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

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

Interaction between common antibiotics and a Shewanella strain isolated from an enhanced biological phosphorus removal activated sludge system.

With increasing production and consumption, more antibiotics are discharged into wastewater treatment plants and generally cannot be sufficiently removed. Because of the complexities of biological treatment processes, the fates of antibiotics and their effects on microorganisms, particularly those involved in the phosphorus removal system, are still unclear. Here, a Shewanella strain was isolated from an enhanced biological phosphorus removal (EBPR) system and was found to have the ability to remove phosphorus (P) and chemical oxygen demand (CODcr). Antibiotics affected the Shewanella strain through metabolism of the three main intracellular polymers, altering the ability of the strain to remove P and CODcr. These effects varied with the structure and concentration of the antibiotics. The Shewanella strain removed cefalexin and amoxicillin by degradation or adsorption, producing 2-hydroxy-3-phenyl pyrazine from cefalexin. This study enabled the recognition of the effect and removal of antibiotics during wastewater treatment.

Pharmacokinetics and pharmacodynamics of oral cephalexin in children with osteoarticular infections.

BACKGROUND: Osteoarticular infections lead to significant morbidity in children. Cephalexin has in vitro activity against methicillin-susceptible Staphylococcus aureus, a predominant pathogen in osteoarticular infection. However, cephalexin pharmacokinetics (PK) and pharmacodynamics (PD) are poorly described in children. This study described cephalexin PK in children treated for osteoarticular infection and assessed the proportion of children achieving surrogate PK/PD target for efficacy in methicillin-susceptible S. aureus infection. METHODS: Children with osteoarticular infection, 1 to 18 years of age, were eligible for this study if they were receiving oral cephalexin per standard of care. PK plasma samples were collected at specified times after multiple doses. PK parameters were estimated using noncompartmental analysis. PK/PD target for efficacy was calculated using the child's PK parameters, minimum inhibitory concentration (MIC) of the isolate when available and previously described MIC of 2 and 4 mg/L. RESULTS: Twelve children were enrolled and PK profiles were obtained from 11 of them. Median age was 7 years, and median cephalexin dose was 40 mg/kg/dose every 8 hours. Median apparent oral clearance, apparent oral volume of distribution and elimination half-life (T1/2) were 0.29 L/h/kg, 0.44 L/kg and 1.1 h, respectively. Time above MIC (T>MIC) was greater than 40% of the dosing interval in 100%, 90% and 80% of the children when MICs were 0.25, 2 and 4 mg/L, respectively. CONCLUSIONS: Oral cephalexin achieved optimal plasma exposure and was well tolerated in children with osteoarticular infection. Correlation between osteoarticular infection clinical outcome and PK/PD parameters needs further evaluation.

The effect of staggered administration of zinc sulfate on the pharmacokinetics of oral cephalexin.

AIMS: To investigate the effect of zinc sulfate on pharmacokinetics of cephalexin when administered concurrently or at strategically spaced dosing times designed to avoid the potential interaction in healthy volunteers. METHODS: In this study, all subjects (n= 12) were randomized to receive the following four treatments, separated by a wash-out period of 7 days: cephalexin 500mg alone, concomitantly with zinc 250mg, 3h after zinc 250mg or 3h before zinc 250mg. RESULTS: All subjects completed the study safely. Zinc supplements administered concurrently with cephalexin significantly decreased the peak serum concentration (C(max) ), area under the plasma concentration-time curve from zero to infinity (AUC(0-∞) ) and the time for which the plasma concentration of the drug remained above the minimal inhibitory concentration of the pathogenic organism (T > MIC) of cephalexin [mean percentage decrease (95% confidence intervals) of 31.05% (22.09-40.01%), 27.40% (18.33-36.47%) and 22.33% (12.51-32.16%), respectively; P < 0.05] compared with administration of cephalexin alone. Also, administration of zinc 3h before cephalexin decreased the C(max) , AUC(0-∞) and T > MIC of the drug compared with administration of cephalexin alone [mean percentage decrease (95% confidence intervals) of 11.48% (3.40-19.55%), 18.12% (9.63-26.60%) and 23.75% (14.30-33.20%), respectively; P < 0.05]. In contrast, the pharmacokinetics of cephalexin was not notably altered by administration of zinc 3h after cephalexin dosing (P > 0.05). CONCLUSIONS: The significant interaction between zinc and cephalexin might affect the clinical outcome of cephalexin therapy. The dosing recommendation is that zinc sulfate can be safely administered 3h after a cephalexin dose.

Effects of Acanthopanax senticosus HARMS extract on drug transport in human intestinal cell line Caco-2.

Acanthopanax senticosus HARMS (AS) is used as a Chinese herbal medicine and as a health supplement in Japan. However, little is known about the interaction between AS and other drugs. In this study, we investigated the effect of AS extract on intestinal drug transporter (P-glycoprotein, or P-gp) and peptide transporter activities in Caco-2 cells. Caco-2 cells were cultured on a culture dish and a permeable membrane for 1-3 weeks. The apical-to-basolateral (A-to-B) transport of digoxin, a P-gp substrate, was significantly increased by the addition of AS extract in a concentration-dependent manner. In contrast, the A-to-B transport of cephalexin, a peptide transporter substrate, was significantly decreased by the addition of AS extract in the same manner. The effects of AS extract addition on the kinetics of the uptake of rhodamine 123, a P-gp substrate, and Gly-Sar, a peptide transporter substrate, were investigated. V (max) for rhodamine 123 uptake was significantly increased by AS extract addition compared with the control, whereas that for Gly-Sar uptake was significantly decreased. On the other hand, K (m) and K (d) for rhodamine 123 and Gly-Sar uptake were not affected. We conducted further investigations to clarify the effect of AS extract addition on P-gp activity. When AS extract was added to the apical side, B-to-A transport of rhodamine 123 was significantly decreased compared with the control. Furthermore, the amount of intracellular rhodamine 123 was increased by AS extract addition compared with the control. These results suggest that P-gp and peptide transporter activities are suppressed by AS extract addition in a non-competitive manner.

Comparação de perfis de dissolução da cefalexina através de estudos de cinética e eficiência de dissolução (ED por cento) / Dissolution profile comparison of cephalexin by dissolution kinetic studies and dissolution efficiency (ED percent)

O presente estudo reporta os resultados comparativos obtidos através da avaliação da cinética e da eficiência de dissolução da cefalexina a partir de dois lotes (1 e 2) de diferentes produtos contendo tal fármaco disponíveis no mercado brasileiro (A e B) sob a forma de comprimidos de liberação convencional. Os perfis de dissolução foram determinados utilizando as seguintes condições: aparato 1 (cesta, 40 mesh); 100 rpm; 900 mL de água destilada mantida a 37±0,5 °C. Amostras coletadas em: 5, 7, 10, 15, 20, 30, 40, 50 e 60 minutos e a concentração de cefalexina foi determinada por espectrofotometria UV (262 nm). A partir dos perfis de dissolução determinou-se: modelo matemático de liberação da cefalexina (primeira-ordem); porcentagem de cefalexina dissolvida em 30 minutos (Q30); constante da velocidade de dissolução (k); meia-vida de dissolução (t50 por cento); eficiência de dissolução (ED por cento). Os valores Q30 obtidos indicaram que os produtos A2 e B2 se apresentaram de acordo com as especificações farmacopéicas. A comparação entre os perfis indicou diferenças estatisticamente significativa entre os produtos A2 e B1 (análise comparativa dos parâmetros cinéticos), A1 e B2 (análise comparativa pelos fatores de diferença - f1 e similaridade - f2) e B1 e B2 (análise comparativa dos parâmetros cinéticos e da ED por cento).

The present study reports the comparative results of the cephalexin dissolution kinetic evaluation and dissolution efficiency (ED percent) considering two brands (1 and 2) of different products (A and B), available within the Brazilian market in the tablet conventional release dosage form. The dissolution profiles have been determined adopting the following conditions: apparatus 1 (basket, 40 mesh); 100 rpm; 900 mL of distilled water kept 37±0,5 °C. Samples have been collected in: 5, 7, 10, 15, 20, 30, 40, 50 and 60 minutes and the cephalexin concentration was determined at UV spectrofotometry (262 nm). Through the dissolution profiles it has been determined: (i) the mathematical model of cephalexin released (first-order); (ii) the percentage of cephalexin dissolved at 30 minutes (Q30); (iii) the constant of the dissolution rate (k); (iv) half-life of dissolution (t50 percent); and, (v) the efficiency of dissolution (ED percent). The percentage of cephalexin dissolved at 30 minutes (Q30) has indicated that the products A2 e B2 were in accordance with the presented pharmacopoeia specifications. Dissolution profile comparison has indicated significant statistic difference between: A2 and B1 (comparative analysis of the kinetic parameters), A1 and B2 (comparative analysis by difference factor - f1 and similarity factor - f2), B1 and B2 (comparative analysis of the kinetic parameters and ED percent).

Rapid elimination of cefaclor from the cerebrospinal fluid is mediated by a benzylpenicillin-sensitive mechanism distinct from organic anion transporter 3.

The purpose of this study was to investigate the carrier-mediated elimination of cephalosporins from the cerebrospinal fluid (CSF) via the choroid plexus. Cefaclor and cefalexin are structural analogs with similar lipophilicity, differing by only one functional group (cefaclor, -Cl; cephalexin, -CH(3)), and they are substrates of rat peptide transporter PEPT2 with similar transport activities. However, cefaclor was cleared from the CSF more rapidly than cefalexin after intracerebroventricular administration (the elimination rate constants were 0.11 and 0.050 min(-1), respectively). The elimination of cefaclor from the CSF was inhibited by benzylpenicillin, but not by glycylsarcosine (GlySar), whereas GlySar, but not benzylpenicillin, had an inhibitory effect on the elimination of cefalexin from the CSF. The uptake of cefaclor by the freshly isolated rat choroid plexus was saturable, with a K(m) value of 250 muM, and the uptake clearance corresponding to saturable components accounts for the major part of the in vivo clearance from the CSF (17 versus 26 mul/min, respectively). The uptake of cefaclor by the choroid plexus was inhibited by benzylpenicillin, but not by GlySar. However, the inhibitory effect of benzylpenicillin was weaker than expected from its own K(m) value, and furthermore, organic anion transporter (Oat)3 substrates (cimetidine or p-aminohippurate) had no effect. These results suggest that cefaclor and cefalexin are eliminated from the CSF by different transporters, and rapid elimination of cefaclor from the CSF is accounted for by a benzylpenicillin-sensitive mechanism distinct from Oat3. A slight modification of a single chemical group of cephalosporins can greatly affect the contribution of the transporters involved, and their duration in the CSF.

Introduction of recirculatory analysis into portal and systemic concentration difference method.

Recirculatory analysis was introduced into the portal and systemic concentration difference method with double dosing (PS-DD method), which is an evaluation system for the local intestinal and hepatic first-pass effect. 5-Fluorouracil (5-FU) and cephalexin (CEX) were selected as model drugs. A new recirculatory system was constructed to predict the time courses of a drug concentration in the systemic and portal bloods. Bioavailability (F), local absorption ratio (Fa), hepatic recovery ratio (FH), and local mean absorption time (ta) estimated by recirculatory analysis were close to those calculated by moment analysis with numerical integration. Using recirculatory analysis, the sampling period was considerably shortened and the sampling number was also reduced, which demonstrates that recirculatory analysis is useful in PS-DD method.

Effects of ceramic component on cephalexin release from bioactive bone cement consisting of Bis-GMA/TEGDMA resin and bioactive glass ceramics.

The purpose of this study was to elucidate the effect of amount of ceramic cement powder on drug release from bioactive bone cement. The associated bone-bonding strength was also investigated. The bioactive bone cement under investigation consisted of bisphenol-alpha-glycidyl methacrylate (Bis-GMA), triethylene-glycol dimethacrylate (TEGDMA) resin and a combination of apatite- and wollastonite-containing glass-ceramic (A-W GC) powder. A-W GC powder (50%, 70% and 80% w/w) containing 5% cephalexin (CEX) powder hardened within 5 min after mixing with Bis-GMA/TEGDMA resin. The compressive strength of the cement with or without drug increased with increasing the amount of ceramic powder. The compressive strength of the 80% ceramic cement without the incorporation of cephalexin was 194 MPa. This compressive strength was about 3 times higher than that for polymethylmethacrylate cement. After the cement was implanted in the proximal metaphysis of the tibiae of male rabbits, the failure load for the cement was found to increase with increasing of the amount of ceramic powder. This finding suggested that the cement formed a bonding with bone. In vitro CEX release from bioactive bone cement pellets in a simulated body fluid at pH 7.25 and 37 degrees C continued for more than 2 weeks. Drug release profile followed the Higuchi equation initially, but not at later stages. The drug release rate increased with increasing amount of ceramic powder in the mixture. Since the pore volume of the cement increased with increasing of amount of ceramic powder, the drug diffused in the pores between the ceramics particle and polymer matrix. As hydroxyapatite precipitated on the cement surface, the drug release rate decreased, as observed at the later release stage. These results suggest that varying the amount of ceramic powder in the cement system could control the drug release rate from bioactive bone cement.

Absorption kinetics and bioavailability of cephalexin in the dog after oral and intramuscular administration.

The pharmacokinetics of cephalexin, a first generation cephalosporin, were investigated in dogs using two formulations marketed for humans, but also often employed by practitioners for pet therapy. Cephalexin was administered to five dogs intravenously and intramuscularly as a sodium salt and by the oral route as a monohydrate. The dosage was always 20 mg/kg of active ingredient. A microbiological assay with Sarcina lutea as the test organism was adopted to measure cephalexin concentrations in serum. The mean residence time (MRT) median values after intravenous (i.v.), intramuscular (i.m.) and oral administration (p.o.) were 86 min, 200 min, and 279 min, respectively. After i.m. and oral dosing the peak serum concentrations (24.2 +/- 1.8 micrograms/mL and 20.3 +/- 1.7 micrograms/mL, respectively) were attained at 90 min in all dogs and bioavailabilities were 63 +/- 10% and 57 +/- 5%, respectively. The time course of the cephalexin serum concentrations after oral administration was best described by a model incorporating saturable absorption kinetics of the Michaelis-Menten type: thus in the gastrointestinal tract of dogs a carrier mediated transport for cephalexin similar to that reported in humans, may exist. The predicted average serum concentrations of cephalexin after repeated i.m. and oral administration indicated that, in order to maintain the therapeutic concentrations, the 20 mg/kg b.w. dosage should be administered every 6-8 h.

Synthesis and biological activity of novel 3-(2-propenyl)-cephalosporins. I.

The synthesis, antibacterial activity and oral absorption of novel cephalosporins (3a-3d) having a 2-propenyl group at the C-3 position are described. Diphenylmethyl 7-amino-3-(2-propenyl)-3-cephem-4-carboxylate HCl (4) prepared from 7-aminocephalosporanic acid in 12 steps was acylated with various acid moieties to give cephems 3a-3d. The cephems 3a-3c showed similar antibacterial activities as cefixime. However, these cephems were not well absorbed orally.