Oral Cephalosporin Options for Respiratory Tract Infections

Patient Population: Pediatric

This section is linked as a resource from the BCH Empiric Antimicrobial Therapy Guideline sections on Community-Acquired Pneumonia, Acute Otitis Media, and Acute Bacterial Sinusitis, and is meant to guide selection of alternative therapy for patients with documented penicillin allergy with lower risk for allergic reaction. Please refer to the linked sections for guidance on first choice therapy, and for patients with penicillin allergy with higher risk for allergic reaction.  

Antibiotic allergy assessment (to determine whether the patient can safely receive first line therapy) is recommended when clinically appropriate and feasible.  

Not all of these listed options may be available on hospital formularies or in outpatient pharmacies, therefore we provide multiple options here with comparison between them.  

Cefprozil (2nd generation cephalosporin) 

  • Dosing (infants, children, adolescents): 15 mg/kg/dose (max 500 mg/dose) enterally bid 
  • Nice alternative to broader spectrum antibiotics (e.g. cefdinir) that provide unnecessary gram-negative coverage 
  • Excellent spectrum of activity against the usual pathogens for infections such as community-acquired pneumonia, acute otitis media, and acute bacterial sinusitis 
  • Available in both tablet and suspension form (tastes great!) 

Cefuroxime (2nd generation cephalosporin) 

  • Dosing (infants, children, adolescents): 15 mg/kg/dose (max 500 mg/dose) enterally bid 
  • Nice alternative to broader spectrum antibiotics (e.g. cefdinir) that provide unnecessary gram-negative coverage  
  • Excellent spectrum of activity against the usual pathogens for infections such as community-acquired pneumonia, acute otitis media and acute bacterial sinusitis 
  • Available only in tablet form (250 mg & 500 mg tablets) 

Cefdinir (3rd generation cephalosporin) 

  • Dosing (infants, children, adolescents): 7 mg/kg/dose (max 300 mg/dose) enterally bid 
  • Though once daily dosing is possible, this decreases antimicrobial exposure to the target organism(s) and further increases the risk for suboptimal treatment (see below) 
  • Often overly broad spectrum of activity for respiratory tract infections such as community-acquired pneumonia, acute otitis media, and acute bacterial sinusitis 
  • Higher rates of antibiotic associated diarrhea compared to 2nd generation cephalosporins 
  • Oral cefdinir and other oral 3rd generation cephalosporins are not considered equivalent to ceftriaxone IV/IM. They have poor oral bioavailability and high protein binding make it difficult to get appropriate concentrations at desired site of action - this could lead to treatment failure and/or more bacterial resistance relative to other options 
  • For example, the estimated likelihood of optimal treatment exposure for acute otitis media is better with high dose amoxicillin than with cefdinir, despite cefdinir having a broader spectrum of activity.  

Cefixime (3rd generation cephalosporin) 

  • Dosing (infants, children, adolescents): 8 mg/kg/dose (max 400 mg/dose) enterally qday 
  • Though once daily dosing is possible, this decreases antimicrobial exposure to the target organism(s) and further increases the risk for suboptimal treatment (see below) 
  • Often overly broad spectrum of activity for respiratory tract infections such as community-acquired pneumonia, acute otitis media, and acute bacterial sinusitis 
  • Higher rates of antibiotic associated diarrhea compared to 2nd generation cephalosporins 
  • Oral cefixime and other oral 3rd generation cephalosporins are not considered equivalent to ceftriaxone IV/IM. They have poor oral bioavailability and high protein binding make it difficult to get appropriate concentrations at desired site of action - this could lead to treatment failure and/or more bacterial resistance relative to other options 
  • For example, the estimated likelihood of optimal treatment exposure for acute otitis media is better with high dose amoxicillin than with cefixime, despite cefixime having a broader spectrum of activity.  

Pediatric Empiric Antimicrobial Therapy Guidelines

This is a subsection of the UCSF Benioff Children’s Hospitals Empiric Antimicrobial Therapy Guidelines, developed by the Pediatric Antimicrobial Stewardship Programs at each campus to inform initial selection of empiric antimicrobial therapy for children at the UCSF Benioff Children’s Hospitals and affiliated outpatient sites. 

These are guidelines only and not intended to replace clinical judgment. Modification of therapy may be indicated based on patient comorbidities, previous antibiotic therapy or infection history. Doses provided are usual doses but may require modification based on patient age or comorbid conditions. Refer to Pediatric Antimicrobial Dosing Guideline for further guidance on dosing in children, and Neonatal Dosing Guideline for infants < 1 month of age. Consult a pediatric pharmacist for individualized renal or hepatic dose adjustment. Durations provided are usual recommendations for patients who are responding appropriately to therapy. For additional guidance, please contact Pediatric Infectious Diseases (ID) or the Pediatric Antimicrobial Stewardship Program (ASP) at the campus where your patient is receiving care.  

For questions or feedback about these guidelines, please email primary content owners, Rachel Wattier, Pediatric ASP Medical Director at BCH SF and Prachi Singh, Pediatric ASP Medical Director at BCH OAK. 

The content of these guidelines was updated in July 2021. See Summary and Rationale for Changes (password login to Box needed) for detailed explanations of the content changes.