Efficacy and safety of cefdinir in the treatment of maxillary sinusitis

WITHDRAWN: Antibiotics for acute maxillary sinusitis in adults

Currently, two separate Cochrane reviews, ‘Antibiotics for acute maxillary sinusitis in adults ’ and ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’ describe the effect of antibiotics for acute rhinosinusitis. Although both Cochrane reviews study the same condition, they look at different populations (patients in which the diagnosis was based on clinical signs and symptoms and patients in which the diagnosis was confirmed by imaging). Because of this, the conclusions are different in these Cochrane reviews. This was confusing for clinicians who needed to read both Cochrane reviews to know which conclusions are most applicable to their patients.
 
 This review is being withdrawn and will be incorporated into the updated publication of ‘Antibiotics for clinically diagnosed acute rhinosinusitis in adults ’. This ‘merged’ review will still maintain the relevant distinction between the two populations. However, information on the effectiveness of antibiotics for rhinosinusitis will be published in the ‘merged’ Cochrane review. We will omit the comparison between antibiotics (as published in this Cochrane review) because the choice for certain antibiotics and/or doses differs according to the local antibiotic resistance patterns and therefore this comparison is less relevant.

The editorial group responsible for this previously published document have withdrawn it from publication.

Antibiotics for acute maxillary sinusitis in adults

BACKGROUND

Sinusitis is one of the most common diagnoses among adults in ambulatory care, accounting for 15% to 21% of all adult outpatient antibiotic prescriptions. However, the role of antibiotics for sinusitis is controversial.

OBJECTIVES

To assess the effects of antibiotics in adults with acute maxillary sinusitis by comparing antibiotics with placebo, antibiotics from different classes and the side effects of different treatments.

SEARCH METHODS

We searched CENTRAL 2013, Issue 2, MEDLINE (1946 to March week 3, 2013), EMBASE (1974 to March 2013), SIGLE (OpenSIGLE, later OpenGrey (accessed 15 January 2013)), reference lists of the identified trials and systematic reviews of placebo-controlled studies. We also searched for ongoing trials via ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We imposed no language or publication restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, confirmed or not by imaging or bacterial culture.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search results, extracted data and assessed trial quality. We calculated risk ratios (RRs) for differences between intervention and control groups in whether the treatment failed or not. All measures are presented with 95% confidence intervals (CIs). We conducted the meta-analyses using either the fixed-effect or random-effects model. In meta-analyses of the placebo-controlled studies, we combined data across antibiotic classes. Primary outcomes were clinical failure rates at 7 to 15 days and 16 to 60 days follow-up. We used GRADEpro to assess the quality of the evidence.

MAIN RESULTS

We included 63 studies in this updated review; nine placebo-controlled studies involving 1915 participants (seven of the studies clearly conducted in primary care settings) and 54 studies comparing different classes of antibiotics (10 different comparisons). Five studies at low risk of bias comparing penicillin or amoxicillin to placebo provided information on the main outcome: clinical failure rate at 7 to 15 days follow-up, defined as a lack of full recovery or improvement, for participants with symptoms lasting at least seven days. In these studies antibiotics decreased the risk of clinical failure (pooled RR of 0.66, 95% CI 0.47 to 0.94, 1084 participants randomised, 1058 evaluated, moderate quality evidence). However, the clinical benefit was small. Cure or improvement rates were high in both the placebo group (86%) and the antibiotic group (91%) in these five studies. When clinical failure was defined as a lack of full recovery (n = five studies), results were similar: antibiotics decreased the risk of failure (pooled RR of 0.73, 95% CI 0.63 to 0.85, high quality evidence) at 7 to 15 days follow-up.Adverse effects in seven of the nine placebo-controlled studies (comparing penicillin, amoxicillin, azithromycin or moxicillin to placebo) were more common in antibiotic than in placebo groups (median of difference between groups 10.5%, range 2% to 23%). However, drop-outs due to adverse effects were rare in both groups: 1.5% in antibiotic groups and 1% in control groups.In the 10 head-to-head comparisons, none of the antibiotic preparations were superior to another. However, amoxicillin-clavulanate had significantly more drop-outs due to adverse effects than cephalosporins and macrolides.

AUTHORS' CONCLUSIONS

There is moderate evidence that antibiotics provide a small benefit for clinical outcomes in immunocompetent primary care patients with uncomplicated acute sinusitis. However, about 80% of participants treated without antibiotics improved within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population levels.

Cefdinir: an oral cephalosporin for the treatment of respiratory tract infections and skin and skin structure infections

Cefdinir is an oral third-generation cephalosporin (also known as an advanced-spectrum or generation cephem) with good in vitro activity against the pathogens responsible for community-acquired respiratory tract infections and uncomplicated skin and skin structure infections. The drug distributes very well in respiratory tract tissues and fluids, as well as skin blisters and ear fluids; its pharmacokinetic profile allows once- or twice-daily administration. Oral cefdinir 300 mg twice daily or 600 mg once daily in adults and adolescents, or 14 mg/kg/day in one or two daily doses in pediatric patients, administered for 5 or 10 days, has shown good clinical and bacteriological efficacy, at least equivalent to that of other oral agents in randomized controlled trials conducted in patients with community-acquired pneumonia, acute bacterial exacerbation of chronic bronchitis, sinusitis, acute otitis media, pharyngitis and uncomplicated skin and skin structure infections. Cefdinir is well tolerated and the oral suspension has shown superior taste or palatability over other comparator oral antimicrobial agents. Thus, cefdinir continues to represent an important cephalosporin option for the treatment of adult, adolescent and pediatric patients with mild or moderate respiratory tract or cutaneous infections, especially in areas with elevated rates of beta-lactamase production in Haemophilus influenzae and where resistance to other commonly used agents has emerged (e.g., macrolides, penicillins, tetracyclines, fluoroquinolones and trimethoprim-sulfamethoxazole).

Antibiotics for acute maxillary sinusitis

BACKGROUND

Expert opinions vary on the appropriate role of antibiotics for sinusitis, one of the most commonly diagnosed conditions among adults in ambulatory care.

OBJECTIVES

We examined whether antibiotics are effective in treating acute sinusitis, and if so, which antibiotic classes are the most effective.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2007, Issue 3); MEDLINE (1950 to May 2007) and EMBASE (1974 to June 2007).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing antibiotics with placebo or antibiotics from different classes for acute maxillary sinusitis in adults. We included trials with clinically diagnosed acute sinusitis, whether or not confirmed by radiography or bacterial culture.

DATA COLLECTION AND ANALYSIS

At least two review authors independently screened search results, extracted data and quality assessed trials. Risk ratios (RR) were calculated for differences in the intervention and control groups to see whether or not the treatment was a failure. In meta-analysing the placebo-controlled studies, the data across antibiotic classes were combined. Primary outcomes were the clinical failure rates at 7 to 15 days and 16 to 60 days follow up.

MAIN RESULTS

Fifty-seven studies were included in the review; six placebo-controlled studies and 51 studies comparing different classes of antibiotics. Five studies involving 631 participants provided data for comparison of antibiotics to placebo, when clinical failure was defined as a lack of cure or improvement at 7 to 15 days follow up. These studies found a slight statistical difference in favor of antibiotics, compared to placebo, with a pooled RR of 0.66 (95% confidence interval (CI) 0.44 to 0.98). However, the clinical significance of the result is equivocal, also considering that cure or improvement rate was high in both the placebo group (80%) and the antibiotic group (90%). Based on six studies, when clinical failure was defined as a lack of total cure, there was significant difference in favor of antibiotics compared to placebo with a pooled RR of 0.74 (95% CI 0.65 to 0.84) at 7 to 15 days follow up. None of the antibiotic preparations was superior to each other.

AUTHORS' CONCLUSIONS

Antibiotics have a small treatment effect in patients with uncomplicated acute sinusitis in a primary care setting with symptoms for more than seven days. However, 80% of participants treated without antibiotics improve within two weeks. Clinicians need to weigh the small benefits of antibiotic treatment against the potential for adverse effects at both the individual and general population level.

Guidelines on the treatment of ABRS in adults

Acute bacterial rhinosinusitis (ABRS) is a common reason for healthcare visits, and one of the more common reasons for the use of antibiotics. In an effort to improve the diagnosis and appropriate therapy of ABRS, several guidelines have been developed. Current guidelines recommend extended-spectrum cephalosporins as one of the first-line options for the treatment of this condition. In addition, most cephalosporins recommended by recent guidelines (e.g. cefuroxime axetil, cefpodoxime proxetil and cefdinir) are unlikely to be associated with cross-reactivity with penicillins, and may be considered effective alternatives to amoxicillin in adults who are allergic to penicillin.

Adverse events associated with the use of oral cephalosporins/cephems

Historically, oral cephalosporins represent one of the most widely used and safest classes of antimicrobials available. Typical adverse events have included nausea, vomiting, diarrhea, and hypersensitivity reactions. Other more serious events such as pseudomembranous colitis, although infrequent, may occur. The exact type and incidence of adverse events varies depending on the cephalosporin being administered. Differences in adverse event profiles may also vary by age of the patient. Reactions are usually not severe and often do not require termination of therapy. The purpose of this review is to present to healthcare providers the historical safety profile of the most commonly used oral cephalosporins.

Oral beta-lactams in the treatment of acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis (ABRS) is a well-known complication of viral upper respiratory tract infection and is associated with a significant socioeconomic burden. Difficulties in diagnosis, a substantial spontaneous resolution rate, and growing concerns regarding antimicrobial resistance make the proper management of ABRS quite challenging. Treatment guidelines have been developed, taking into account the major bacterial pathogens, rates of antimicrobial resistance, spontaneous resolution rates, and pharmacokinetic and pharmacodynamic considerations. Optimal choices for initial treatment of ABRS in patients without prior antibacterial exposure include the oral beta-lactam agents amoxicillin/clavulanate, cefdinir, cefpodoxime, and cefuroxime. Clinicians are encouraged to consider the local pathogen distribution and rates of antibacterial resistance in selecting therapy for ABRS.

Therapeutic experience with cefdinir in the treatment of uSSSIs

Uncomplicated skin and skin-structure infections (uSSSIs) are common community-acquired infections which are often caused by Staphylococcus aureus and Streptococcus pyogenes, although other pathogens are often involved. A recent treatment algorithm has recommended the use of cephalosporins as an appropriate antibiotic therapy for uSSSIs and, in particular, highlighted cefdinir as an extended-spectrum, third-generation cephalosporin with good antimicrobial activity and favourable tolerability. This case report briefly reviews the rationale for the use of cefdinir in the treatment of uSSSIs and presents two case studies to highlight the clinical use of this agent.

The efficacy of cefdinir in acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis is a common infection resulting in substantial morbidity. Cefdinir, an oral cephalosporin, has extended-spectrum, bactericidal activity against common acute bacterial rhinosinusitis pathogens, including Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Cefdinir shows rapid oral absorption and good respiratory tissue penetration, and may be administered once daily. In randomised clinical trials, cefdinir showed efficacy similar to that of other recommended regimens in the treatment of acute bacterial rhinosinusitis, namely amoxicillin/clavulanate and levofloxacin. Cefdinir is well tolerated and has shown a low propensity to suppress the normal commensal flora. Cefdinir oral suspension is rated highly by children in terms of its taste and smell. As the only once-daily beta-lactam currently recommended by acute bacterial rhinosinusitis guidelines (for first-line use in patients with mild acute bacterial rhinosinusitis and no recent antibacterial use), cefdinir offers a convenient and attractive treatment option.

Cefdinir: An oral alternative to parenteral cephems

Cost savings are possible if oral cephems of equivalent efficacy can be substituted for parenteral cephems. An in vitro study was performed to compare the activity of cefdinir, cefoxitin, cefazolin, ceftriaxone, ceftazidime, and cefepime against 243 clinical isolates of human pathogens. Activities were determined by National Committee for Clinical Laboratory Standards microbroth dilution methodology using an inoculum of approximately 5 x 10(5) CFU/mL. Cefdinir was the single or equally most potent agent against Streptococcus pyogenes, penicillin-susceptible Streptococcus pneumoniae, methicillin-susceptible Staphylococcus aureus, and Klebsiella pneumoniae isolates that produced a variety of beta-lactamase types. Cefdinir was less potent than ceftriaxone, ceftazidime, and cefepime against Haemophilus influenzae, but was 2- to 8-fold more potent than cefoxitin and 8- to 32-fold more potent than cefazolin. Cefdinir was slightly less potent than ceftazidime, against beta-lactamase-positive Moraxella catarrhalis. These data support clinical consideration of cefdinir as an alternative to parenteral cephems in infections where adequate tissue levels can be safely assured.

Cefdinir: a review of its use in the management of mild-to-moderate bacterial infections

Cefdinir (Omnicef) is an oral third-generation cephalosporin with good in vitro activity against many pathogens commonly causative in community-acquired infections. The drug provides good coverage against Haemophilus influenzae, Moraxella catarrhalis and penicillin-susceptible Streptococcus pneumoniae, the most common respiratory tract pathogens. Cefdinir is stable to hydrolysis by commonly occurring plasmid-mediated beta-lactamases and retains good activity against beta-lactamase-producing strains of H. influenzae and M. catarrhalis. The drug distributes into various tissues (e.g. sinus and tonsil) and fluids (e.g. middle ear), and has a pharmacokinetic profile that allows for once- or twice-daily administration.Cefdinir, administered for 5 or 10 days, has shown good clinical and bacteriological efficacy in the treatment of a wide range of mild-to-moderate infections of the respiratory tract and skin in adults, adolescents and paediatric patients in randomised, controlled trials. In adults and adolescents, cefdinir is an effective treatment for both lower (acute bacterial exacerbations of chronic bronchitis [ABECB], community-acquired pneumonia) and upper (acute bacterial rhinosinusitis, streptococcal pharyngitis) respiratory tract infections, and uncomplicated skin infections. Its bacteriological and clinical efficacy in patients with lower respiratory tract infections was equivalent to that of comparator agents (cefprozil [bacteriological only], loracarbef, cefuroxime axetil and cefaclor). In one trial in patients with ABECB, cefdinir produced a higher rate of clinical cure than cefprozil (95% CIs indicated nonequivalence). Cefdinir also produced good clinical and bacteriological responses equivalent to responses with amoxicillin/clavulanic acid in patients with acute bacterial rhinosinusitis. In addition, it was at least as effective as penicillin V (phenoxymethylpenicillin) in streptococcal pharyngitis/tonsillitis and as effective as cefalexin in uncomplicated skin infections. In paediatric patients aged > or =6 months, cefdinir showed similar efficacy to that of amoxicillin/clavulanic acid or cefprozil in acute otitis media, and cefalexin in uncomplicated skin infections. Cefdinir given for 5 or 10 days was at least as effective as penicillin V for 10 days in patients with streptococcal pharyngitis/tonsillitis. Cefdinir is usually well tolerated. Diarrhoea was the most common adverse event in trials in all age groups. Although the incidence of diarrhoea in cefdinir recipients was generally higher than in adults and adolescents treated with comparators, discontinuation rates due to adverse events were generally similar for cefdinir and comparator groups. In conclusion, cefdinir is a third-generation cephalosporin with a broad spectrum of antibacterial activity encompassing pathogens that are commonly causative in infections of the respiratory tract or skin and skin structure. Depending on the infection being treated, cefdinir can be administered as a convenient once- or twice-daily 5- or 10-day regimen. Clinical evidence indicates that cefdinir is an effective and generally well tolerated drug with superior taste over comparator antibacterial agents and is therefore a good option for the treatment of adults, adolescents and paediatric patients with specific mild-to-moderate respiratory tract or skin infections, particularly in areas where beta-lactamase-mediated resistance among common community-acquired pathogens is a concern.

Antibiotics for acute maxillary sinusitis

BACKGROUND

For adults seeking care in ambulatory medical practices, sinusitis is the most common diagnosis treated with antibiotics.

OBJECTIVES

We examined whether antibiotics are indicated for acute sinusitis, and if so, which antibiotic classes are most effective.

SEARCH STRATEGY

Relevant studies were identified from searches of MEDLINE and EMBASE in December 2001, contacts with pharmaceutical companies and bibliographies of included studies.

SELECTION CRITERIA

Randomized trials were eligible that compared antibiotic to control or antibiotics from different classes, for acute maxillary sinusitis. Additional criteria for inclusion were diagnostic confirmation by radiograph or sinus aspiration, outcomes that included clinical cure or improvement, and a sample size of 30 or more adults. Of 2058 potentially relevant studies, two or more reviewers identified 49 studies meeting selection criteria.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two persons and synthesized descriptively. Some data were analyzed quantitatively using a random effects model. Primary outcomes were: a) clinical cure, and b) clinical cure or improvement. Secondary outcomes were radiographic improvement, relapse rates, and dropouts due to adverse effects.

MAIN RESULTS

Forty-nine trials, involving 13,660 participants, evaluated antibiotic treatment for acute maxillary sinusitis. Major comparisons were antibiotic versus control (n of 5); newer, non-penicillin antibiotic versus penicillin class (n of 10); and amoxicillin-clavulanate versus other extended spectrum antibiotics (n of 17), where n is the number of trials. Most trials were conducted in otolaryngology settings. Only 8 trials described adequate allocation and concealment procedures; 20 were double-blind. Compared to control, penicillin improved clinical cures [relative risk (RR) 1.72; 95% CI 1.00 to 2.96]. Treatment with amoxicillin did not significantly improve cure rates (RR 2.06; 95% CI 0.65 to 6.53) but there was significant variability between studies. Radiographic outcomes were improved by antibiotic treatment. Comparisons between classes of antibiotics showed no significant differences: newer non-penicillins versus penicillins (RR for cure 1.07; 95% CI 0.99 to 1.17); newer non-penicillins versus amoxicillin-clavulanate (RR for cure 1.03; 95% CI 0.96 to 1.11). Compared to amoxicillin-clavulanate, dropouts due to adverse effects were significantly lower for cephalosporin antibiotics (RR 0.47; 95% CI 0.30 to 0.73). Relapse rates within one month of successful therapy were 7.7%.

REVIEWER'S CONCLUSIONS

For acute maxillary sinusitis confirmed radiographically or by aspiration, current evidence is limited but supports the use of penicillin or amoxicillin for 7 to 14 days. Clinicians should weigh the moderate benefits of antibiotic treatment against the potential for adverse effects.

Cefdinir: an advanced-generation, broad-spectrum oral cephalosporin

BACKGROUND

Cefdinir is an advanced-generation, broad-spectrum cephalosporin antimicrobial agent that has been approved for the treatment of community-acquired pneumonia, acute bacterial exacerbations of chronic bronchitis, acute maxillary sinusitis, pharyngitis/tonsillitis, acute bacterial otitis media, and uncomplicated skin and skin-structure infections in adult and pediatric patients.

OBJECTIVE

The purpose of this article was to review the in vitro antimicrobial activity, pharmacokinetics, clinical efficacy, safety, and potential role of cefdinir.

METHODS

Studies were identified by a MEDLINE search (January 1983-September 2001) of the English-language medical literature, a review of identified articles and their bibliographies, and a review of data on file with the manufacturer. Clinical efficacy data were selected from all published trials mentioning cefdinir. Information concerning in vitro susceptibility, safety, chemistry, and the pharmacokinetic profile of cefdinir also was reviewed.

RESULTS

Cefdinir has a broad spectrum of activity against many gram-negative and gram-positive aerobic organisms, including Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae, and Moraxella catarrhalis. Cefdinir is stable to hydrolysis by 13 of the common beta-lactamases. It is rapidly absorbed from the gastrointestinal tract (mean time to peak plasma concentration, 3 hours) and is almost entirely eliminated via renal clearance of unchanged drug. The terminal disposition half-life of cefdinir is approximately 1.5 hours. Efficacy has been demonstrated in 19 clinical trials in adults and children with upper and lower respiratory tract infections (eg, pharyngitis, sinusitis, acute otitis media, acute bronchitis, acute bacterial exacerbation of chronic bronchitis, community-acquired pneumonia), and skin and skin-structure infections. The adverse-event profile is similar to that of comparator agents, although in 4 adult and adolescent studies and 1 adult study, diarrhea occurred significantly more frequently in cefdinir recipients than in recipients of penicillin V, cephalexin, cefaclor, and cefprozil.

CONCLUSIONS

Cefdinir is an alternative to other antimicrobial agents and can be dosed once or twice daily for the treatment of upper and lower respiratory tract infections and skin and skin-structure infections. Similar to other oral expanded-spectrum cephalosporins, cefdinir has activity against common pathogens of the respiratory tract and skin and is stable in the presence of selected beta-lactamases. The clinical choice of an oral expanded-spectrum cephalosporin will be based on patient acceptance, frequency of administration, and cost.