Evaluation of a Clinical Decision Support System and an Automated Electronic Health Record Alert on Outpatient Prescribing of Cefdinir

Acute bacterial upper respiratory infections are common indications for antibiotics in pediatrics, and many prescriptions may be inappropriate. Novel approaches to outpatient antimicrobial stewardship interventions are needed. This quasi-experimental study of an order set and best practice advisory alert targeting cefdinir prescriptions demonstrated an 8.4% decrease in cefdinir prescribing (P ≤ .001).

Renin-angiotensin inhibitors reduce thrombotic complications in Essential Thrombocythemia and Polycythemia Vera patients with arterial hypertension

Essential Thrombocythemia (ET) and Polycythemia Vera (PV) are chronic myeloproliferative neoplasms (MPNs) characterized by thrombotic and hemorrhagic complications, leading to a high risk of disability and mortality. Although arterial hypertension was found to be the most significant modifiable cardiovascular (CV) risk factor in the general population, little is known about its role in MPNs as well as a possible role of renin-angiotensin system inhibitors (RASi) in comparison with other anti-hypertensive treatments. We investigated a large cohort of 404 MPN adult patients, 133 diagnosed with PV and 271 with ET. Over half of the patients (53.7%) reported hypertension at MPN diagnosis. The 15-year cumulative incidence of thrombotic-adverse events (TAEs) was significantly higher in patients with hypertension (66.8 ± 10.3% vs 38.5 ± 8.4%; HR = 1.83; 95%CI 1.08-3.1). Multivariate analysis showed that PV diagnosis and hypertension were independently associated with a higher risk of developing TAEs (HR = 3.5; 95%CI 1.928-6.451, p < 0.001 and HR = 1.8; 95%CI 0.983-3.550, p = 0.05, respectively). In multivariate analysis, the diagnosis of PV confirmed a significant predictive role in developing TAEs (HR = 4.4; 95%CI 1.92-10.09, p < 0.01), also considering only MPN patients with hypertension. In addition, we found that the use of RASi showed a protective effect from TAEs both in the whole cohort of MPN with hypertension (HR = 0.46; 95%CI 0.21-0.98, p = 0.04) and in the subgroup of thrombotic high-risk score patients (HR = 0.49; 95%CI 0.24-1.01, p = 0.04). In particular, patients with ET and a high risk of thrombosis seem to benefit most from RASi treatment (HR = 0.27; 95%CI 0.07-1.01, p = 0.03). Hypertension in MPN patients represents a significant risk factor for TAEs and should be adequately treated.

Prevalence of metabolic syndrome and components in rural, semi-urban and urban areas in the littoral region in Cameroon: impact of physical activity

BACKGROUND

Living areas in developing countries impact seriously lifestyle by modifying energy consumption and energy expenditure. Thus, urbanization is associated with less practice of physical activity (PA), a leading cause of metabolic syndrome (MetS) which prevalence vary in African countries. The present study aimed to assess the effect of PA on MetS according to urbanization level in the littoral region, Cameroon.

METHODS

A cross-sectional study was conducted in three geographical settings (urban, semi-urban, and rural) in the littoral region in Cameroon. A total of 879 participants were included (urban: 372, semi-urban: 195 and rural: 312). MetS was defined according to the International Federation of Diabetes 2009. The level of PA was assessed using the Global Physical Activity questionnaire.

RESULTS

Low level of PA was (P < 0.0001) reported in urban (54.5%), semi-urban (28.7%) and rural (16.9%) and high level in rural area (77.9%). The prevalence of MetS was higher in urban areas (37.2%), then rural (36.8%) and finally semi-urban (25.9%). Hyperglycemia (p = 0.0110), low HDL-c (p < 0.0001) and high triglyceridemia (p = 0.0068) were most prevalent in urban residents. Participants with low level of PA were at risk of MetS (OR: 1.751, 95% CI 1.335-2.731, p = 0.001), hyperglycemia (OR: 1.909, 95% CI 1.335-2.731, p = 0.0004) abdominal obesity(OR: 2.007, 95% CI 1.389-2.900, p = 0.0002), low HDL-c (OR: 1.539, 95% CI 1.088-2.179, p = 0.014) and those with moderate level of PA were protected against high blood pressure(OR: 0.452, 95% CI 0.298-0.686, p = 0.0002) and compared to those with high level of PA. Urban dwellers were at the risk of MetS compared to rural residents (OR: 1.708, 95% CI. 1.277-2.285, p = 0.003) and protected against high blood pressure (OR:0.314, 95% CI 0.212-0.466, p < 0.0001), abdominal obesity (OR: 0.570, 95% CI 0.409-0.794, p = 0.0009), and low HDL-c (OR: 0.725, 95% CI 0.534-0.983, p = 0.038) compared to rural residents.

CONCLUSIONS

MetS was more prevalent in urban dwellers and was associated with a low level of PA.

Elevated SIRT2 of serum exosomes is positively correlated with diagnosis of acute ischemic stroke patients

BACKGROUND

Silent Information Regulator 2 (SIRT2) protein inhibition has been shown to play a neuroprotective role in acute ischemic stroke (AIS) in mice. However, its role in AIS patients has not been fully understood. In this study, we aimed to analyze SIRT2 protein expression in serum exosomes of AIS and non-AIS patients, and evaluate its potential role in diagnosis and prognosis of AIS.

METHODS

Serum exosomes from 75 non-AIS subjects and 75 AIS patients were isolated. The SIRT2 protein levels in exosomes were analyzed using enzyme linked immunosorbent assay (ELISA). The National Institutes of Health Stroke Scale (NIHSS) was used to evaluate the severity of the disease. The modified Rankin Scale (mRS) was employed to assess the functional outcomes of the patients at 3-months following stroke onset.

RESULTS

The SIRT2 protein concentration of serum exosomes were higher in AIS patients than non-AIS patients (p < 0.001). Furthermore, the receiver operative characteristic curve (ROC) demonstrated that higher serum exosome SIRT2 could differentiate AIS patients from non-AIS patients with a sensitivity of 81.3% and a specificity of 75.3%. The area under the curve was 0.838 (95% CI: 0.775, 0.902). Additionally, higher SIRT2 concentration of serum exosomes were associated with NIHSS ≥ 4 (p < 0.001) and mRS ≥ 3 (p = 0.025) in AIS patients. The ROC analysis showed SIRT2 could discriminate stroke with NIHSS ≥ 4 from mild stroke (NIHSS < 4) with a sensitivity of 75.0% and a specificity of 69.6%. The area under the curve was 0.771 (95% CI: 0.661,0.881). Similarly, the test showed SIRT2 could differentiate between AIS patients with mRS ≥ 3 from those with mRS < 3 with a sensitivity of 78.3% and a specificity of 51.9%. The area under the curve was 0.663 (95% CI: 0.531,0.796). The logistic regression analysis revealed that SIRT2 concentration in serum exosomes can independently predict the diagnosis of AIS (odd ratio = 1.394, 95%CI 1.231-1.577, p < 0.001) and higher NIHSS scores (≥ 4) (odd ratio = 1.258, 95%CI 1.084-1.460, p = 0.002). However, it could not independently predict the prognosis of AIS (odd ratio = 1.065, 95%CI 0.983-1.154, p = 0.125).

CONCLUSION

The elevation of SIRT2 in serum exosomes may be a valuable biomarker of AIS, which may be a potential diagnostic tool to facilitate decision making for AIS patients.

Effectiveness of psychosocial interventions for infertile women: A systematic review and meta-analysis with a focus on a method-critical evaluation

BACKGROUND

Approximately seven to nine percent of couples of reproductive age do not get pregnant despite regular and unprotected sexual intercourse. Various psychosocial interventions for women and men with fertility disorders are repeatedly found in the literature. The effects of these interventions on outcomes such as anxiety and depression, as well as on the probability of pregnancy, do not currently allow for reliable generalisable statements. This review includes studies published since 2015 performing a method-critical evaluation of the studies. Furthermore, we suggest how interventions could be implemented in the future to improve anxiety, depression, and pregnancy rates.

METHOD

The project was registered with Prospero (CRD42021242683 13 April 2021). The literature search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Six databases were searched and 479 potential studies were discovered. After reviewing the full texts, ten studies were included for the synthesis. Not all studies reported the three outcomes: four studies each for depression, three for anxiety and nine studies for pregnancy rates were included in the meta-analysis, which was conducted using the Comprehensive meta-analysis (CMA) software.

RESULTS

Psychosocial interventions do not significantly change women's anxiety (Hedges' g -0,006; CI: -0,667 to 0,655; p = 0,985), but they have a significant impact on depression in infertile women (Hedges' g -0,893; CI: -1,644 to -0,145; p = 0,026). Implementations of psychosocial interventions during assisted reproductive technology (ART) treatment do not increase pregnancy rates (odds ratio 1,337; 95% CI 0,983 to 1,820; p = 0,064). The methodological critical evaluation indicates heterogeneous study design and samples. The results of the studies were determined with different methods and make comparability difficult. All these factors do not allow for a uniform conclusion.

METHODOLOGICAL CRITICAL EVALUATION

Study design (duration and timing of intervention, type of intervention, type of data collection) and samples (age of women, reason for infertility, duration of infertility) are very heterogeneous. The results of the studies were determined with different methods and make comparability difficult. All these factors do not allow for a uniform conclusion.

CONCLUSION

In order to be able to better compare psychosocial interventions and their influence on ART treatment and thus also to achieve valid results, a standardised procedure to the mentioned factors is necessary.

Utilization of nonguideline concordant antibiotic treatment following acute otitis media in children in the United States

PURPOSE

Acute otitis media (AOM) is a common indication for antibiotics in children. We sought to characterize the frequency of nonguideline concordant antibiotic therapy for AOM in the United States, by agent and duration.

METHODS

Using national administrative claims data (2016-2019), we identified children aged 6 months to 17 years with an oral antibiotic dispensed within 3 days of a new diagnosis of suppurative AOM. Use of nonguideline concordant agents and durations, defined based on national treatment guidelines, were summarized by age, race, rurality, region, and insurance type. Subsequent oral antibiotic dispensing within the year after AOM diagnosis was also evaluated. We created sunburst diagrams to visualize longitudinal patterns of within-person antibiotic utilization for AOM, by agent and duration.

RESULTS

We identified 789 424 eligible commercially-insured and 502 239 medicaid-insured children. Among commercially insured children, 35% received nonguideline concordant agents for AOM, including cefdinir (16%), amoxicillin-clavulanate (12%), and azithromycin (7%). Fewer children age <2 years received a nonguideline concordant initial agent (27%) compared to age ≥6 years (41%). More children age <2 years received three or more antibiotics over the following year (34% vs. 3% for children age ≥6 years). The most common treatment duration was 10 days for all ages; treatment duration for the initial antibiotic was nonguideline concordant for 95% and 89% of children age 2-5 years and ≥6 years, respectively. Patterns were similar for medicaid-insured children.

CONCLUSIONS

Nonguideline concordant antibiotic use is common when treating AOM in children, including use of broad-spectrum agents and longer-than-recommended antibiotic durations.

Bloody Stool: Is It Really Scary in Kids? Four Benign Cases

Cefdinir is a third-generation oral cephalosporin used frequently in the pediatric population. The most common side effects of cefdinir are diarrhea, nausea and dyspepsia. The side effect of turning the stool color to red and giving a bloody appearance, which is alarming for both families and physicians, is very rare. In this case report, we discussed 4 cases who referred to the emergency department with bloody stool due to the use of cefdinir. The important conclusion to be drawn from this case report is to know the rare side effects of commonly used drugs such as cefdinir. This will save time and resources and prevent unnecessary interventions on the patient.

Amoxicillin Versus Other Antibiotic Agents for the Treatment of Acute Otitis Media in Children

OBJECTIVES

The objective of the study was to compare the antibiotic treatment failure and recurrence rates between antibiotic agents (amoxicillin, amoxicillin-clavulanate, cefdinir, and azithromycin) for children with uncomplicated acute otitis media (AOM).

STUDY DESIGN

We completed a retrospective cohort study of children 6 months-12 years of age with uncomplicated AOM identified in a nationwide claims database. The primary exposure was the antibiotic agent, and the primary outcomes were treatment failure and recurrence. Logistic regression was used to estimate ORs, and analyses were stratified by primary exposure, patient age, and antibiotic duration.

RESULTS

Among the 1 051 007 children included in the analysis, 56.6% were prescribed amoxicillin, 13.5% were prescribed amoxicillin-clavulanate, 20.6% were prescribed cefdinir, and 9.3% were prescribed azithromycin. Most prescriptions (93%) were for 10 days, and 98% were filled within 1 day of the medical encounter. Treatment failure and recurrence occurred in 2.2% (95% CI: 2.1, 2.2) and 3.3% (3.2, 3.3) of children, respectively. Combined failure and recurrence rates were low for all agents including amoxicillin (1.7%; 1.7, 1.8), amoxicillin-clavulanate (11.3%; 11.1, 11.5), cefdinir (10.0%; 9.8, 10.1), and azithromycin (9.8%; 9.6, 10.0).

CONCLUSIONS

Despite microbiologic changes in AOM etiology, treatment failure and recurrence were uncommon for all antibiotic agents and were lower for amoxicillin than for other agents. These findings support the continued use of amoxicillin as a first-line agent for AOM when antibiotics are prescribed.

Influence of Organic Matter on the Sorption of Cefdinir, Memantine and Praziquantel on Different Soil and Sediment Samples

Pharmaceuticals are known for their great effects and applications in the treatment and suppression of various diseases in human and veterinary medicine. The development and modernization of science and technologies have led to a constant increase in the production and consumption of various classes of pharmaceuticals, so they pose a threat to the environment, which can be subjected to the sorption process on the solid phase. The efficiency of sorption is determined by various parameters, of which the physicochemical properties of the compound and the sorbent are very important. One of these parameters that determine pharmaceutical mobility in soil or sediment is the soil−water partition coefficient normalized to organic carbon (Koc), whose determination was the purpose of this study. The influence of organic matter, suspended in an aqueous solution of pharmaceutical (more precisely: cefdinir, memantine, and praziquantel), was studied for five different types of soil and sediment samples from Croatia. The linear, Freundlich, and Dubinin−Raduskevich sorption isotherms were used to determine specific constants such as the partition coefficient Kd, which directly describes the strength of sorbate and sorbent binding. The linear model proved to be the best with the highest correlation coefficients, R2 > 0.99. For all three pharmaceuticals, a positive correlation between sorption affinity described by Kd and Koc and the amount of organic matter was demonstrated.

Sorption of cefdinir, memantine, praziquantel and trimethoprim in sediment and soil samples

The everyday use of various pharmaceuticals to treat humans or animals means that they are increasingly found in the environment. Contamination of the soil can cause the active ingredients to be strongly sorbed to the soil or sediment. In the worst case, they can also be expected to occur in the aquatic environment due to their different polarity. In this study, four drugs from different therapeutic classes (trimetoprim, memantine, cefdinir, praziquantel) were used in dissolved form in two sediment and three soil samples to obtain data that can describe their fate and behavior in the environment. The sorption affinities of the pharmaceuticals were described using linear, Freundlich and Dubinin-Radushkevich sorption isotherms. The highest K_d values were obtained for cefdinir, while memantine and praziquantel tended to be present in water due to their very low sorption coefficients. The studied influence of pH showed a negative trend for memantine and trimetoprim, while an increase in ionic strength resulted in higher K_d values for all drugs. The sorption mechanism for all tested samples was best described by the pseudo-secondary kinetic model (R² > 0.9999).

Cephalosporins-induced intestinal dysbiosis exacerbated pulmonary endothelial barrier disruption in streptococcus pneumoniae-infected mice

Antibiotic abuse is growing more severe in clinic, and even short-term antibiotic treatment can cause long-term gut dysbiosis, which may promote the development and aggravation of diseases. Cephalosporins as the broad-spectrum antibiotics are widely used for prevention and treatment of community-acquired respiratory tract infection in children. However, their potential consequences in health and disease have not been fully elaborated. In this study, the effects of cefaclor, cefdinir and cefixime on intestinal microbiota and lung injury were investigated in Streptococcus pneumoniae (Spn)-infected mice. The results showed that the proportion of coccus and bacillus in intestinal microbiota were changed after oral administration with cefaclor, cefdinir and cefixime twice for 10 days, respectively. Compared with the Spn-infected group, the proportion of Bifidobacterium and Lactobacillus in intestine were significantly reduced, while Enterococcus and Candida was increased after cephalosporin treatment. Furthermore, 3 cephalosporins could obviously increase the number of total cells, neutrophils and lymphocytes in BALF as well as the serum levels of endotoxin, IL-2, IL-1β, IL-6 and TNF-α. Mechanically, cephalosporins accelerated Spn-induced pulmonary barrier dysfunction via mediating the mRNA expressions of endothelial barrier-related proteins (Claudin 5, Occludin, and ZO-1) and inflammation-related proteins (TLR4, p38 and NF-κB). However, all of those consequences could be partly reversed by Bifidobacterium bifidum treatment, which was closely related to the elevated acetate production, indicating the protective effects of probiotic against antibiotic-induced intestinal dysbiosis. Therefore, the present study demonstrated that oral administration with cephalosporins not only disrupted intestinal microecological homeostasis, but also increased the risk of Spn infection, resulting in severer respiratory inflammation and higher bacterial loads in mice.

Assessment of nationally recommended antibiotics for treatment of UTI in U.S.-Mexico border emergency departments

BACKGROUND

Urinary tract infections (UTIs) seen in the emergency department are commonly treated as an outpatient with oral antibiotics. Given that antibiotics are available for over-the-counter purchase in Mexico, there is speculation that potential misuse and overuse of antibiotics in United States-Mexico border areas could lead to antibiotic resistance patterns that would render some empiric treatments for UTIs less effective. The purpose of this study was to examine the effectiveness of Infectious Disease Society of America (IDSA) guideline-recommended antibiotics for treatment of outpatient UTI diagnosed in the emergency department. Data were collected from a county hospital on the U.S.-Mexico border with a metropolitan area of over 2 million people. Secondary analysis included frequency of urine culture isolated, resistance rates of urine pathogens, and prescriber habits.

METHODS

This study was a retrospective chart review of adult patients diagnosed and treated for UTI from August 1, 2019, to February 29, 2020. Culture results of included patients were analyzed against in vitro-tested antibiotics. Bacterial isolate frequency, resistance rates, and prescribing habits were collected.

RESULTS

A total of 985 patient charts were reviewed, of which 520 patients met inclusion criteria for analysis of prescribing habits. Of these, 329 positive bacterial culture growths were included in the analysis of antibiotic resistance rates. Oral antibiotics with comparatively lower resistance rates were amoxicillin/clavulanate, cefdinir, cefuroxime, and nitrofurantoin. Oral antibiotics with notably high resistance rates included trimethoprim-sulfamethoxazole (TMP-SMX), tetracycline, ciprofloxacin, levofloxacin, and cephalexin. Nitrofurantoin was prescribed most frequently for outpatient treatment of UTI/cystitis (41.6%) while cephalexin was the most commonly prescribed antibiotic for outpatient treatment of pyelonephritis (50%).

CONCLUSION

Our findings suggest that, while part of standard IDSA guidelines, fluoroquinolones and TMP-SMX are not ideal empiric antibiotics for treatment of outpatient UTI in the U.S.-Mexico border region studied due to high resistance rates. Although not listed as first line agents per current IDSA recommendations, 2nd and 3rd generation cephalosporins, and amoxicillin/clavulanate would be acceptable options given resistance patterns demonstrated in accordance with IDSA allowance for tailoring selection to local resistance. Nitrofurantoin appears to be consistent with recommendations and demonstrates a favorable resistance profile for treatment of outpatient UTI within this region.

Analytical method development and validation of spectrofluorimetric and spectrophotometric determination of some antimicrobial drugs in their pharmaceuticals

In this study, three novel, sensitive, simple and validated spectrophotometric and spectrofluorimetric methods have been proposed for estimation of some important antimicrobial drugs. The first two methods have been proposed for estimation of two important third-generation cephalosporin antibiotics namely, cefixime and cefdinir. Both methods were based on condensation of the primary amino group of the studied drugs with acetyl acetone and formaldehyde in acidic medium. The resulting products were measured by spectrophotometric (Method I) and spectrofluorimetric (Method II) tools. Regarding method I, the absorbance was measured at 315nm and 403nm with linearity ranges of 5.0-140.0 and 10.0-100.0μg/mL for cefixime and cefdinir, respectively. Meanwhile in method II, the produced fluorophore was measured at λ_em 488nm or 491nm after excitation at λ_ex 410nm with linearity ranges of 0.20-10.0 and 0.20-36.0μg/mL for cefixime and cefdinir, respectively. On the other hand, method III was devoted to estimate nifuroxazide spectrofluorimetrically depending on formation of highly fluorescent product upon reduction of the studied drug with Zinc powder in acidic medium. Measurement of the fluorescent product was carried out at λ_em 335nm following excitation at λ_ex 255nm with linearity range of 0.05 to 1.6μg/mL. The developed methods were subjected to detailed validation procedure, moreover they were used for the estimation of the concerned drugs in their pharmaceuticals. It was found that there is a good agreement between the obtained results and those obtained by the reported methods.

Cefdinir Solid Dispersion Composed of Hydrophilic Polymers with Enhanced Solubility, Dissolution, and Bioavailability in Rats

The aim of this work was to develop cefdinir solid dispersions (CSDs) prepared using hydrophilic polymers with enhanced dissolution/solubility and in vivo oral bioavailability. CSDs were prepared with hydrophilic polymers such as hydroxypropyl-methylcellulose (HPMC; CSD1), carboxymethylcellulose-Na (CMC-Na; CSD2), polyvinyl pyrrolidone K30 (PVP K30; CSD3) at the weight ratio of 1:1 (drug:polymer) using a spray-drying method. The prepared CSDs were characterized by aqueous solubility, differential scanning calorimetry (DSC), powder X-ray diffraction (p-XRD), scanning electron microscopy (SEM), aqueous viscosity, and dissolution test in various media. The oral bioavailability of CSDs was also evaluated in rats and compared with cefdinir powder suspension. The cefdinir in CSDs was amorphous form, as confirmed in the DSC and p-XRD measurements. The developed CSDs commonly resulted in about 9.0-fold higher solubility of cefdinir and a significantly improved dissolution profile in water and at pH 1.2, compared with cefdinir crystalline powder. Importantly, the in vivo oral absorption (represented as AUC_inf) was markedly increased by 4.30-, 6.77- and 3.01-fold for CSD1, CSD2, and CSD3, respectively, compared with cefdinir suspension in rats. The CSD2 prepared with CMC-Na would provide a promising vehicle to enhance dissolution and bioavailability of cefdinir in vivo.

INVASIVE SALMONELLOSIS PRESENTING AS A LUNG ABSCESS: A CASE REPORT

Salmonella spp are an uncommon cause of lung abscess. A 59 year old man presented to our hospital with a 1 month history of cough and low grade fever progressing to high grade fever for 1 week. He had a past medical history significant for diabetes mellitus type 2 and focal segmental glomerulosclerosis for which he was receiving prednisolone, initially at 60 mg daily tapering to 20 mg daily. On presentation he was febrile and had decreased breath sounds and dullness to percussion over the right lower lung field. A chest X-ray showed a cavitary lesion with an air-fluid level in the right lung. Computed tomography of the lung revealed 2 cavitary lesions in the right upper and lower lungs. Sputum culture revealed Salmonella spp group B. He was treated successfully with ceftriaxone intravenously for 1 month followed by oral cefdinir. A chest X-ray at 1 month showed significant improvement; he was treated conservatively without surgical drainage. Salmonella can cause lung abscesses, especially in the immune suppressed.

Sensitive and Simplified Detection of Antibiotic Influence on the Dynamic and Versatile Changes of Fecal Short-Chain Fatty Acids

Short-chain fatty acids (SCFAs), produced by anaerobic fermentation of mainly indigestible dietary carbohydrates by gut microbiota, have a profound influence on intestinal function and host energy metabolism. Antibiotics may seriously disturb the balance of fecal SCFAs. To evaluate the impacts of antibiotics on fecal SCFAs produced by gut microbiota, a simple, reproducible and accurate gas chromatography (GC) method, which can simultaneously analyze seven SCFAs in fecal samples, was developed and validated. The ranges of detection and quantitation of the SCFAs reached 0.0868 ~ 0.393 and 0.261 ~ 1.18 μg·mL-1 respectively, in an optimized protocol for SCFAs extraction and analysis that used 10 mL 75% ethanol aqueous solution containing 1% HCl, without ultrasonication. The technique exhibited excellent intra-day (relative standard deviation (RSD) ≤ 2.54%) and inter-day (RSD ≤ 4.33%) precisions for all the SCFAs. Later, we administered broad-spectrum antibiotics, cefdinir or azithromycin to rats and analyzed the alterations in fecal SCFAs. The total amount, types and distribution of nearly all fecal SCFAs were significantly altered during the administration and even after withdrawal of the antibiotics in rats. The effects of cefdinir on the SCFAs were more pronounced than those of azithromycin. Our findings suggest SCFAs may serve as sensitive indicators to monitor the influences of antibiotics on SCFAs originated by intestinal bacteria. Our improved SCFAs analysis method is a potential platform for a standard clinical test of the effects of new antibiotics on SCFAs.

[Construction of the quantitative structure retention relationship of cefdinir related substances]

The molecular descriptors of impurities with known structure in cefdinir were calculated, selected and associated with the chromatographic retention behavior to establish a model. This quantitative structure retention relationships (QSRR) model for the related substances of cefdinir was established under specific chromatographic condition and verified by other impurities. 12 molecular descriptors were used to establish the QSRR model, F_AFRBWF, Blbn_J, SsCH3, SssCH2, SsNH2, SssNH, SssS, SHdCH2, EEM_AFc, EEM_AFpl, EEM_XFpl and Pi_MaxQ. The relativity between true values and predictions in QSRR of cefdinir is R2 = 0.9836 (n = 18), ΔRRT is no more than 0.154, as 10.17% in RRT. The results indicate that the QSRR model for the related substances of cefdinir can be used to evaluate the analysis methods for related substances and predict the chromatographic behavior of new impurities, which will provide a new way for the evaluation of the effectiveness for drug quality control.

Facial vein thrombophlebitis: an uncommon complication of sinusitis

Facial vein thrombophlebitis is an uncommon complication of sinusitis. In cases where periorbital swelling complicating sinusitis is diagnosed, clinical findings of swelling and erythema extending beyond the orbital region into the cheek should alert the physician about this unusual complication and the need for further contrast-enhanced imaging and venography. The radiologist must be particularly careful in the evaluation of vascular structures of the face and neck in these children. CT and MRI with contrast material and MR venography are studies that clearly demonstrate the vascular anatomy and possible complications. However, MR venography confirms flow abnormalities within the venous system with the advantage of avoiding radiation exposure to the pediatric patient.

SMN04 for degradation of cefdinir, a cephalosporin antibiotic: kinetics, enzyme analysis and biodegradation pathway

A new yeast strain isolated from the pharmaceutical wastewater was capable of utilizing cefdinir as a sole carbon source for their growth in mineral medium. The yeast was identified and named as Candida sp. SMN04 based on morphology and 18S-ITS-D1/D2/D3 rRNA sequence analysis. The interaction between factors pH (3.0-9.0), inoculum dosage (1-7%), time (1-11 day) and cefdinir concentration (50-450 mg/L) was studied using a Box-Behnken design. The factors were studied as a result of their effect on cell dry weight (R1; g/L), extended spectrum β-lactamase (ESBL) assay (R2; mm), P450 activity (R3; U/mL) and degradation (R4; %). Maximum values of R1, R2, R3 and R4 were obtained at central values of all the parameters. The isolated yeast strain efficiently degraded 84% of 250 mg L⁻¹ of cefdinir within 6 days with a half-life of 2.97 days and degradation rate constant of 0.2335 per day. Pseudo-first-order model efficiently described the process. Among the various enzymes tested, the order of activity at the end of Day 4 was noted to be: cytochrome P450 (1.76 ± 0.03) > NADPH reductase (1.51 ± 0.20) > manganese peroxidase and amylase (0.66 ± 0.15; 0.66 ± 0.70). Intermediates were successfully characterized by liquid chromatography-mass spectrometry. The opening of the β-lactam ring involving ESBL activity was considered as one of the major steps in the cefdinir degradation process. Fourier transform-infrared spectroscopy analysis showed the absence of spectral vibrations between 1766 and 1519 cm⁻¹ confirming the complete removal of lactam ring during cefdinir degradation. The results of the present study are promising for the use of isolated yeast Candida sp. SMN04 as a potential bioremediation agent.

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).

Cefdinir

Cefdinir is a third-generation oral cephalosporin antibiotic. Nomenclature, formulae, elemental analysis, and appearance of the drug are mentioned. The uses and applications and the several methods described for its preparation of the drug are outlined. The profile contains the physical characteristics including: pKa value, solubility, X-ray powder diffraction, melting point, and differential scanning calorimetry. The ultraviolet spectrum, vibrational spectrum, nuclear magnetic resonance ((1)H and (13)C NMR) spectra and the mass spectrum and fragmentation patterns of cefdinir together with the corresponding figures and/or tables are all produced. This profile includes the monographs of the Japanese pharmacopeia and the United States pharmacopeia. The several reported analytical methods that had been reported of the analysis of cefdinir include: spectrophotometric, polarographic, voltammetric, and chromatographic methods. The pharmacokinetics and stability of the drug are also provided. About 80 references are listed at end of this comprehensive profile.

Otitis media

Acute otitis media (AOM) is diagnosed based on visualization of a full or bulging tympanic membrane with middle ear effusion. The distribution of bacteria causing AOM in North America under the influence of pneumococcal conjugate vaccination and antibiotic selection pressure has resulted in a predominance of β-lactamase-producing Haemophilus influenzae followed by penicillin-resistant Streptococcus pneumoniae. Although guidelines continue to endorse amoxicillin as the preferred treatment, amoxicillin/clavulanate in high dosage would be the preferred treatment based on the otopathogen mix currently. Antibiotic prophylaxis has fallen into disfavor as a preventative strategy for AOM recurrences.

Antibiotics as part of the management of severe acute malnutrition

BACKGROUND

Severe acute malnutrition contributes to 1 million deaths among children annually. Adding routine antibiotic agents to nutritional therapy may increase recovery rates and decrease mortality among children with severe acute malnutrition treated in the community.

METHODS

In this randomized, double-blind, placebo-controlled trial, we randomly assigned Malawian children, 6 to 59 months of age, with severe acute malnutrition to receive amoxicillin, cefdinir, or placebo for 7 days in addition to ready-to-use therapeutic food for the outpatient treatment of uncomplicated severe acute malnutrition. The primary outcomes were the rate of nutritional recovery and the mortality rate.

RESULTS

A total of 2767 children with severe acute malnutrition were enrolled. In the amoxicillin, cefdinir, and placebo groups, 88.7%, 90.9%, and 85.1% of the children recovered, respectively (relative risk of treatment failure with placebo vs. amoxicillin, 1.32; 95% confidence interval [CI], 1.04 to 1.68; relative risk with placebo vs. cefdinir, 1.64; 95% CI, 1.27 to 2.11). The mortality rates for the three groups were 4.8%, 4.1%, and 7.4%, respectively (relative risk of death with placebo vs. amoxicillin, 1.55; 95% CI, 1.07 to 2.24; relative risk with placebo vs. cefdinir, 1.80; 95% CI, 1.22 to 2.64). Among children who recovered, the rate of weight gain was increased among those who received antibiotics. No interaction between type of severe acute malnutrition and intervention group was observed for either the rate of nutritional recovery or the mortality rate.

CONCLUSIONS

The addition of antibiotics to therapeutic regimens for uncomplicated severe acute malnutrition was associated with a significant improvement in recovery and mortality rates. (Funded by the Hickey Family Foundation and others; ClinicalTrials.gov number, NCT01000298.).

[Identification of impurity peaks in the HPLC chromatogram by LC-MS and two-dimensional chromatographic correlation spectroscopy]

A novel qualitative analytical method by using two-dimensional chromatographic correlation spectroscopy techniques for recognizing impurity peaks of HPLC methods of quality control and LC-MS chromatographic system was established. The structures of major degradation products of ceftizoxime and cefdinir were identified by LC-MS and MassWorks application; the standard chromatographic and spectral data of the degradation impurities were obtained by high-performance liquid chromatography with diode array detection. The impurity peaks of two-dimensional chromatography were matched by comparison of spectra and calculating correlation coefficients. Peaks in chromatography can be identified accurately and rapidly in different chromatographic systems such as column and mobile phase changed. The method provides a new way and thought to identify the peaks in quality control of impurities without reference impurity substances.

In vitro antimicrobial activity of cefditoren and other oral antibiotics against Streptococcus pneumoniae, isolated from children with community acquired respiratory tract infections

The antibacterial susceptibility to frequently prescribed antibiotics of Streptococcus pneumoniae isolated from the pediatric patients with acute respiratory infectious diseases was investigated in a study of three medical institutions in Korea. Total 143 clinical isolates of S. pneumoniae were available for susceptibility tests between May 2003 and July 2007. Antimicrobial susceptibility data for S. pneumoniae were analyzed by using agents of amoxicillin, cefaclor, cefuroxime, cefdinir, and cefditoren as the test antibiotics. The prevalence of each resistance class, penicillin-resistant S. pneumoniae (PRSP) were high with the proportion of MIC range (susceptible = 8.4%, intermediate resistance = 18.2%, resistance = 73.4%). MIC90 and susceptible (S) rate of antimicrobial agents to the strains tested were amoxicillin (MIC90 = 4 microg/ml, S = 76.2%), cefaclor (MIC90 = 128 microg/ml, S=8.4%), cefuroxime (MIC90 = 16 microg/ml, S = 24.5%), cefdinir (MIC90 = 16 microg/ml, S = 21.8%), and cefditoren (MIC90 = 0.5 microg/ml, S=90.2%) respectively. Against clinical isolates including PRSP, cefditoren demonstrated the strongest antibacterial activity intrinsically among the antibiotics tested. Conclusively, the antimicrobial activity of cefditoren to S. pneumoniae strains isolated from pediatric patients with acute respiratory infection is very high. In South Korea, where the antibiotic resistance ofS. pneumoniae is issued, cefditoren is expected to be used as a primary or secondary antibiotic. Moreover, cefditoren may serve as a useful option for secondary antibiotics after failure of amoxicillin treatment, which is most primarily used for acute respiratory S. pneumoniae infection in children.

Comparison of the efficacies of oral beta-lactams in selection of Haemophilus influenzae transformants with mutated ftsI genes

Horizontal transfer of the mutated ftsI gene from beta-lactamase-nonproducing ampicillin-resistant (BLNAR) Haemophilus influenzae to a susceptible strain was examined in vitro under selection with nine oral beta-lactams (ampicillin, amoxicillin, cefprozil, cefuroxime, cefpodoxime, cefdinir, cefcapene, cefditoren, and tebipenem). Compared to the penicillins and the carbapenem, the cephalosporins showed a wide selection window for the genetic transfer.

Effect of l-phenylalanine supplementation and a high-protein diet on pharmacokinetics of cefdinir in healthy volunteers: an exploratory study

BACKGROUND

Upregulation of oligopeptide transport activity by dietary protein, certain dipeptides and amino acids has been reported in the rat intestine and a human intestinal cell line.

OBJECTIVE

In this study, the pharmacokinetics of cefdinir were investigated after L-phenylalanine supplementation and a high-protein diet (HPD) in humans to explore changes in the activities of intestinal and renal oligopeptide transporters.

METHODS

A normal-protein diet (NPD, 73.2 +/- 2.6 g/day), NPD + l-phenylalanine (7.5 g/day), or HPD (141.3 +/- 3.7 g/day) was given to six male healthy volunteers for 12 days followed by a single dose of cefdinir after an overnight fast in a randomized three-way crossover study with a 22-day washout. Blood and urine were collected over a 12-h period after administration of cefdinir. Concentrations of cefdinir in plasma and/or urine were measured by high-performance liquid chromatography.

RESULTS

Plasma concentrations and urinary excretion of the drug did not change throughout the study. Physiological variables and laboratory values did not reveal any differences between the three periods except for serum and urinary nitrogen levels and serum triglyceride.

DISCUSSION

A reason for the unchanged pharmacokinetics of cefdinir may be due to lower doses of L-phenylalanine and protein in humans than in animals when converting animal effective doses to humans.

CONCLUSION

In humans, L-phenylalanine supplementation and HPD do not seem to upregulate intestinal and renal oligopeptide transport in the ranges of duration and dose examined.

Isolation, structural elucidation and characterization of impurities in Cefdinir

Three unknown impurities in Cefdinir bulk drug at levels below 0.2% (ranging from 0.05 to 0.2%) have been detected by high performance liquid chromatography (HPLC). These impurities were isolated from crude sample of Cefdinir using preparative HPLC. Based on the spectral data (NMR, IR and MS) the structures of these impurities were characterized as (6R, 7R)-7-[(z)-2-(2-aminothiazol-4-yl)-2-hydroxyiminoacetamido]-8-oxo-3-vinyl-5-thia-1-azabicyclo [4.2.0] oct-2-ene-2-carboxylic acid-5-oxide (I). (6R, 7R)-7-[(z)-2-(2-aminothiazol-4-yl)-2-hydroxyiminoacetamido]-8-oxo-3-vinyl-5-thia-1-azabi-cyclo [4.2.0] oct-3-ene-2-carboxylic acid (II). (6R, 7R)-7-[(z)-2-(2-aminothiazol-4-yl)-2-hydroxyiminoacetamido]-8-oxo-3-methyl-5-thia-1-azabicyclo-[4.2.0]oct-2-ene-2-carboxylic acid (III), respectively. The origin and structural elucidation of all impurities have been discussed.

Bayesian Estimation of Intervention Effect with Pre- and Post-Misclassified Binomial Data

We consider studies in which an enrolled subject tests positive on a fallible test. After an intervention, disease status is re-diagnosed with the same fallible instrument. Potential misclassification in the diagnostic test causes regression to the mean that biases inferences about the true intervention effect. The existing likelihood approach suffers in situations where either sensitivity or specificity is near 1. In such cases, common in many diagnostic tests, confidence interval coverage can often be below nominal for the likelihood approach. Another potential drawback of the maximum likelihood estimator (MLE) method is that it requires validation data to eliminate identification problems. We propose a Bayesian approach that offers improved performance in general, but substantially better performance than the MLE method in the realistic case of a highly accurate diagnostic test. We obtain this superior performance using no more information than that employed in the likelihood method. Our approach is also more flexible, doing without validation data if necessary, but accommodating multiple sources of information, if available, thereby systematically eliminating identification problems. We show via a simulation study that our Bayesian approach outperforms the MLE method, especially when the diagnostic test has high sensitivity, specificity, or both. We also consider a real data example for which the diagnostic test specificity is close to 1 (false positive probability close to 0).

cephalexin for mild to moderate uncomplicated skin and skin structure infections in adolescents and adults

OBJECTIVES

To compare the efficacy and safety of cefdinir to that of cephalexin in adolescents and adults with mild to moderate uncomplicated skin and skin structure infections (USSSI).

RESEARCH DESIGN AND METHODS

This was an investigator-blinded, multicenter study in which patients at least 13 years of age with USSSI were randomized to receive 10 days of cefdinir 300 mg twice daily (BID) or cephalexin 250 mg four times daily (QID). Patients were evaluated at baseline, by telephone on Days 3-5, and during office visits on Days 12-14 (end-of-therapy [EOT] visit) and Days 17-24 (test-of-cure [TOC] visit).

MAIN OUTCOME MEASURES

Clinical response was evaluated at the TOC visit. Patient reported outcomes, including a usefulness questionnaire, were also assessed.

RESULTS

Three hundred and ninety-one patients were treated. The treatment groups were well matched with regard to demographic characteristics and types of infection. Abscess(es) (26%), wound infection (24%), and cellulitis (21%) were the most common infections. At the TOC visit, the clinical cure rate for both treatment groups was 89% (151/170 for cefdinir and 154/174 for cephalexin) in clinically evaluable patients (95% CI for difference in cure rates [-6.7 to 7.3]). In the intent-to-treat analysis, cure rates were 83% for cefdinir vs. 82% for cephalexin. Clinical cure rates for infections caused by methicillin-susceptible (MSSA) and methicillin-resistant (MRSA) Staphylococcus aureus were 93% (37/40) and 92% (35/38) for cefdinir vs. 91% (29/32) and 90% (37/41) for cephalexin (p > 0.999 comparing treatment groups for MSSA; p > 0.999 for MRSA). The usefulness questionnaire demonstrated that cefdinir was more highly rated in the mean composite score (87.4 vs. 83.6, p = 0.04), with the difference primarily due to the respondents' preference for the convenience of taking the study medication (mean score 93.5 vs. 74.1 for cephalexin, p < 0.001). The study had the following limitations: the requirement for culture at baseline likely skewed the enrollment of patients towards those with abscesses; the results of culture in patients with USSSIs are often nonspecific; in some patients entering the study with a diagnosis of cellulitis, the cellulitis was associated with an abscess; and, incision and drainage (I&D), spontaneous drainage, and needle aspiration are likely to have contributed to clinical response for purulent infections, and in particular MRSA-associated infections. Both study drugs were well tolerated. The most common treatment-related adverse events were diarrhea (10% cefdinir, 4% cephalexin, p = 0.017), nausea (3% and 6%, respectively, p = 0.203), and vaginal mycosis (3% and 6% of females, respectively, p = 0.500).

CONCLUSIONS

This study demonstrated that empiric coverage of USSSIs with cephalosporin therapy remains an appropriate clinical strategy. MRSA infections responded well in both arms of the study, suggesting that the choice of a cephalosporin did not adversely affect patient outcome. However, cephalosporins do not have accepted, clinically relevant in vitro activity against MRSA. Hence, the clinical response rates seen in this study against MRSA infections must be interpreted with caution. Cefdinir was more highly rated than cephalexin in a composite usefulness assessment.

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.

monohydrate formMicrostructure and tabletting behaviour

Anhydrous cefdinir (AC) vs. monohydrated cefdinir (MHC) was compared in order to be used as antimicrobial in therapeutics. Different techniques have been used to characterize physically AC and MHC, and also a complete microstructural analysis of raw materials was carried out. Cefdinir and Maltodextrin QDM 500 (3:2) formulations were compressed in order to obtain tablets with typical dose of Cefdinir, i.e. 300 mg. Dissolution profiles were obtained for both AC and MHC tablets. Finally tablet X-ray diffraction was performed to ensure the stability of the monohydrated form after tabletting being clearly different in both AC and MHC crystals. AC crystal structure was agreed with the known pattern of anhydrous Cefdinir described in the literature. Microstructural analysis showed large differences in specific surface area (SSA), confirmed by mercury intrusion. Crystal structures of both AC and MHC were stable under mixing, compression and storing processes. Dissolution profiles were faster for hydrate form, probably related to microstructural properties of the crystal which remained after tabletting. In conclusion, it is possible to isolate Cefdinir in two forms anhydrous and monohydrate, well characterized and differentiated. The use of this later improves dissolution of tablet dosage form due to the lack of interconversion during tablet manufacture.

high-dose amoxicillin/clavulanate oral suspension for acute otitis media in young children

OBJECTIVES

To compare efficacy, tolerability, and parental satisfaction of cefdinir and high-dose amoxicillin/clavulanate oral suspensions given to young children with non-refractory acute otitis media (AOM) based on clinical endpoints and outcomes measures.

RESEARCH DESIGN AND METHODS

This was an investigator-blinded, multicenter study in which 318 children 6 months through 6 years of age with a clinical diagnosis of AOM were randomized to receive 10 days of either cefdinir (14 mg/kg divided BID) or high-dose amoxicillin/clavulanate (90/6.4 mg/kg divided BID).

MAIN OUTCOME MEASURES

Investigators evaluated clinical response at an end-of-therapy (EOT) office visit conducted on day 12-15. Outcomes of satisfaction, tolerability, and adherence were also assessed at that visit using an Otitis Parent Questionnaire.

RESULTS

The treatment groups were similar at baseline with respect to patient demographics. At the EOT visit, for cefdinir and amoxicillin/clavulanate, respectively, intent-to-treat (ITT) clinical cure rates were 82% (129/158) and 85% (134/158) (p = 0.547; 95% confidence interval [CI] -11.7 to 5.4) and per-protocol cure rates were 82% (123/150) and 90% (129/143) (p = 0.045; 95% CI -16.4 to 0.0). This difference was driven primarily by reduced cefdinir response in patients with recurrent AOM (p = 0.010) and those younger than 24 months (p = 0.039). Comparing cefdinir with amoxicillin/clavulanate, parents more often reported significantly better ease of use (89% vs. 57%; p < 0.0001), better taste (85% vs. 39%; p < 0.0001), and better adherence (at least 95% of doses) (82% vs. 61%; p < 0.0001). Diarrhea/loose stools were more common in the amoxicillin/clavulanate group than in the cefdinir group (28% vs. 18%, respectively; p = 0.0341). One patient in the cefdinir group and eight patients in the amoxicillin/clavulanate group withdrew from the study prematurely due to at least one adverse event (p = 0.0364). Study limitations included assessment of clinical recurrence by telephone call rather than office visit, exclusion of children with refractory AOM, and no assessment of middle ear microbiology.

CONCLUSIONS

Among young children with non-refractory AOM, cefdinir was as efficacious as high-dose amoxicillin/clavulanate in the ITT group, but somewhat less effective in per-protocol analysis. From the parental perspective, cefdinir was easier to administer, had a better taste, caused less diarrhea, and resulted in higher treatment adherence than high-dose amoxicillin clavulanate.

Update on the cefdinir spectrum and potency against pathogens isolated from uncomplicated skin and soft tissue infections in North America: are we evaluating the orally administered cephalosporins correctly?

The spectrum and potency of cefdinir, an orally administered cephalosporin, was reevaluated for the uncomplicated skin and soft tissue infection (uSSTI) indication using contemporary isolates from 2004 to 2005. Cefdinir continues to have high rates of susceptibility against methicillin-susceptible staphylococci (100.0%), beta-hemolytic streptococci (groups A and B; 100.0%), viridans group streptococci (88.9%), Escherichia coli (93.2%), and Klebsiella pneumoniae (90.0%). No diminished activity was detected since the last evaluation (1997-2002 isolates), and cefdinir remains significantly more potent (4- to 16-fold) than cephalexin, even when using surrogate agents of cephalexin susceptibility that were suspect for estimating true clinical utility. Activity greater than cephalexin (4-fold) was also noted for cefdinir against community-associated methicillin-resistant Staphylococcus aureus isolates. Cefdinir should be considered as a viable option for the therapy uSSTI caused by indicated species.

Fluoroquinolone-resistant urinary isolates of Escherichia coli from outpatients are frequently multidrug resistant: results from the North American Urinary Tract Infection Collaborative Alliance-Quinolone Resistance study

Ciprofloxacin-resistant Escherichia coli isolates (n = 1,858) from outpatient midstream urine specimens at 40 North American clinical laboratories in 2004 to 2005 were frequently resistant to ampicillin (79.8% of isolates) and trimethoprim-sulfamethoxazole (66.5%); concurrent resistance to cefdinir (9.0%) or nitrofurantoin (4.0%) was less common. Only 10.8% of isolates were resistant to ciprofloxacin alone. Fluoroquinolone-resistant isolates of E. coli from urine were frequently multidrug resistant.

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.

A comparison of 5 days of therapy with cefdinir or azithromycin in children with acute otitis media: a multicenter, prospective, single-blind study

BACKGROUND

Short-course therapy for acute otitis media (AOM) improves adherence and may reduce secondary bacterial resistance.

METHODS

In this multicenter, prospective, investigator-blinded study, patients between the ages of 6 months and 6 years with a clinical diagnosis of AOM were randomized to receive cefdinir oral suspension 7 mg/kg q12h for 5 days or azithromycin oral suspension 10 mg/kg once daily on day 1 and 5 mg/kg once daily on days 2 through 5. Clinical response was assessed at the end-of-therapy (EOT) visit (days 7-9) and the follow-up visit (days 20-25).

RESULTS

Three hundred fifty-seven patients were enrolled in the study. The treatment groups were similar at baseline with respect to demographic characteristics (mean [SD] age, 3.0 [1.7] years; 55% male), incidence of bilateral AOM (45%), and presenting signs and symptoms. The majority of evaluable children (77%) had previously received conjugated heptavalent pneumococcal vaccine (PCV7) against Streptococcus pneumoniae. At the EOT visit, clinical cure rates were comparable for cefdinir and azithromycin (87% [151/174] and 85% [149/176], respectively; 95% CI, -5.5 to 9.8). In addition, clinical cure rates at the EOT visit in the children who had been vaccinated with PCV7 were comparable between cefdinir and azithromycin (86% vs 83%; 95% CI, -6.5 to 11.8). No significant difference in clinical cure rates was observed at the follow-up visit (76% and 86%; 95% CI, -18.9 to 0.0). Parental satisfaction was similar between treatment groups with regard to ease of use, taste, compliance, health care resource utilization, and missed days of work and day-care. Both antibiotics were well tolerated; diarrhea and abnormal stools were the most common antibiotic-related adverse events (< or = 7% each).

CONCLUSIONS

Short courses (5 days) of therapy with cefdinir or azithromycin were comparable in these children with AOM based on clinical end points, parental preferences, and health care utilization.

Microdialysis studies of the distribution of antibiotics into chinchilla middle ear fluid

For conditions such as acute otitis media, in which antibiotic penetration into middle ear fluid (MEF) may be slow or limited, antibiotic plasma levels may not reflect the concentrations at the site of infection that are relevant to clinical outcome. In such cases, a model is needed that will enable prediction of the time course of unbound, pharmacologically active antibiotic levels in MEF. We describe the use of microdialysis as a sampling tool for measurement of unbound antibiotic concentrations in the MEF of the awake, freely moving chinchilla. Results of studies of MEF penetration of the beta-lactam antibiotic, cefdinir, with use of this technique are also described. Preliminary results of studies of the penetration of antibiotics into MEF of the chinchilla appear consistent with clinical findings and suggest that the chinchilla microdialysis model may prove to be a useful tool for predicting antibiotic efficacy in patients.

Selective method for the determination of cefdinir in human plasma using liquid chromatography electrospray ionization tandam mass spectrometry

A sensitive and selective liquid chromatographic-tandem mass spectrometric (LC-MS/MS) method was developed for the determination of cefdinir in human plasma. After a simple protein precipitation using trichloracetic acid, the post-treatment samples were applied to a prepacked RP18 Waters SymmetryShield column interfaced with a triple quadrupole tandem mass spectrometer. Positive electrospray ionization was employed as the ionization source. The mobile phase consisted of methanol-water-formic acid (25:75:0.075, v/v/v). The analyte and I.S. cefaclor were both detected by the use of selected reaction monitoring mode. The method was linear in the concentration range of 5-2,000 ng/ml. The lower limit of quantification was 5 ng/ml. The intra- and inter-day relative standard deviation across three validation runs over the entire concentration range was less than 4.3%. The accuracy determined at three concentrations (36, 360 and 1,800 ng/ml for cefdinir) ranged from 99.6 to 106.7% in terms of recovery. The chromatographic run time for each plasma sample was less than 3 min. The method herein described was successfully applied for the evaluation of pharmacokinetic profiles of cefdinir capsule in 12 healthy volunteers.

A multicenter, open label, double tympanocentesis study of high dose cefdinir in children with acute otitis media at high risk of persistent or recurrent infection

BACKGROUND

Given the relatively high prevalence of recurrent and persistent acute otitis media (AOM) and the prominent etiologic role of Streptococcus pneumoniae, especially penicillin-nonsusceptible strains in children with these conditions, new alternative treatments are desirable.

METHODS

Children 6 months-4 years of age with AOM considered to be at risk for recurrent or persistent infection received large dosage cefdinir 25 mg/kg oral suspension once daily for 10 days. Children were evaluated pretreatment (day 1), on therapy (days 4-6), end of therapy (days 12-14) and at follow-up (days 25-28). All children had tympanocentesis at enrollment. In culture-positive children, tympanocentesis was repeated after 3-5 days (days 4-6) unless evidence of absence of middle ear effusion was documented.

RESULTS

Of 447 children enrolled, 230 were clinically and bacteriologically evaluable (74% 2 years old or younger; 57% treated for AOM in previous 3 months). Bacteriologic eradication, based on repeat tympanocentesis on days 4-6, was achieved in 74% (170 of 230) of children; 76% (201 of 266) of AOM pathogens were eradicated. Eradication of penicillin-susceptible, -intermediate and -resistant S. pneumoniae was 91% (50 of 55), 67% (18 of 27) and 43% (10 of 23), respectively (P < 0.001); eradication of H. influenzae was 72% (90 of 125). Overall clinical response at days 12-14 was 83% (76 and 82% for children with S. pneumoniae and Haemophilus influenzae, respectively). Sustained clinical response at days 25-28 was 85%. Clinical response was 83% for culture-positive children versus 96% for culture-negative children at baseline tympanocentesis (P < 0.001).

CONCLUSIONS

In this study of AOM among children at risk for persistent or recurrent infection, large dose cefdinir resulted in an overall successful clinical response at end of treatment of 83%. This regimen was efficacious against penicillin-susceptible S. pneumoniae, but effectiveness was markedly decreased against nonsusceptible strains and was moderate for H. influenzae strains.

Cefdinir pharmacokinetics and tolerability in children receiving 25 mg/kg once daily

BACKGROUND

Of several oral cephalosporins, cefdinir is recommended as an alternative therapy for children with acute otitis media who have type 1 hypersensitivity to beta-lactams. Because the current cefdinir dosage of 14 mg/kg/d is approved for treatment of acute otitis media caused by penicillin-susceptible Streptococcus pneumoniae, we hypothesized that a 25-mg/kg dose given daily would be more effective for nonsusceptible S. pneumoniae.

METHODS

We performed pharmacokinetic analyses on 37 infants and children who were given cefdinir in dosages of 14 or 25 mg/kg once daily for 10 days, for the treatment of respiratory and skin or skin structure infections. Cefdinir plasma concentrations were determined with validated liquid chromatology, and pharmacokinetics and pharmacodynamics were determined in relation to the minimum inhibitory concentration values of S. pneumoniae.

RESULTS

The maximal plasma concentrations and area-under-the-curve values were significantly higher after the 25-mg/kg in relation to the minimum inhibitory concentration values for S. pneumoniae strains. The pharmacodynamics measure of bacteriologic effectiveness was <40% of the dosing interval (ie, 24 hours), indicating that many of the penicillin-nonsusceptible S. pneumoniae causing acute otitis media would not be effectively treated. Diarrhea occurred in 20% of the 39 subjects that received the larger dosage of cefdinir.

CONCLUSION

A cefdinir dosage of 25 mg/kg daily would be ineffective for treatment of acute otitis media caused by penicillin-nonsusceptible S. pneumoniae strain.

Efficacy of penicillin versus cefdinir in eradication of group A streptococci and tonsillar flora

Core tonsillar cultures were obtained from 40 children with recurrent tonsillitis treated with either penicillin or cefdinir. Group A beta-hemolytic streptococci were isolated from 11 penicillin- and 3 cefdinir-treated (P < 0.001) patients. beta-Lactamase producers were recovered from 17 penicillin- and 3 cefdinir-treated (P < 0.01) patients. Inhibiting alpha-hemolytic streptococci were isolated less often from penicillin-treated patients than from cefdinir-treated patients.

Susceptibility of recent bacterial isolates to cefdinir and selected antibiotics among children with urinary tract infections

BACKGROUND

Cefdinir, an extended-spectrum cephalosporin administered orally, is approved by the U.S. Federal Drug Administration for treatment of skin and respiratory tract infections. During the last two years at the authors' institution, this agent has been used as an off-label treatment for urinary tract infections in children.

OBJECTIVES

To evaluate antimicrobial susceptibility testing data in children to determine whether there is support for this prescribing practice.

METHODS

In this retrospective study (2003-2004), the authors compared the susceptibility patterns of urinary pathogens to cefdinir and selected antibiotics in children who were evaluated for urinary tract infections in an urban tertiary academic pediatric emergency department. Pathogens (community acquired vs. opportunistic or nosocomial) were categorized as susceptible, indeterminate, or resistant on the basis of antibiotic susceptibility breakpoints. The frequency of these categorizations for individual drugs was determined.

RESULTS

Seven hundred five isolates were recovered from urine during the study period. Pathogens isolated most frequently were Escherichia coli, Klebsiella spp, and Proteus spp. Of 431 isolates retained in the data set, 412 (95.6%) were susceptible to cefdinir. This rate was comparable or superior to rates observed for other antibiotics: 49.4% for ampicillin, 84.9% for trimethoprim-sulfamethoxazole, 88.4% for cefazolin, 93.3% for nitrofurantoin, 94.2% for ticarcillin-clavulanate potassium, 97.5% for gentamicin, and 97.7% for ceftriaxone. Cefdinir, however, had lower activity (64.7%) against 17 bacterial isolates categorized as opportunistic or nosocomial pathogens.

CONCLUSIONS

Cefdinir provides good coverage against common pathogens responsible for urinary tract infections in children and compares favorably with other oral and parenteral antibiotics that are used in the empiric treatment of this infection.

A pooled analysis of seven randomized crossover studies of the palatability of cefdinir oral suspension versus amoxicillin/clavulanate potassium, cefprozil, azithromycin, and amoxicillin in children aged 4 to 8 years

OBJECTIVE

This analysis of the results of 7 trials compared the taste and smell acceptability scores of cefdinir oral suspension and 4 other pediatric antibiotic oral suspensions--amoxicillin/clavulanate potassium, cefprozil, azithromycin, or generic amoxicillin--using a visual smile-face scale.

METHODS

Data from 7 randomized, single-blind, cross-over trials were pooled and analyzed. In each study, children aged 4 to 8 years were asked to taste and smell 2 different antibiotic suspensions and assign preference using a visual smile-face scale. Ratings were converted to a numeric score ranging from 5 (really good) to 1 (really bad).

RESULTS

A total of 1011 healthy subjects were randomly assigned to 1 of 2 treatment-order groups; 965 were evaluable for the taste and smell analyses. Baseline demographics of evaluable subjects were similar among test groups. Approximately even proportions of participants were female or male (50.1 % vs 49.9%), most (84.1%) were white, and slightly more participants were aged 7 or 8 years rather than younger (age 4 years, 16.0%; age 5 years, 17.4%; age 6 years, 18.7%; age 7 years, 23.2%; age 8 years, 24.8%). Of the 965 children who tasted both antibiotic suspensions and determined their preference, 798 (82.7%) rated the taste of cefdinir as really good or good (the highest possible ratings); 712 (73.8%) assigned the same ratings to amoxicillin/clavulanate potassium, cefprozil, azithromycin, or generic amoxicillin (P < or = 0.001). With regard to smell, 671 (69.5%) rated the smell of cefdinir as really good or good; 636 (65.9%) assigned these same ratings to the comparator agents (P = NS).

CONCLUSION

In this pooled analysis of data from 7 randomized, single-blind, crossover trials, children between the ages of 4 and 8 years preferred the taste of cefdinir oral suspension to that of other pediatric antibiotic suspensions. Based on smile-face scores, subjects found the smell of cefdinir oral suspension to be at least as good as that of the comparators.

Determination of Cefdinir by a stability-indicating liquid chromatographic method

A simple, fast, specific, stability-indicating, and precise reversed-phase liquid chromatographic method was developed for the determination of Cefdinir in its different dosage forms, i.e., capsules and suspensions. The method was developed and optimized by analyzing the placebo preparation, formulations, and degraded samples of the drug substance according to the International Conference on Harmonization. The proposed method can successfully separate the drug from degradation products formed under stress conditions along with pharmaceutical ingredients such as preservatives. The developed method was used successfully to determine Cefdinir in capsules and Insta-use suspensions. The developed method was found to be linear for a concentration range of 6-14 microg/mL. Average recoveries obtained with the method were 99.3 +/- 0.4 and 99.6 +/- 0.4% for Insta-use suspensions and capsules, respectively. The method was shown to be specific, precise, and robust.

Effects of amoxicillin and cefdinir on nasopharyngeal bacterial flora

OBJECTIVE

To compare the effects of cefdinir (14 mg/kg per day) and amoxicillin (90 mg/kg per day) antimicrobial therapy on the nasopharyngeal flora of children with acute otitis media.

DESIGN

Nasopharyngeal cultures for aerobic and facultative bacteria were obtained before therapy and 2 to 4 days after completion of therapy.

SETTING

Outpatient clinic.

PATIENTS

Fifty children, aged 7 months to 5 years 4 months.

MAIN OUTCOME MEASURES

After completion of therapy, 22 (88%) of the 25 patients treated with cefdinir and 16 (64%) of the 25 patients treated with amoxicillin were considered clinically cured (P<.05). A significant reduction in the number of all isolates occurred following therapy in those treated with cefdinir (36 vs 71, P<.01) or with amoxicillin (56 vs 73, P<.05). However, the total number of isolates recovered after therapy was significantly lower in those treated with cefdinir (36) compared with those treated with amoxicillin (56) (P<.01).

RESULTS

The recovery of potential pathogenic organisms (eg, Streptococcus pneumoniae, Staphylococcus aureus, beta-hemolytic streptococci, Haemophilus species, and Moraxella catarrhalis), as well as penicillin-resistant bacteria, was lower following completion of therapy in the cefdinir group (6 pathogens, including 5 that were penicillin resistant), compared with the amoxicillin group (27 pathogens, including 16 that were penicillin resistant) (P<.01).

CONCLUSION

This study illustrates the greater ability of cefdinir compared with amoxicillin to reduce the number of potential nasopharyngeal pathogens as well as penicillin-resistant bacteria in children with acute otitis media.

A pooled comparison of cefdinir and penicillin in the treatment of group a β-hemolytic streptococcal pharyngotonsillitis

OBJECTIVE

This pooled analysis compared the clinical cure and bacterial eradication rates achieved by cefdinir and penicillin in the treatment of group A beta-hemolytic streptococcal (GABHS) pharngotonsillitis.

METHODS

Data from 4 multicenter, randomized, controlled, investigator-blinded trials, 2 in children receiving oral suspensions and 2 in adults receiving capsules/tablets, were pooled and analyzed in terms of clinical cure rates, microbiologic eradication rates, and adverse events.

RESULTS

A total of 2751 patients were enrolled (age <13 years, n = 1274; age > or =13 years, n = 1477). Patients were randomized to receive cefdinir once daily (n = 569) or twice daily (n = 1086) for 5 or 10 days, or penicillin 4 times daily (n = 1096) for 10 days. Of the 2751 patients enrolled, 2198 were evaluable for clinical and microbiologic outcomes. Compared with the 10-day penicillin regimens, the cefdinir regimens for 5 or 10 days produced higher clinical cure and microbiologic eradication rates. Combined clinical cure rates were significantly higher for cefdinir compared with penicillin (94% vs 83%, respectively; P < 0.001). Combined microbiologic eradication rates were also significantly higher for cefdinir compared with penicillin (92% vs 77%; P < 0.001). Both cefdinir and penicillin were well tolerated, as >98% of patients completed the course of therapy.

CONCLUSION

In this pooled analysis of data from 4 multicenter, randomized, controlled, investigator-blinded trials in children and adults, 5- and 10-day regimens of cefdinir achieved significantly higher clinical cure and microbiologic eradication rates compared with 10-day penicillin regimens in the treatment of GABHS pharyngotonsillitis.

Parent-reported outcomes for treatment of acute otitis media with cefdinir or amoxicillin/clavulanate oral suspensions

OBJECTIVE

To compare parent-reported outcomes (satisfaction, tolerability, compliance, and work/daycare missed) for children (aged 6 months to 6 years) receiving either cefdinir or amoxicillin/clavulanate for acute otitis media.

METHOD

In a phase IV, investigator-blinded, parallel-group, randomized, multicenter study, parents or legal guardians were asked to complete the Otitis Parent Questionnaire (OPQ) 12-14 days after the first dose of cefdinir or amoxicillin/clavulanate oral suspensions. Responses in each of the outcome domains were analyzed using non-parametric statistical analysis.

RESULTS

Of 367 parents/guardians who completed the questionnaire, better ease of use (p = 0.009) and taste (p < 0.0001) were associated with cefdinir versus amoxicillin/clavulanate treatment, and children were significantly more likely to experience vomiting with amoxicillin/clavulanate (16% vs 8%; p = 0.016). Parents also reported that their children were much more likely to take all of their medication if receiving cefdinir (68% vs 53% for amoxicillin/clavulanate; p = 0.005). There were no statistically significant differences between groups in work/daycare missed.

CONCLUSION

Based on parents' assessment using the OPQ, cefdinir was easier to administer and tasted better than amoxicillin/clavulanate. Children who received cefdinir also experienced less vomiting and had greater compliance than children who received amoxicillin/clavulanate.