Professional Documents
Culture Documents
Ertapenem
The production of plasmid-encoded extended-spectrum b-lactamase
enzymes by increasing numbers of gram-negative bacteria is becoming
a more signicant source of microbial resistance in health care settings and
* Corresponding author.
E-mail address: kkaye@rics.bwh.harvard.edu (K.M. Kaye).
0891-5520/04/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.idc.2004.04.006
604
Table 1
Features of the dierent carbapenems
Antimicrobial coverage
Dosage/
Intervals
Imipenem 1 g q 68 h Cilastatin
Meropenem 1 g q 8 h
None
Ertapenem 1 g q 24 h None
1h
1h
4h
605
606
Cefditoren
Cefditoren is a third-generation orally administered cephalosporin.
Although available in Japan for a number of years, it was approved by
the FDA in September of 2001 for use in the United States by adults and
children 12 years of age or older. With the increase in multidrug-resistant
respiratory pathogens, particularly Streptococcus pneumoniae, the availability of an eective oral third-generation cephalosporin may be of use in
ambulatory settings for the treatment of respiratory tract infections.
The prodrug cefditoren pivoxil, formerly ME-1207, is an esteried
aminothiazolyl cephalosporin that passively diuses through the intestinal
membranes after ingestion. There it is hydrolyzed by esterase enzymes into
the active form cefditoren and an inactive metabolite, pivalate. The prodrug
does not enter the circulation intact, and seems to have no antimicrobial
activity [15]. Tablets come in 200-mg increments and also contain sodium
caseinate, a protein that may cross-react with patients who have milk
hypersensitivity. Once absorbed, dosages of 200 and 400 mg achieve plasma
concentrations of 2.46 mg/L [15] and 4.1 mg/L, respectively [16]. Although
607
food may have little eect on the rate of absorption itself, the fat content of
a meal can increase the plasma concentrations and bioavailability of the
drug, a phenomenon also common to other cephalosporin esters [17].
Various trials show that administering the drug after a meal increases the
peak plasma concentrations to a range of 2.62 to 3.1 mg/L for a 200-mg
dose, and 3.84 to 4.57 mg/L for a 400-mg dose [15]. Without the aid of fat in
absorption, cefditoren seems to have a bioavailability of only 14%. With
a low-fat meal (14 g of fat), this can increase to roughly 16%, and with
a high-fat meal (up to 64 g of fat), it can reach levels of almost 25% [18].
Direct drug-drug interactions seem minimal. The use of intravenous
antihistamine H2 blockers that decrease acid secretion led to a decrease in
drug levels. Likewise, oral antacids, such as aluminum and magnesium
hydroxide, also lower plasma concentrations [19]. Studies with proton pump
inhibitors are lacking, but it is recommended to avoid concomitant
administration based on the previously mentioned data.
Cefditoren does not seem to undergo any signicant metabolism, and is
excreted into the urine largely unchanged with a half-life of roughly 1.5
hours [15]. In the serum, it is highly protein-bound at 88% [20]. The inactive
metabolite, pivalate, is also renally excreted, but as the modied pivaloyl
carnitine. The binding of pivalate to carnitine can result in decreased levels
of the latter in patients. As such, it is generally not recommended for
patients with carnitine deciency or inborn errors of metabolism that result
in low levels of carnitine. Studies of 14-day regimens resulted in signicant
drops of serum carnitine levels, but the drops were less than 10% of total
body stores, an amount that is not expected to result in adverse clinical
eects in the average patient [21]. Moderate to severe renal insuciency
increases plasma concentrations of the drug and extends the half-life up to
a little over 5 hours depending on the extent of renal dysfunction [22].
Testing in mild to moderate hepatic insuciency has yielded no statistical
dierences in blood levels compared with healthy volunteers. Severe hepatic
dysfunction has yet to be tested [23].
Currently, the FDA has approved cefditoren pivoxil for use in treating
pharyngitis and tonsillitis, acute exacerbations of chronic bronchitis, and
uncomplicated skin and soft tissue infections. Like all cephalosporins,
cefditoren acts by binding to PBPs and interfering with the synthesis of
peptidoglycan cell wall synthesis of bacteria. Recommended dosages by the
manufacturer are 400 mg orally twice daily for 10 days to treat bronchitis
and 200 mg orally twice daily for 10 days to treat uncomplicated skin and
soft tissue infections. The manufacturer suggests not using higher than 200
mg twice daily with moderate renal insuciency, such as a creatinine
clearance less than 40 mL/L. In severe renal disease, a creatinine clearance
less than 10 mL/L, no more than 200 mg once daily, is recommended.
Cefditorens spectrum of activity covers a broad array of gram-positive
and gram-negative organisms, but notably lacks activity against Pseudomonas aeruginosa and many atypical pathogens implicated in pneumonia, such
608
609
tolerated. In the one published trial for skin and soft tissue infections,
cefditoren was comparable with cefuroxime and cefadroxil for cure rate and
tolerability, including documented S aureus and Streptococcus pyogenes
infections [32].
These clinical trials and other unpublished data indicate that cefditoren
pivoxil is, overall, a well-tolerated medication with an acceptable safety
prole. The most common adverse events were gastrointestinal, with up to
14% of patients suering from diarrhea and up to 6% with nausea. The
diarrhea was higher in comparison with the other agents on average, and
was the most frequent cause of discontinuation of therapy by the patients.
Other common side eects were considered mild and seemed equally
common among the comparing agents. These included headache in 2%,
abdominal pain in 2%, vaginal candidiasis in up to 6%, and dyspepsia in up
to 2% [2631].
The in vitro data for cefditoren show promise for a number of pathogens,
most notably penicillin-resistant pneumococci and other respiratory pathogens with b-lactamase activity, such as H inuenzae and M catarrhalis.
Cefditoren notably lacks activity toward Pseudomonas, and is not indicated
in settings where it may be of concern. The in vivo data are somewhat
limited for cefditoren, however, and point toward equal ecacy with other
oral third-generation cephalosporins, but it has yet to be proved more
ecacious. It has not been studied in pregnant women and has been
assigned to category B by the FDA. Sucient studies are also lacking for the
treatment of children, and it is currently not approved for children under
age 12. Other possible indications may be using cefditoren pivoxil as an oral
step-down therapy in patients after intravenous courses of cefotaxime or
ceftriaxone.
Ceftidoren does not seem to have any unique aspects to separate it from
other oral third-generation cephalosporins. It is, however, the most active of
the oral cephalosporins against S pneumoniae.
High-dose amoxicillin-clavulanate
The combination of the b-lactam antibiotic amoxicillin with the blactamase inhibitor clavulanate is a well-established and commonly used
antimicrobial combination for the treatment of a broad array of infections
in both adults and children. Its safety and ecacy have been detailed in
numerous studies and reviews [3337]. Amoxicillin is a semisynthetic
analogue of ampicillin, and is derived from the basic penicillin nucleus, 6aminopenicillanic acid. Clavulanate is an acid produced from the fermentation of Streptomyces clavuligerus, which is structurally related to
penicillins, but has little antibacterial activity; it inactivates various blactamases produced by many pathogens [38]. In response to the recent
emergence of penicillin-resistant pneumococci, formulations containing
610
611
Amoxicillin not only has a long record of safety and ecacy in treating
acute otitis media, but had previously demonstrated longest time above the
MIC90 against drug-resistant pneumococcus compared with many other
orally available agents [49]. Studies showed, however, that standard doses of
the drug (4045 mg/kg/d) achieved middle ear uid concentrations of 1 to 6
mg/L, a level that some considered ineectual in a proportion of cases [46].
Higher-dose therapy in the form of amoxicillin-clavulanate, 90 and 6.4 mg/
kg/d, divided for twice a day administration, achieved middle ear amoxicillin levels of 3 to 8 mg/L at 3 hours after the rst dose [50]. In vitro
pharmacokinetic modeling indicates that such levels should be sucient to
eliminate some penicillin-nonsusceptible strains of pneumococci [51].
Appropriate candidates for high-dose therapy (amoxicillin, 8090 mg/kg/d)
were patients who were considered to be at highest risk for infections with
drug-resistant S pneumoniae, such as patients with day care exposure,
previous antibimicrobial use in the last 3 months, and those 2 years old or
younger [46].
The Centers for Disease Control and Prevention panels recommendation
for its use led to a large, open-label, multicenter study for the treatment of
acute otitis media in children and infants [52]. A total of 521 patients were
enrolled between the ages of 3 and 48 months, with a mean age of 18.6
months, and treated with amoxicillin-clavulanate, 90 and 6.4 mg/kg/d in two
divided doses for 10 days. Baseline tympanocentesis was performed on all
children with intact tympanic membranes. Cultures of discharge were
obtained with swabs from perforated membranes. One or more pathogens
were isolated in 355 of the enrollees (68%). Pathogens included S pneumoniae, H inuenzae, M catarrhalis, and S pyogenes. H inuenzae was the most
commonly isolated (N = 197), 37% of which tested positive for blactamase. S pneumoniae was the second most commonly isolated organism
(N = 159), 55% of which were considered penicillin-susceptible, 18% were
penicillin-intermediate, and 28% were penicillin-resistant. M catarrhalis was
the third most commonly isolated pathogen (N = 30), all of which were blactamase positive. Repeat tympanocentesis was performed at days 4 to 6
irrespective of the ndings on original sample collection in three of the
centers. In 22 of the centers, repeat tympanocentesis was performed only if S
pneumoniae was recovered, and in any patient who experienced clinical
failure after day 4.
Follow-up cultures showed bacterial elimination from 96% of patients
undergoing repeat tympanocentesis. A previous study comparing normally
dosed amoxicillin with azithromycin for the treatment of acute otitis media
had shown an eradication rate of 83% [53]. Specically, 98% of any
S pneumoniae isolates, 94% of H inuenzae, and 100% of M catarrhalis were
eectively eradicated. The eradication for S pneumoniae with penicillin
resistance showing an MIC of less than or equal to 2 mg/L was greater than
95%. For even more resistant pneumococcus with an MIC of 4 mg/L, the
eradication rate was lower at 86%. Patients with penicillin-resistant
612
Cefepime
Cefepime is a parenterally administered fourth-generation cephalosporin
rst approved by the FDA in 1997. Cephalosporins are a broad group of
b-lactam antibiotics classied into generations, based loosely on their
spectrum of activity. Cefepime has been classied as a fourth-generation
613
614
615
Summary
The number of b-lactam antibiotics continues to grow and change,
largely in response to developing bacterial resistance. These include new
antibiotics and new formulations of old antibiotics. The b-lactams described
here are some of the most recently approved antibiotics in the United States.
These agents have novel features that should provide advantages over
previously available antibiotics in certain situations. The decision to use any
of these newer agents over other, older antibiotics, however, should be
determined on an individual basis after full clinical evaluation.
References
[1] Kohler J, Dorso K, Young K, et al. In vitro activities of the potent, broad-spectrum
carbapenem MK-0826 against broad-spectrum b-lactamase- and extended-spectrum blactamase-producing Klebsiella pneumoniae and Escherichia coli clinical isolates. Antimicrob Agents Chemother 1999;43:11706.
[2] Majumdar AK, Musson DG, Birk KL, et al. Pharmacokinetics of ertapenem in healthy
young volunteers. Antimicrob Agents Chemother 2002;46:350611.
616
[3] Legua P, Lema J, Moll J, et al. Safety and local tolerability of intramuscularly
administered ertapenem diluted in lidocaine: a prospective, randomized, double-blind
study versus intramuscular ceftriaxone. Clin Ther 2002;24:43444.
[4] Shah PM, Isaacs RD. Ertapenem, the rst of a new group of carbapenems. J Antimicrob
Chemother 2003;52:53842.
[5] Livermore DM, Carter MW, Bagel S, et al. In vitro activities of ertapenem (MK-0826)
against recent clinical bacteria collected in Europe and Australia. Antimicrob Agents
Chemother 2001;45:18607.
[6] Goldstein EJC, Citron DM, Merriam CV, et al. Comparative in vitro activities of
ertapenem (MK-0826) against 1,001 anaerobes isolated from human intra-abdominal
infections. Antimicrob Agents Chemother 2000;44:238994.
[7] Friedland IR, Isaacs R, Mixson LA, Motyl M, Woods GL. Use of surrogate antimicrobial
agents to predict susceptibility to ertapenem. Diagn Microbial Infect Dis 2002;43:614.
[8] Ortiz-Ruiz G, Caballero-Lopez J, Friedland IR, Woods GL, Carides A. The Protocol 018
Ertapenem Community-Acquired Pneumonia Study Group. A study evaluating the
ecacy, safety, and tolerability of ertapenem versus ceftriaxone for the treatment of
community-acquired pneumonia in adults. Clin Infect Dis 2002;34:107683.
[9] Vetter N, Cambronero-Hernandez E, Rohlf J, et al. A prospective, randomized, doubleblind multicenter comparison of parenteral ertapenem and ceftriaxone for treatment of
hospitalized adults with community-acquired pneumonia. Clin Ther 2002;24:177085.
[10] Tomera KM, Burdmann EA, Pamo Reyna OG, et al. Ertapenem versus ceftriaxone
followed by appropriate oral therapy for treatment of complicated urinary tract infections
in adults: results of a prospective, randomized, double-blind multicenter study. Antimicrob
Agents Chemother 2002;46:2895900.
[11] Jimenez-Cruz F, Jasovich A, Cajigas J, et al. A prospective, multicenter, randomized, doubleblind study comparing ertapenem and ceftriaxone followed by appropriate oral therapy for
treatment of complicated urinary tract infections in adults. Urology 2002;60:1622.
[12] Solomkin JS, Yellin AE, Rotstein OD, et al. Ertapenem versus piperacillin/tazobactam in
the treatment of complicated intra-abdominal infections. Ann Surg 2003;237:23545.
[13] Graham DR, Lucasti C, Malafaia O, et al. Ertapenem once daily versus piperacillintazobactam 4 times per day for treatment of complicated skin and skin-structure infections
in adults: results of a prospective, randomized, double-blind multicenter study. Clin Infect
Dis 2002;34:14608.
[14] Roy S, Higareda I, Angel-Muller E, et al. Ertapenem once a day versus piperacillintazobactam every 6 hours for treatment of acute pelvic infections: a prospective,
multicenter, randomized double-blind study. Infect Dis Obstet Gynecol 2003;11:111.
[15] Li JT, Hou F, Lu H, et al. Phase I clinical trial of cefditoren pivoxil (ME 1207):
pharmacokinetics in healthy volunteers. Drugs Exp Clin Res 1997;23:14550.
[16] Kuti JL, Quintiliani R. Cefditoren pivoxil. Formulary 2001;36:26575.
[17] Kneer J. Pharmacokinetic properties of new oral cephalosporins. Med Mal Infect 1992;22:
55664.
[18] Darkes MJM, Plosker GL. Cefditoren pivoxil. Drugs 2002;62:31936.
[19] Mayer M, Mulford D, Witt G. Eect of an H2 receptor antagonist or an antacid on the
pharmacokinetics of cefditoren [abstract]. In: Programs and abstracts of the 40th annual
interscience conference on antimicrobial agents and chemotherapy. Washington: American
Society for Microbiology: 2000. poster no. 313.
[20] TAP Pharmaceuticals. Spectracef (cefditoren) package insert. Lake Forest (IL): TAP
Pharmaceuticals; 2001.
[21] Brass EP, Mayer MD, Mulford DJ, et al. Impact on carnitine homeostasis of short-term
treatment with the pivalate prodrug cefditoren pivoxil. Clin Pharmacol Ther 2003;73:
33847.
[22] Mulford D, Mayer M, Witt G. Eect of renal impairment on the pharmacokinetics of
cefditoren [abstract]. In: Programs and abstracts of the 40th annual interscience conference
[23]
[24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
[41]
[42]
617
on antimicrobial agents and chemotherapy. Washington: American Society for Microbiology; 2000. poster no. 311.
Mayer M, Mulford D, Witt G. Eect of hepatic impairment on the pharmacokinetics of
cefditoren [abstract]. In: Programs and abstracts of the 41st annual interscience conference
on antimicrobial agents and chemotherapy. Washington: American Society for Microbiology; 2001. poster no. 312.
Chin NX, Zhang YX, Neu HC. In vitro activity of a new cephalosporin ME-1206
compared with other agents. Diagn Microbiol Infect Dis 1991;14:41724.
Jacobs MR, Bajaksouzian S, Zilles A, et al. Susceptibilities of Streptococcus pneumoniae
and Haemophilus inuenzae to 10 oral antimicrobial agents based on pharmacodynamic
parameters: 1997 USA surveillance study. Antimicrob Agents Chemother 1999;43:19018.
Clark CL, Nagai K, Dewasse BE, et al. Activity of cefditoren against respiratory
pathogens. J Antimicrob Chemother 2002;50:3341.
Kaplan EL, Tucker RM, Poling TL, et al. A multicenter comparison of cefditoren pivoxil
and penicillin VK. J Respir Dis 2001;22(Suppl 8):604.
van Zyl L, le Roux JG, LaFata JA, et al. Cefditoren pivoxil versus cefpodoxime proxetil
for community-acquired pneumonia: results of a multicenter, prospective, randomized,
double-blind study. Clin Ther 2002;24:184053.
Fogarty CM, Cyganowski M, Palo WA, et al. A comparison of cefditoren pivoxil and
amoxicillin/clavulanate for the treatment of community-acquired pneumonia: a multicenter, prospective, randomized, investigator-blinded, parallel-group study. Clin Ther 2002;
24:185470.
Henry DC, Poling TL, Bettis RB, et al. A double-blind, randomized study of cefditoren
versus cefuroxime for acute exacerbations of chronic bronchitis (AECB). J Respir Dis
2001;22(Suppl 8):6974.
Ramirez JA, Tucker RM, Bettis RB, et al. Treating acute exacerbations of chronic
bronchitis. J Respir Dis 2001;22(Suppl 8):7580.
Bucko AD, Hunt BJ, Kidd SL, et al. Randomized, double-blind, multicenter comparison
of oral cefditoren 200 or 400mg bid with either cefuroxime 250 mg bid or cefadroxil 500 mg
bid for the treatment of uncomplicated skin and skin-structure infections. Clin Ther 2002;
24:113447.
Brogden RN, Carmine A, Heel RC, et al. Amoxycillin/clavulanic acid: a review of its
antibacterial activity, pharmacokinetics and therapeutic use. Drugs 1981;22:33762.
Weber DJ, Tolko-Rubin NE, Rubin RH. Amoxicillin and potassium clavulanate: an
antibiotic combination: mechanism of action, pharmacokinetics, antimicrobial spectrum,
clinical ecacy and adverse eects. Pharmacotherapy 1984;4:12236.
Stein GE, Gurwith MJ. Amoxicillin-potassium clavulanate, a b-lactamase-resistant
antibiotic combination. Clin Pharm 1984;3:5919.
Smith BR, LeFrock JL. Amoxicillin-potassium clavulanate: a novel b-lactamase inhibitor.
Drug Intell Clin Pharm 1985;19:41520.
Todd PA, Beneld P. Amoxicillin/clavulanic acid: an update of its antibacterial activity,
pharmacokinetic properties and therapeutic use. Drugs 1990;39:264307.
Neu HC, Fu KP. Clavulanic acid, a novel inhibitor of b-lactamases. Antimicrob Agents
Chemother 1984;14:6505.
Jackson D, Cooper DL, Horton R, et al. Augmentin: absorption, excretion and
pharmacokinetic studies in man. Postgrad Med 1984;76:5170.
GlaxoSmithKline. Augmentin XR (amoxicillin-clavulanate) package insert. Research
Triangle Park (NC): GlaxoSmithKline; 2003.
Kaye C, Allen A, Perry S, et al. The clinical pharmacokinetics of a new pharmacokinetically enhanced formulation of amoxicillin/clavulanate. Clin Ther 2001;23:57884.
Adam D, De Visser I, Koeppe P. Pharmacokinetics of amoxicillin and clavulanic
acid administered alone and in combination. Antimicrob Agents Chemother 1982;22:
3537.
618
[43] Staniforth DH, Jackson D, Clark HL, et al. Amoxycillin/clavulanic acid: the eect of
probenecid. J Antimicrob Chemother 1983;12:2735.
[44] Amoxicillin-clavulanic acid (Augmentin). Med Lett Drugs Ther 1984;26:99100.
[45] Fuchs PC, Barry AL, Thornsberry C, et al. In vitro evaluation of Augmentin by both
microdilution and disk diusion susceptibility testing: regression analysis, tentative interpretive criteria, and quality control limits. Antimicrob Agents Chemother 1983;24:318.
[46] Dowell SF, Butler JC, Giebink GS, et al. Acute otitis media: management and surveillance
in an era of pneumococcal resistance: report from the Drug-Resistant S. pneumoniae
Therapeutic Working Group. Pediatr Infect Dis J 1999;18:19.
[47] Thornsberry C, Ogilvie P, Kahn J, Mauriz Y. Surveillance of antimicrobial resistance in
Streptococcus pneumoniae, Haemophilus inuenzae, and Moraxella catarrhalis in the United
States in 1996-1997 respiratory season. Diagn Microbiol Infect Dis 1997;29:24957.
[48] Dowell SF, Schwartz B. Resistant pneumococci: protecting patients through judicious use
of antibiotics. Am Fam Physician 1997;55:164754.
[49] Craig WA, Andes D. Pharmacokinetics and pharmacodynamics of antibiotics in otitis
media. Pediatr Infect Dis J 1996;15:2559.
[50] Seikel K, Shelton S, McCracken GH. Middle ear uid concentrations of amoxicillin after
large dosages in children with acute otitis media. Pediatr Infect Dis J 1997;16:7101.
[51] Lister PD, Pong A, Chartrand SA, Sanders CC. Rationale behind high-dose amoxicillin
therapy for acute otitis media due to penicillin-nonsusceptible pneumococci: support from
in vitro pharmacodynamic studies. Antimicrob Agents Chemother 1997;41:192632.
[52] Dagan R, Hoberman A, Johnson C, et al. Bacteriologic and clinical ecacy of high dose
amoxicillin/clavulanate in children with acute otitis media. Pediatr Infect Dis J 2001;20:
82937.
[53] Dagan R, Johnson CE, McLinn S, et al. Bacteriologic and clinical ecacy of amoxicillin/
clavulanate vs. azithromycin in acute otitis media. Pediatr Infect Dis J 2000;19:95104.
[54] Botteneld GW, Burch DJ, Hedrick JA, et al. Safety and tolerability of a new formulation
(90 mg/kg/day divided every 12h) of amoxicillin/clavulanate (Augmentin) in the empiric
treatment of pediatric acute otitis media caused by drug-resistant Streptococcus pneumoniae. Pediatr Infect Dis J 1998;17:9638.
[55] Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute
bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2000;123:S132.
[56] American Thoracic Society. Guidelines for the management of adults with communityacquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy, and
prevention. Am J Respir Crit Care Med 2001;163:173054.
[57] Sanders CC. Cefepime: the next generation? Clin Infect Dis 1993;17:36979.
[58] Marshall WF, Blair JE. The cephalosporins. Mayo Clin Proc 1999;74:10795.
[59] Naito T, Aburaki S, Kamachi H, et al. Synthesis and structure activity relationships of
a new series of cephalosporins, BMY-28142 and related compounds. J Antibiot (Tokyo)
1986;39:1092107.
[60] Barbhaiya RH, Forgue ST, Gleason CR, et al. Pharmacokinetics of cefepime after single
and multiple intravenous administrations in healthy subjects. Antimicrob Agents Chemother 1992;36:5527.
[61] Barbhaiya RH, Forgue ST, Gleason CR, et al. Safety, tolerance, and pharmacokinetic
evaluation of cefepime after administration of single intravenous doses. Antimicrob Agents
Chemother 1990;34:111822.
[62] Barbhaiya RH, Knupp CA, Tenney J, et al. Safety, tolerance, and pharmacokinetics of
cefepime administered intramuscularly to healthy subjects. J Clin Pharmacol 1990;30:
90010.
[63] Gubbelmans HL, Materman EC, Maesen FP. Cefepime versus ceftriaxone: a tolerance
study by intramuscular injection. Drug Ther Res 1990;15:1246.
[64] Bristol-Myers Squibb. Maxipime (cefepime) package insert. Princeton, NJ: Bristol-Myers
Squibb; 1996.
619
[65] Chadha D, Wise R, Baldwin DR, et al. Cefepime concentrations in bronchial mucosa and
serum after a single 2 gram intravenous dose. J Antimicrob Chemother 1990;25:95963.
[66] Okamoto MP, Chin A, Gill MA, et al. Analysis of cefepime tissue penetration into human
appendix. Pharmacotherapy 1991;11:3538.
[67] Kalman D, Barriere SL, Johnson BL. Pharmacokinetic disposition and bactericidal
activities of cefepime, ceftazidime, and cefoperazone in serum and blister uid. Antimicrob
Agents Chemother 1991;36:4537.
[68] Saez-Llorens X, Castano E, Garcia R, et al. Prospective randomised comparison of
cefepime and cefotaxime for treatment of bacterial meningitis in infants and children.
Antimicrob Agents Chemother 1995;39:93740.
[69] Barbhaiya RH, Knupp CA, Forgue ST, et al. Disposition of the cephalosporin cefepime in
normal and renally impaired subjects. Diagn Metab Dispos 1991;19:6873.
[70] Wynd MA, Paladino JA. Cefepime: a fourth generation parenteral cephalosporin. Ann
Pharmacother 1996;30:141424.
[71] Kessler RE, Bies M, Buck RE, et al. Comparison of a new cephalosporin, BMY-28142,
with other broad spectrum beta-lactam antibiotics. Antimicrob Agents Chemother 1985;
27:20716.
[72] Rolston KV, Alvarez ME, Hsu KC, et al. In vitro activity of cefpirome (HR-810), WIN49375, BMY-28142, and other antibiotics against nosocomially important isolates from
cancer patients. J Antimicrob Chemother 1986;17:4537.
[73] Conrad DA, Scribner RK, Weber AH, Marks MI. In vitro activity of BMY-28142 against
pediatric pathogens, including isolates from cystic brosis sputum. Antimicrob Agents
Chemother 1985;28:5863.
[74] Sanders WE Jr, Tenney JH, Kessler RE. Ecacy of cefepime in the treatment of infections
due to multiply resistant Enterobacter species. Clin Infect Dis 1996;23:45461.
[75] Kessler RE, Fung-Tomc J. Susceptibility of recent bacterial isolates from the cefepime
clinical trials in the United States. Am J Med 1993;95:107.
[76] Neu HC. Safety of cefepime: a new extended-spectrum cephalosporin antibiotic. Am J
Med 1993;95:6774.
[77] Acar J. Rapid emergence of resistance to cefepime during treatment. Clin Infect Dis 1998;
26:14846.