro- such as folliculitis, cellulitis, impetigo, and wound files, and modes of administration among many infections including infected ulcers and periopera- cephalosporins.2-7 As stated in a review of tive infection.2-7 Other applications include treat- cephalosporins, “differences among the numerous ing some sexually transmitted bacterial diseases cephalosporin antimicrobial agents are sometimes and early Lyme disease (erythema chronicum subtle; however, an understanding of these differ- migrans stage).2,3,8 ences is essential for optimal use of these agents.”5 Eleven oral cephalosporins are available for clin- ical use in the United States (Table). In the follow- ing sections, I focus on oral cephalosporin use for Accepted for publication December 6, 2002. dermatologic applications and review practical cor- From the Department of Dermatology, University of Nevada relations of tissue pharmacokinetics, pharmaco- School of Medicine, Las Vegas. dynamic activity, clinical indications, and selected Dr. Del Rosso has served as a consultant and/or speaker for 3M Pharmaceuticals; Allergan, Inc; Berlex Laboratories; Bristol- safety issues. Myers Squibb Company; Connetics Corporation; Dermik Laboratories, Inc; Galderma Laboratories, LP; GlaxoSmithKline; Healthpoint, Ltd; Janssen Pharmaceutica Products, LP; Medicis, What is the significance of categorizing The Dermatology Company; Novartis Pharmaceuticals Corporation; cephalosporins by generation? and Ortho Neutrogena. Reprints: James Q. Del Rosso, DO, Las Vegas Skin & Cancer Since the release of cephalexin in 1967, “four gener- Clinics, 4488 S Pecos Rd, Las Vegas, NV 89121 ations of cephalosporin antibiotics have emerged, (e-mail: [email protected]). based loosely on both the timing of development and VOLUME 71, FEBRUARY 2003 153 Drug Therapy Topics release, and their spectrum of antimicrobial activity. [Each] subsequent decade correlates loosely with Oral Cephalosporin Antibiotics the onset of a new generation of cephalosporin Available in the United States* compounds.”9 A common oversimplification is that, with the release of each new generation of cepha- Antibiotic Brand Name(s) losporins, antibacterial activity decreases against gram-positive organisms and increases against gram- First generation negative organisms.4,5 In fact, several important Cephalexin Keflex®, Keftab® exceptions render this “rule” potentially misleading.9 Cefadroxil Duricef®, Ultracef® Although most cephalosporins are clinically active Cephradine Velosef® against a variety of both gram-positive and gram- negative bacteria, the relative degree of inhibitory Second generation activity of individual cephalosporin compounds is Cefaclor Ceclor® irrespective of their categorized generation, both Cefprozil Cefzil® in vitro and in vivo.2,9 In one study involving several Cefuroxime axetil Ceftin® oral cephalosporin and macrolide antibiotics, inves- Loracarbef† Lorabid® tigators confirmed significant variability in inhibitory activity against community-acquired Third generation pathogens and concluded that the antistaphylo- Cefdinir Omnicef® coccal activity of oral cephalosporins “can be deter- Cefixime Suprax® mined only by testing the individual agents.”10 Ceftibuten Cedax® Differences in bacterial sensitivity profiles among Cefpodoxime proxetil Vantin® cephalosporins may correlate at least partially with *All these antibiotics are available in both solid and liquid/ the susceptibility patterns of individual cephalo- suspension formulations, except cephradine (solid only). sporins to specific types of ␤-lactamases produced by †Structurally a carbacephem derivative. different bacterial organisms.11 How do cephalosporins produce and sustain their antibacterial effect? efficacy and is less likely to result in the emergence Pharmacologically, cephalosporins bind to peptidase of resistant bacterial strains.15 Time-dependent enzyme target sites (ie, penicillin-binding proteins) antibacterial activity demands close attention to in the outer cytoplasmic membrane of bacteria. pharmacokinetic differences among individual This binding impairs integration of bacterial pepti- cephalosporins. Use of proper dosages and dosing doglycan into a lattice forming the structural sup- intervals and patient adherence are vital to the port of the bacterial cell wall.2,5,7 Structural success of therapy.9 modifications of the basic cephalosporin nucleus— usually alterations in specific side chains—have produced differences in the spectrum of organism What are the most common uses of coverage and in pharmacokinetic profiles, and these oral cephalosporins in dermatology? differences significantly affect selection of anti- The majority of cephalosporin use in dermatology biotics in clinical practice. is for uncomplicated skin and soft-tissue infections From a pharmacodynamic perspective, cephalo- such as folliculitis, furunculosis, superficial sporin antibiotics exhibit time-dependent antibac- abscesses, impetigo, cellulitis, infected eczematous terial activity.12-16 An antibacterial effect is exerted dermatoses, infected skin ulcers, ecthyma, and when the concentration of cephalosporin at the postsurgical wound infections.2,4,5 Most cutaneous infection site exceeds the minimum inhibitory con- infections, depending on clinical type and presen- centration (MIC). Raising the concentration more tation, are caused by Staphylococcus aureus or than 2- to 4-fold above the MIC provides no addi- Staphylococcus pyogenes. Responsive gram-negative tional antibacterial benefit.15,16 Maintaining the pathogens may be causative in some cases of concentration above the MIC for 50% to 70% of infected lower extremity ulcers or cellulitis and the dosing interval (period between doses) is diabetic foot infections.17-19 Because S aureus is the needed to sustain antibacterial activity.15,16 Further- pathogen most commonly identified in studies more, maintaining the concentration above the of superficial diabetic foot infections, empiric MIC during the entire dosing interval maximizes antibiotic therapy should allow for appropriate 154 CUTIS® Drug Therapy Topics coverage of this pathogen, pending results from influenzae, erythromycin-resistant S aureus, and culture and sensitivity testing.17,19 Antibiotics from several cephalexin-resistant pathogens.2,20,23,27-32 several medication classes (eg, semisynthetic According to in vitro evaluations, including penicillins, cephalosporins, macrolides, quino- 2 comparative studies inclusive of 1069 clinical lones) may be selected for treatment of skin and isolates, the activity of cefdinir against several gram- soft-tissue infections based on specific clinical fac- positive and gram-negative pathogens, including tors (eg, medication allergy history, potential med- S aureus and S pyogenes, is superior to that of several ication interactions), clinical presentation, and the other cephalosporins, including cephalexin and causative pathogen. For cephalosporin treatment cefadroxil.2,10,20,23,27-32 In a study evaluating the clin- of milder, superficial cutaneous infections, an oral ical efficacy of using cefdinir versus cephalexin to agent with established clinical efficacy against treat uncomplicated cutaneous infections in adult commonly encountered gram-positive and gram- patients, the eradication rate of S aureus was 92% negative pathogens (eg, cefdinir, cefprozil) is a in the group treated with cefdinir (nϭ143) versus rational choice. Organisms resistant to available 88% in the group treated with cephalexin oral cephalosporins are methicillin-resistant (nϭ165).27 In the same study, cefdinir eradicated S aureus; enterococci; Chlamydia species; and 88% of cephalexin-resistant gram-positive and Pseudomonas species, including Pseudomonas gram-negative organisms. In a study of 231 pediatric aeruginosa.2,4,5,17,18,20
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