NOVACEF Tablets (Cefuroxime axetil)

Table of Content

Cefuroxime axetil is a second-generation cephalosporin antibiotic. It is a broad-spectrum antibacterial agent with a favorable pharmacokinetic profile that allows convenient twice-daily administration. The drug is an effective and well-tolerated treatment in patients with various infections, including otitis media, pharyngitis, sinusitis, community acquired pneumonia and acute exacerbations of chronic bronchitis. Cefuroxime has also been proved effective as a component of intravenous/oral sequential therapy in the treatment of CAP, although there are currently no dosage recommendations available for this regimen in some countries.

In view of its broad coverage, cefuroxime may be considered as an empirical therapy for a range of community-acquired infections, including those in which beta-lactamase-producing strains of common respiratory pathogens are identified as the causative organisms. In an era of rapidly emerging bacterial resistance, empirical treatment with agents such as cefuroxime may ensure the appropriate use of newer antibacterial agents, thereby potentially preventing the emergence of bacterial resistance to these newer drugs.

Cefuroxime is indicated for the treatment of patients with mild-to-moderate infections caused by susceptible strains in the conditions such as Upper & Lower Respiratory Tract Infections, Skin & Skin-Structure Infections, Urinary Tract Infections, Bone & joint infections, Gonorrhea, Septicemia, Meningitis, Early Lyme disease & Prophylaxis.

NOVACEF tablets (Cefuroxime axetil) is available as 250/500 mg oral tablets and the recommended dose is 250– 500 mg b.i.d. for 5–10 days, depending upon the severity of infection. NOVACEF injection (Cefuroxime axetil) is available as 750 mg & 1.5 gm injection and the recommended adult dosage is every 8 hours, for 5 to 10 days. For detailed description on administration and reconstitution please refer the full prescribing information.

 

Composition

NOVACEF 250 Tablets

Each film-coated tablet contains:

Cefuroxime Axetil, IP, equivalent to Cefuroxime …. 250 mg

NOVACEF 500 Tablets

Each film-coated tablet contains:

Cefuroxime Axetil, IP, equivalent to Cefuroxime …. 500 mg

Dosage Form

Oral tablet

Pharmacology

Pharmacodynamics

Cefuroxime axetil is a semisynthetic, broad-spectrum cephalosporin antibiotic for oral administration. The in vivo bactericidal activity of cefuroxime axetil is due to its binding to essential target proteins and the resultant inhibition of cell-wall synthesis. Cefuroxime is bactericidal against a wide range of common pathogens, including many beta-lactamase–producing strains. It is stable to many bacterial beta-lactamases, especially plasmid-mediated enzymes that are commonly found in Enterobacteriaceae.

Cefuroxime has been demonstrated to be active against most strains of the following microorganisms both in vitro and in clinical infections as described in the INDICATIONS section.

Aerobic Gram-positive Microorganisms

Staphylococcus aureus (including beta-lactamase-producing strains)

Streptococcus pneumoniae

Streptococcus pyogenes

Aerobic Gram-negative Microorganisms

Escherichia coli

Haemophilus influenzae (including beta-lactamase-producing strains)

Haemophilus parainfluenzae

Klebsiella pneumoniae

Moraxella catarrhalis (including beta-lactamase-producing strains)

Neisseria gonorrhoeae (including beta-lactamase-producing strains)

Spirochetes

Borrelia burgdorferi

Cefuroxime has been shown to be active in vitro against most strains of the following microorganisms; however, the clinical significance of these findings is unknown.

It exhibits in vitro minimum inhibitory concentrations (MICs) of 4.0 mcg/mL or less (systemic susceptible breakpoint) against most (>90%) strains of the following microorganisms; however, the safety and effectiveness of cefuroxime in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled trials.

Aerobic Gram-positive Microorganisms

Staphylococcus epidermidis

Staphylococcus saprophyticus

Streptococcus agalactiae

NOTE: Listeria monocytogenes and certain strains of enterococci, e.g., Enterococcus faecalis (formerly Streptococcus faecalis) and methicillin-resistant Staphylococci are resistant to cefuroxime.

Aerobic Gram-negative Microorganisms

Morganella morganii

Proteus inconstans

Proteus mirabilis

Providencia rettgeri

NOTE: Pseudomonas spp., Campylobacter spp., Acinetobacter calcoaceticus, Legionella spp., and most strains of Serratia spp. and Proteus vulgaris are resistant to most first- and second-generation cephalosporin. Some strains of Morganella morganii, Enterobacter cloacae, and Citrobacter spp. have been shown by in vitro tests to be resistant to cefuroxime and other cephalosporins.

Anaerobic Microorganisms

Peptococcus niger

NOTE: Most strains of Clostridium difficile and Bacteroides fragilis are resistant to cefuroxime.

Pharmacokinetics

Absorption and Metabolism

After oral administration, cefuroxime axetil is absorbed from the gastrointestinal tract and rapidly hydrolyzed by nonspecific esterases in the intestinal mucosa and blood to cefuroxime. Cefuroxime is subsequently distributed throughout the extracellular fluids. The axetil moiety is metabolized to acetaldehyde and acetic acid.

Approximately 50% of serum cefuroxime is bound to protein. Serum pharmacokinetic parameters for cefuroxime tablets are shown in Table 1.

Table 1: Postprandial Pharmacokinetics of Cefuroxime Administered as Tablets to Adults*

Dose† (Cefuroxime Equivalent)

Peak Plasma Concentration (mcg/mL)

Time of Peak Plasma Concentration (hr)

Mean Elimination Half-Life (hr)

 

AUC (mcg-hr mL)

125 mg

250 mg

500 mg

1,000 mg

2.1

4.1

7.0

13.6

2.2

2.5

3.0

2.5

1.2

1.2

1.2

1.3

6.7

12.9

27.4

50.0

*Mean values of 12 healthy adult volunteers.

†Drug administered immediately after a meal.

Food Effect on Pharmacokinetics

Absorption of the tablet is greater when taken after food (absolute bioavailability of Cefuroxime tablets increases from 37% to 52%). Despite this difference in absorption, the clinical and bacteriologic responses of patients were independent of food intake at the time of tablet administration in two studies where this was assessed.

Renal Excretion

Cefuroxime is excreted unchanged in the urine; in adults, approximately 50% of the administered dose is recovered in the urine within 12 hours. The pharmacokinetics of cefuroxime in the urine of pediatric patients has not been studied at this time. Until further data are available, the renal pharmacokinetic properties of cefuroxime axetil established in adults should not be extrapolated to pediatric patients.

Because cefuroxime is renally excreted, the serum half-life is prolonged in patients with reduced renal function. In a study of 20 elderly patients (mean age = 83.9 years) having a mean creatinine clearance of 34.9 mL/min, the mean serum elimination half-life was 3.5 hours. Despite the lower elimination of cefuroxime in geriatric patients, dosage adjustment based on age is not necessary.

Indications

Cefuroxime tablets are indicated for the treatment of patients with mild-to-moderate infections caused by susceptible strains of the designated microorganisms in the conditions listed below:

—Pharyngitis/Tonsillitis caused by Streptococcus pyogenes.

NOTE: The usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever, is penicillin given by the intramuscular route. Cefuroxime tablets are generally effective in the eradication of streptococci from the nasopharynx; however, substantial data establishing the efficacy of cefuroxime in the subsequent prevention of rheumatic fever are not available. Please also note that in all clinical trials, all isolates had to be sensitive to both penicillin and cefuroxime. There are no data from adequate and well-controlled trials to demonstrate the effectiveness of cefuroxime in the treatment of penicillin-resistant strains of Streptococcus pyogenes.

—Acute Bacterial Otitis Media caused by Streptococcus pneumoniae, Haemophilus Influenzae (including beta-lactamase-producing strains), Moraxella catarrhalis (including beta-lactamase-producing strains), or Streptococcus pyogenes.

—Acute Bacterial Maxillary Sinusitis caused by Streptococcus pneumoniae or Haemophilus influenzae (non-beta-lactamase-producing strains only).

NOTE: In view of the insufficient numbers of isolates of beta-lactamase-producing strains of Haemophilus influenzae and Moraxella catarrhalis that were obtained from clinical trials with cefuroxime tablets for patients with acute bacterial maxillary sinusitis, it was not possible to adequately evaluate the effectiveness of cefuroxime tablets for sinus infections known, suspected, or considered potentially to be caused by beta-lactamase-producing Haemophilus influenzae or Moraxella catarrhalis.

—Acute Bacterial Exacerbations of Chronic Bronchitis and Secondary Bacterial

Infections of Acute Bronchitis caused by Streptococcus pneumoniae, Haemophilus influenzae (beta-lactamase-negative strains), or Haemophilus parainfluenzae (beta-lactamase-negative strains). (See DOSAGE AND ADMINISTRATION section.)

—Uncomplicated Skin and Skin-Structure Infections caused by Staphylococcus aureus (including beta-lactamase-producing strains) or Streptococcus pyogenes.

—Uncomplicated Urinary Tract Infections caused by Escherichia coli or Klebsiella pneumoniae.

—Uncomplicated Gonorrhea, urethral and endocervical, caused by penicillinase-producing and non-penicillinase-producing strains of Neisseria gonorrhoeae and uncomplicated gonorrhea, rectal, in females, caused by non-penicillinase-producing strains of Neisseria gonorrhoeae.

—Early Lyme disease (erythema migrans) caused by Borrelia burgdorferi.

Dosage and Administration

Table 2: Cefuroxime tablets may be administered without regard to meals.

Population/Infection

Dosage

Duration (days)

Adolescents and Adults (13 years and older)

Pharyngitis/tonsillitis

250 mg b.i.d.

10

Acute bacterial maxillary sinusitis

250 mg b.i.d.

10

Acute bacterial exacerbations of chronic bronchitis

250 or 500 mg b.i.d.

 

10*

 

Secondary bacterial infections of acute bronchitis

250 or 500 mg b.i.d.

 

5–10

 

Uncomplicated skin and skin structure infections

250 or 500 mg b.i.d.

 

10

 

Uncomplicated urinary tract infections

250 mg b.i.d.

 

7–10

Uncomplicated gonorrhea

1,000 mg once

Single dose

 

Early Lyme disease

500 mg b.i.d.

20

Pediatric Patients (who can swallow tablets whole)

Acute otitis media

 

250 mg b.i.d.

 

10

 

Acute bacterial maxillary sinusitis

250 mg b.i.d.

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*The safety and effectiveness of cefuroxime administered for less than 10 days in patients with acute exacerbations of chronic bronchitis have not been established.

Patients with Renal Failure

The safety and efficacy of cefuroxime axetil in patients with renal failure have not been established.

Cefuroxime is primarily excreted by the kidneys. In patients with markedly impaired renal function it is recommended that the dosage of cefuroxime should be reduced to compensate for its slower excretion. Cefuroxime is effectively removed by dialysis.

Table 3: Recommended Doses for Cefuroxime in Renal Impairment

Creatinine Clearance

T1/2 (hrs)

Recommended Dosage

≥30 mL/min/1.73 m2

1.4–2.4

No dose adjustment necessary (standard dose of 125–500 mg given twice daily)

10–29 mL/min/1.73 m2

4.6

Standard individual dose given every 24 hours

<10 mL/min/1.73 m2

16.8

Standard individual dose given every 48 hours

Patients on hemodialysis

2–4

A further standard individual dose should be given at the end of each dialysis

Contraindications

Cefuroxime products are contraindicated in patients with a known allergy to the cephalosporin group of antibiotics.

Warnings and Precautions

Before therapy with cefuroxime products is instituted, careful inquiry should be made to determine whether the patient has had previous hypersensitivity reactions to cefuroxime products, other cephalosporin, penicillin, or other drugs. If this product is to be given to penicillin-sensitive patients, caution should be exercised because cross-hypersensitivity among beta-lactam antibiotics has been clearly documented and may occur in up to 10% of patients with a history of penicillin allergy. If a clinically significant allergic reaction to cefuroxime products occurs, discontinue the drug and institute appropriate therapy. Serious acute hypersensitivity reactions may require treatment with epinephrine and other emergency measures, including oxygen, intravenous fluids, intravenous antihistamines, corticosteroids, pressor amines and airway management, as clinically indicated.

Clostridium difficile-associated diarrhea (CDAD) has been reported with the use of nearly all antibacterial agents, including cefuroxime, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile.

C. difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require a colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.

General

As with other broad-spectrum antibiotics, prolonged administration of cefuroxime axetil may result in the overgrowth of non-susceptible microorganisms. If super-infection occurs during therapy, appropriate measures should be taken.

Cephalosporins, including cefuroxime axetil, should be given with caution to patients receiving concurrent treatment with potent diuretics because these diuretics are suspected of adversely affecting renal function.

Cefuroxime axetil, as with other broad-spectrum antibiotics, should be prescribed with caution in individuals with a history of colitis. The safety and effectiveness of cefuroxime axetil hasw not been established in patients with gastrointestinal malabsorption. Patients with gastrointestinal malabsorption were excluded from participating in the clinical trials of cefuroxime axetil.

Cephalosporins may be associated with a fall in prothrombin activity. Those at risk include patients with renal or hepatic impairment or poor nutritional state, as well as patients receiving a protracted course of antimicrobial therapy, and patients previously stabilized on anticoagulant therapy. Prothrombin time should be monitored in patients at risk and exogenous vitamin K administered as indicated.

Prescribing cefuroxime in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.

Diarrhea is a common problem caused by antibiotics, which usually ends when the antibiotic is discontinued. Sometimes, after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as 2 or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.

Drug Interactions

Concomitant administration of probenecid with cefuroxime axetil tablets increases the area under the serum concentration versus time curve by 50%. The peak serum cefuroxime concentration after a 1.5 g single dose is greater when taken with 1 g of probenecid (mean = 14.8 mcg/mL) than without probenecid (mean = 12.2 mcg/mL).

Drugs that reduce gastric acidity may result in a lower bioavailability of cefuroxime compared with that of the fasting state and tend to cancel the effect of postprandial absorption.

In common with other antibiotics, cefuroxime axetil may affect the gut flora, leading to lower estrogen reabsorption and reduced efficacy of combined oral estrogen/progesterone contraceptives.

Drug/Laboratory Test Interactions

A false-positive reaction for glucose in the urine may occur with copper reduction tests (Benedict's or Fehling's solution or with CLINITEST® tablets), but not with enzyme-based tests for glycosuria (e.g., CLINISTIX®). As a false-negative result may occur in the ferricyanide test, it is recommended that either the glucose oxidase or hexokinase method be used to determine blood/plasma glucose levels in patients receiving cefuroxime axetil. The presence of cefuroxime does not interfere with the assay of serum and urine creatinine by the alkaline picrate method.

Renal Impairment

The safety and efficacy of cefuroxime axetil in patients with renal failure has not been established. Since cefuroxime is renally eliminated, its half-life will be prolonged in patients with renal failure (refer to DOSAGE AND ADMINISTRATION).

Hepatic Impairment

There are no data available for patients with hepatic impairment. Since cefuroxime is primarily eliminated by the kidneys, the presence of hepatic dysfunction is expected to have no effect on the pharmacokinetics of cefuroxime.

Pregnancy 

Teratogenic Effects

Pregnancy Category B: Reproduction studies have been performed in mice at doses up to 3,200 mg/kg/day (14 times the recommended maximum human dose based on mg/m2) and in rats at doses up to 1,000 mg/kg/day (9 times the recommended maximum human dose based on mg/m2) and have revealed no evidence of impaired fertility or harm to the fetus due to cefuroxime axetil. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.

Lactation 

Because cefuroxime is excreted in human breast milk, consideration should be given to discontinuing nursing temporarily during treatment with cefuroxime axetil.

Pediatric Use 

The safety and effectiveness of cefuroxime have been established for pediatric patients aged 3 months to 12 years for acute bacterial maxillary sinusitis based upon its approval in adults. Use of cefuroxime in pediatric patients is supported by pharmacokinetic and safety data in adults and pediatric patients and by clinical and microbiological data from adequate and well-controlled studies of the treatment of acute bacterial maxillary sinusitis in adults and of acute otitis media with effusion in pediatric patients. It is also supported by post marketing adverse events surveillance (refer to PHARMACOLOGY, INDICATIONS and UNDESIRABLE EFFECTS, Adverse Reactions).

Geriatric Use

Of the total number of subjects who received cefuroxime axetil in 20 clinical studies of cefuroxime, 375 were aged 65 years and over while 151 were 75 years and over. No overall differences in safety or effectiveness were observed between these subjects and younger adult subjects. The geriatric patients reported somewhat fewer gastrointestinal events and less frequent vaginal candidiasis compared with patients aged 12 to 64 years; however, no clinically significant differences were reported between the elderly and younger adult patients. Other reported clinical experience has not identified differences in responses between the elderly and younger adult patients.

Undesirable Effects

Cefuroxime Tablets in Clinical Trials

Multiple-Dose Dosing Regimens

7–10 Days Dosing: Using multiple doses of cefuroxime axetil tablets, 912 patients were treated with cefuroxime axetil (125–500 mg twice daily). There were no deaths or permanent disabilities thought related to drug toxicity. Medication was discontinued by 20 (2.2%) patients due to adverse events thought by the investigators to be possibly, probably, or almost certainly related to drug toxicity. Of the 20 patients, 17 (85%) who discontinued therapy did so because of gastrointestinal disturbances, including diarrhea, nausea, vomiting, and abdominal pain. The percentage of cefuroxime axetil tablets-treated patients who discontinued the study drug because of adverse events was very similar at daily doses of 1,000, 500, and 250 mg (2.3%, 2.1%, and 2.2%, respectively). However, the incidence of gastrointestinal adverse events increased with the higher recommended doses.

The following adverse events were thought by the investigators to be possibly, probably, or almost certainly related to cefuroxime axetil tablets in multiple-dose clinical trials (n = 912 cefuroxime axetil-treated patients).

Table 4: Adverse Reactions—Cefuroxime Tablets

Multiple-Dose Dosing Regimens—Clinical Trials

Incidence ≥1%

Diarrhea/loose stools               3.7%

Nausea/vomiting                      3.0%

Transient elevation in AST         2.0%

Transient elevation in ALT         1.6%

Eosinophilia                               1.1%

Transient elevation in LDH         1.0%

Incidence

<1% but >0.1%

Abdominal pain

Abdominal cramps

Flatulence

Indigestion

Headache

Vaginitis

Vulvar itch Rash

Hives

Itch Dysuria

Chills

Chest pain

Shortness of breath

Mouth ulcers

Swollen tongue

Sleepiness

Thirst

Anorexia

Positive Coomb’s test

5-Day Experience: In clinical trials using cefuroxime in a dose of 250 mg twice daily in the treatment of secondary bacterial infections of acute bronchitis, 399 patients were treated for 5 days and 402 patients were treated for 10 days. No difference in the occurrence of adverse events was found between the two regimens. 

In Clinical Trials for Early Lyme Disease with 20 Days Dosing: Two multicenter trials assessed cefuroxime axetil tablets 500 mg twice a day for 20 days. The most common drug-related adverse experiences were diarrhea (10.6% of patients), Jarisch-Herxheimer reaction (5.6%), and vaginitis (5.4%). Other adverse experiences occurred with frequencies comparable to those reported with 7–10 days dosing.

Single-Dose Regimen for Uncomplicated Gonorrhea: In clinical trials using a single dose of cefuroxime axetil tablets, 1,061 patients were treated with the recommended dosage of cefuroxime axetil (1,000 mg) for the treatment of uncomplicated gonorrhea. There were no deaths or permanent disabilities thought related to drug toxicity in these studies.

The following adverse events were thought by the investigators to be possibly, probably, or almost certainly related to cefuroxime axetil in 1,000 mg single-dose clinical trials of cefuroxime axetil tablets in the treatment of uncomplicated gonorrhea conducted in the United States.

Table 5: Adverse Reactions—Cefuroxime Tablets

1 g Single-Dose Regimen for Uncomplicated Gonorrhea—Clinical Trials

Incidence ≥1%

Nausea/vomiting      6.8%

Diarrhea                   4.2%

Incidence

<1% but >0.1%

Abdominal pain

Dyspepsia Erythema

Rash

Pruritus

Vaginal candidiasis

Vaginal itch

Vaginal discharge

Headache

Dizziness

Somnolence

Muscle cramps

Muscle stiffness

Muscle spasm of neck

Tightness/pain in chest

Bleeding/pain in urethra

Kidney pain

Tachycardia

Lockjaw-type reaction

Postmarketing Experience with Cefuroxime

In addition to adverse events reported during clinical trials, the following events have been identified during clinical practice in patients treated with cefuroxime tablets and were reported spontaneously. Data are generally insufficient to allow an estimate of incidence or to establish causation.

General: The following hypersensitivity reactions have been reported: anaphylaxis, angioedema, pruritus, rash, serum sickness-like reaction, urticaria.

Gastrointestinal: Pseudomembranous colitis (refer to WARNINGS AND PRECAUTIONS).

Hematologic: Hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia and increased prothrombin time.

Hepatic: Hepatic impairment including hepatitis and cholestasis, jaundice.

Neurologic: Seizure.

Skin: Erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis.

Urologic: Renal dysfunction.

Cephalosporin-Class Adverse Reactions

In addition to the adverse reactions listed above that have been observed in patients treated with cefuroxime axetil, the following adverse reactions and altered laboratory tests have been reported for cephalosporin-class antibiotics: toxic nephropathy, aplastic anemia, hemorrhage, increased BUN, increased creatinine, false-positive test for urinary glucose, increased alkaline phosphatase, neutropenia, elevated bilirubin, and agranulocytosis.

Several cephalosporins have been implicated in triggering seizures, particularly in patients with renal impairment when the dosage was not reduced. If seizures associated with drug therapy occur, the drug should be discontinued. Anticonvulsant therapy can be given if clinically indicated.

Overdosage

Overdosage of cephalosporins can cause cerebral irritation, leading to convulsions. Serum levels of cefuroxime can be reduced by hemodialysis and peritoneal dialysis.

Shelf-Life

30 months.

Storage and Handling Instructions

Protect from light and moisture.

Keep out of the reach of children.

Packaging Information

NOVACEF 250 Tablets ………….. Strip pack of 4 tablets
NOVACEF 500 Tablets ………….. Strip pack of 4 tablets

Last updated: Aug 2015
Last reviewed: July 2016