A pharmacokinetic comparison of cephalexin and cefadroxil using HPLC assay procedures

A Systematic Review on the Clinical Pharmacokinetics of Cephalexin in Healthy and Diseased Populations

Cephalexin is a first-generation β-lactam antibiotic used in adults and pediatrics to treat various streptococcal and staphylococcal infections. This review aims to summarize and evaluate all the pharmacokinetic (PK) data on cephalexin by screening out all pertinent studies in human beings following the per oral (PO) route. By employing different online search engines such as Google Scholar, PubMed, Cochrane Central, and Science Direct, 23 studies were retrieved, among which nine were in healthy subjects, five in diseased ones, and the remaining were drug-drug, drug-food, and bioequivalence-related. These studies were included only based on the presence of plasma concentration-time profiles or PK parameters, i.e., maximum plasma concentration (Cmax), half-life (t1/2) area under the curve from time 0-infinity (AUC0-∞), and clearance (CL/F). A dose-proportional increase in AUC0-∞ and Cmax can be portrayed in different studies conducted in the healthy population. In comparison to cefaclor, Cmax was recorded to be 0.5 folds higher for cephalexin in the case of renal impairment. An increase in AUC0-∞ was seen in cephalexin on administration with probenecid, i.e., 117 µg.h/mL vs. 68.1 µg.h/mL. Moreover, drug-drug interactions with omeprazole, ranitidine, zinc sulfate, and drug-food interactions for cephalexin and other cephalosporins have also been depicted in different studies with significant changes in all PK parameters. This current review has reported all accessible studies containing PK variables in healthy and diseased populations (renal, dental, and osteoarticular infections, continuous ambulatory peritoneal dialysis) that may be favorable for health practitioners in optimizing doses among the latter.

Two Times Versus Four Times Daily Cephalexin Dosing for the Treatment of Uncomplicated Urinary Tract Infections in Females

Background

The current treatment guidelines of the Infectious Diseases Society of America recommend β-lactam antibiotics as alternative rather than first-line agents for the treatment of uncomplicated urinary tract infection (uUTI). Cephalexin is a commonly prescribed first-generation cephalosporin with excellent bioavailability and urinary penetration; however, little data exist to support optimal dosing for uUTI.

Methods

This retrospective multicenter cohort study included adult female patients who received 5 to 7 days of cephalexin for symptomatic uUTI with a cefazolin-susceptible urine culture. The primary objective was to compare uUTI treatment failure (eg, continued or recurrent symptoms within 30 days) between patients treated with cephalexin 500 mg twice daily (BID group) and 500 mg 4 times daily (QID group) in the outpatient setting. Secondary outcomes included time to treatment failure, reported adverse events within 7 days of treatment, and occurrence of Clostridioides difficile within 30 days of treatment.

Results

A total of 261 patients were included (BID, n = 173; QID, n = 88). Baseline characteristics were similar between the groups. Escherichia coli was the most commonly isolated pathogen (85.4%). There was no difference in treatment failure observed between the groups (BID 12.7% vs QID 17%, P = .343), including failure while undergoing therapy (BID 2.3% vs QID 5.7%, P = .438) or recurrence within 30 days (BID 10.4% vs QID 11.3%, P = .438). No differences in reported adverse events (BID 4.6% vs QID 5.6%, P = .103) were observed between groups.

Conclusions

Twice-daily cephalexin is as effective as 4-times-daily dosing for uUTI. A twice-daily dosing strategy may improve patient adherence.

A Critical Review of Cephalexin and Cefadroxil for the Treatment of Acute Uncomplicated Lower Urinary Tract Infection in the Era of "Bad Bugs, Few Drugs"

First-generation oral cephalosporins (cephalexin and cefadroxil) have traditionally been considered second-line treatment options for uncomplicated lower urinary tract infections (uLUTIs).  However, in the current age of "bad bugs, few drugs", where there are increasingly limited oral options against resistant Enterobacteriaceae, there is an urgent need to rethink how best to utilize the available antibiotic armamentarium.  This review examines the historical clinical trials and experimental studies of cephalexin and cefadroxil, particularly through the modern lens of pharmacokinetics/pharmacodynamics (PK/PD), to better appreciate the efficacy of these drugs in uLUTIs.  Furthermore, newer cefazolin-cephalexin surrogate testing, as recommended by the Clinical and Laboratory Standards Institute (CLSI) and the United States Committee on Antimicrobial Susceptibility Testing (USCAST), has recategorized cephalexin in many instances from resistant to susceptible.  We conclude that cephalexin and cefadroxil have very good early bacteriological and clinical cures in uLUTIs due to non-extended-spectrum beta-lactamase-producing (ESBL) Enterobacteriaceae comparable to many traditionally first-line agents.  Cephalexin can be conveniently administered as 500 mg twice or thrice daily, similar to cefadroxil (500 mg twice daily); therefore, either agent may be used as a fluoroquinolone-sparing alternative. Cephalexin may be the more practical choice for many clinicians because reliable antimicrobial susceptibility test interpretative criteria (STIC) are provided by CLSI, USCAST, and the European Committee on Antimicrobial Susceptibility Testing (EUCAST), whereas direct cefadroxil STIC is offered only by EUCAST.

Interethnic differences in pharmacokinetics of antibacterials

BACKGROUND

Optimal antibacterial dosing is imperative for maximising clinical outcome. Many factors can contribute to changes in the pharmacokinetics of antibacterials to the extent where dose adjustment may be needed. In acute illness, substantial changes in important pharmacokinetic parameters such as volume of distribution and clearance can occur for certain antibacterials. The possibility of interethnic pharmacokinetic differences can further complicate attempts to design an appropriate dosing regimen. Factors of ethnicity, such as genetics, body size and fat distribution, contribute to differences in absorption, distribution, metabolism and elimination of drugs. Despite extensive previous work on the altered pharmacokinetics of antibacterials in some patient groups such as the critically ill, knowledge of interethnic pharmacokinetic differences for antibacterials is limited.

OBJECTIVES

This systematic review aims to describe any pharmacokinetic differences in antibacterials between different ethnic groups, and discuss their probable mechanisms as well as any clinical implications.

METHODS

We performed a structured literature review to identify and describe available data of the interethnic differences in the pharmacokinetics of antibacterials.

RESULTS

We found 50 articles that met our inclusion criteria and only six of these compared antibacterial pharmacokinetics between different ethnicities within the same study. Overall, there was limited evidence available. We found that interethnic pharmacokinetic differences are negligible for carbapenems, most β-lactams, aminoglycosides, glycopeptides, most fluoroquinolones, linezolid and daptomycin, whereas significant difference is likely for ciprofloxacin, macrolides, clindamycin, tinidazole and some cephalosporins. In general, subjects of Asian ethnicity achieve drug exposures up to two to threefold greater than Caucasian counterparts for these antibacterials. This difference is caused by a comparatively lower volume of distribution and/or drug clearance.

CONCLUSION

Interethnic pharmacokinetic differences of antibacterials are likely; however, the clinical relevance of these differences is unknown and warrants further research.

Three-ways crossover bioequivalence study of cephalexin in healthy Malay volunteers

CONTEXT

Although the general pharmacokinetics of cephalexin is quite established up-to-date, however, no population-based study on Cephalexin pharmacokinetics profile in Malay population has been reported yet in the literature.

OBJECTIVE

The objective of this study was to investigate the pharmacokinetics and to compare the bioavailability of three cephalexin products, Ospexin® versus MPI Cephalexin® tablet and MPI Cephalexin® capsule, in healthy Malay ethnic male volunteers in Malaysia.

MATERIAL AND METHOD

A single dose, randomized, fasting, three-period, three-treatment, three-sequence crossover, open label bioequivalence study was conducted in 24 healthy Malay adult male volunteers, with 1 week washout period. The drug concentration in the sample was analyzed using high performance liquid chromatography.

RESULT

The mean (SD) pharmacokinetic parameter results of Ospexin® were Cmax, 17.39 (4.15) μg/mL; AUC0-6, 28.90 (5.70) µg/mL * h; AUC0-∞, 30.07 (5.94) µg/mL * h; while, those of MPI Cephalexin® tablet were Cmax, 18.29 (3.01) μg/mL; AUC0-6, 30.02 (4.80) µg/mL * h; AUC00-∞, 31.33 (5.18) µg/mL * h and MPI Cephalexin® capsule were Cmax, 18.25 (3.92) μg/mL; AUC0-6, 30.04 (5.13) µg/mL * h; AUC0-∞, 31.22 (5.29) µg/mL * h.

CONCLUSION

The 90% confidence intervals for the logarithmic transformed Cmax, AUC0-6 and AUC0-∞, of Ospexin® versus MPI Cephalexin® tablet and Ospexin® versus MPI Cephalexin® capsule were between 0.80 and 1.25. Both Cmax and AUC met the predetermined criteria for assuming bioequivalence. The pharmacokinetic profile of cephalexin in Malay population does not vary much from other world population.

Comparative bioavailability of two cefadroxil products using serum and urine data in healthy human volunteers

1. The aim of the present study was to assess the bioequivalence of two cefadroxil products, namely Ultracef (a reference product) in the form of a 500 mg capsule (produced by Bristol-Myers Squibb Laboratories, Princeton, NJ, USA) and Roxil (a test product) in the form of a 500 mg capsule (produced by Tabuk Pharmaceutical Manufacturing, Tabuk, Saudi Arabia). 2. The study was performed under US Food and Drug Administration (FDA) guidelines (http://www.fda.gov/cder) on 24 healthy male subjects. Both products were administered orally as a single dose (1 x 500 mg capsule) separated by a 1 week washout period. Following oral administration, blood and urine samples were obtained and analysed for cefadroxil concentrations using a sensitive and specific HPLC assay. 3. There were no statistically significant differences between the two products in either the mean concentration-time profiles or the cumulative urinary excretion of cefadroxil at various times. Similarly, no statistical significance was observed in the pharmacokinetic parameters reflecting rate and extent of drug absorption. The relative extent of drug absorption, assessed by calculating the area under the curve (AUC) ratio for Roxil/Ultracef for 10 h and for infinity was 0.94 with 90% confidence limits (CL) of 0.91-0.98. In agreement with serum data, the average ratio (Roxil/Ultracef) of the cumulative amount of cefadroxil excreted in urine 10 h after the dose was found to be 0.97, with 90% CL of 0.88-1.05. The CL of the AUC and cumulative urinary excretion ratios are within the FDA accepted limits for bioequivalent products (0.80-1.25). 4. These findings show that serum and urine data of cefadroxil are in agreement and indicate that Roxil (the test product) and Ultracef (the reference product) are bioequivalent in terms of the rate and extent of drug absorption.

Intestinal absorption of cephalexin in diabetes mellitus model rats

We investigated the intestinal absorption and pharmacokinetics of cephalexin, as well as the intestinal H+/oligopeptide transporter PEPT1 mRNA and protein levels in type 1 and type 2 diabetic rats. Cephalexin disappearance from the duodenum loop was significantly lower in streptozotocin-induced type 1 diabetic rats and higher in hyperinsulinemic type 2 diabetic GK and Zucker-fa/fa (Zucker) rats, than in control rats. These results were speculated to be due to the enhancement of intestinal absorption of cephalexin in GK and Zucker rats. Intestinal PEPT1 mRNA levels were not significantly different between control and diabetic rats; however, the brush-border membrane vesicle PEPT1 protein levels were increased in GK and Zucker rats. After oral administration of cephalexin, plasma cephalexin concentrations and pharmacokinetic parameters, area under the concentration versus time curve from 0 to infinity, AUC(0-->infinity), and maximum plasma concentration, Cmax, in GK and Zucker rats were markedly higher than in control rats. From these findings, it is considered that intestinal absorption of drugs mediated by PEPT1 may be enhanced in hyperinsulinemic type 2 diabetes mellitus rats.

Multiple pharmacokinetic parameter prediction for a series of cephalosporins

The goal of quantitative structure-pharmacokinetic relationship analyses is to develop useful models that can predict one or more pharmacokinetic properties of a particular compound. In the present study, a multiple-output artificial neural network model was constructed to predict human half-life, renal and total body clearance, fraction excreted in urine, volume of distribution, and fraction bound to plasma proteins for a series of cephalosporins. Descriptors generated solely from drug structure were used as inputs for the model, and the six pharmacokinetic parameters were simultaneously predicted as outputs. The final 10 descriptor model contained sufficient information for successful predictions using both internal and external test compounds. Descriptors were found to contribute to individual pharmacokinetic parameters to differing extents, such that descriptor importance was independent of the relationships between pharmacokinetic parameters. This technique provides the advantage of simultaneous prediction of multiple parameters using information obtained by nonexperimental means, with the potential for use during the early stages of drug development.

Evaluation of human intestinal absorption data and subsequent derivation of a quantitative structure–activity relationship (QSAR) with the Abraham descriptors

The human intestinal absorption of 241 drugs was evaluated. Three main methods were used to determine the human intestinal absorption: bioavailability, percentage of urinary excretion of drug-related material following oral administration, and the ratio of cumulative urinary excretion of drug-related material following oral and intravenous administration. The general solvation equation developed by Abraham's group was used to model the human intestinal absorption data of 169 drugs we considered to have reliable data. The model contains five Abraham descriptors calculated by the ABSOLV program. The results show that Abraham descriptors can successfully predict human intestinal absorption if the human absorption data is carefully classified based on solubility and administration dose to humans.

Enhancing paracellular permeability by modulating epithelial tight junctions

The intestinal epithelium is a major barrier to the absorption of hydrophilic drugs. The presence of intercellular junctional complexes, particularly the tight junctions (zona occludens), renders the epithelium impervious to hydrophilic drugs, which cannot diffuse across the cells through the lipid bilayer of the cell membranes. There have been significant advances in understanding the structure and cellular regulation of tight junctions over the past decade. This article reviews current knowledge regarding the physiological regulation of tight junctions and paracellular permeability, and recent progress towards the rational design of agents that can effectively and safely increase paracellular permeability via modulation of tight junctions.

High-performance liquid chromatographic determination of cephalosporin antibiotics using 0.3 mm I.D. columns

Four cephalosporins, cefazolin, ceftizoxime, cefaloridine and cefaclor, were determined using a novel microbore high-performance liquid chromatographic system designed to be entirely compatible with direct liquid interfacing (DLI) for mass spectrometric analysis. The chromatographic support was a 5-micron C18 column of 0.3 mm I.D., compared with the usual microbore column diameters of 1-2 mm. The mobile phase contained no buffers or salts which may have caused column blocking or mobile phase crystallization, and the use of a concentration column allowed the injection of large volumes of analyte (up to 500 microliters). The assay was reproducible, the relative standard deviations being less than 20% within-day and between-day for all the drugs. The detection limit for cefaloridine and cefazolin was 1 ng and for cefaclor and ceftizoxime 5 ng.