Cefoxitin Sodium

Class: Cephamycins
CAS Number: 33564-30-6
Brands: Mefoxin

Introduction

Antibacterial; β-lactam antibiotic; cephamycin.^c

Uses for Cefoxitin Sodium

Bone and Joint Infections

Treatment of bone and joint infections caused by susceptible S. aureus (including penicillinase-producing strains).^{149 150 151 156}

Gynecologic Infections

Treatment of gynecologic infections (including endometritis, pelvic cellulitis, pelvic inflammatory disease [PID]) caused by susceptible S. agalactiae (group B streptococci), E. coli, Neisseria gonorrhoeae, Bacteroides (including B. fragilis), Clostridium, Peptococcus niger, or Peptostreptococcus.^{149 150 151 156}

Cefoxitin (or cefotetan) in conjunction with doxycycline considered a regimen of choice by CDC and others when a parenteral regimen is indicated for treatment of PID.^{100 114 155}

When an oral regimen is used for treatment of mild to moderately severe acute PID, CDC recommends a single IM dose of ceftriaxone, cefoxitin (with oral probenecid), or other parenteral third-generation cephalosporin (e.g., cefotaxime) given in conjunction with a 14-day regimen of oral doxycycline.^{100 155}

Because cefoxitin (like cephalosporins) is not active against Chlamydia, concomitant use of a drug active against Chlamydia (e.g., doxycycline) is necessary when these organisms are suspected pathogens.^{100 114}

Intra-abdominal Infections

Treatment of intra-abdominal infections (including peritonitis and intra-abdominal abscess) caused by susceptible E. coli, Klebsiella, Bacteroides (including B. fragilis), or Clostridium.^{149 150 151 156}

Has been effective in mixed aerobic-anaerobic infections.^c However, cefoxitin may no longer provide reliable coverage against B. fragilis, and metronidazole is recommended by many clinicians to provide coverage against B. fragilis in combination anti-infective regimens used for empiric treatment of intra-abdominal infections.¹²³

Respiratory Tract Infections

Treatment of lower respiratory tract infections (including pneumonia and lung abscess) caused by susceptible Staphylococcus aureus (including penicillinase-producing strains), Streptococcus pneumoniae, or other streptococci (except enterococci), Haemophilus influenzae, Escherichia coli, Klebsiella, or Bacteroides.^{149 150 151 156}

Septicemia

Treatment of septicemia caused by susceptible S. aureus (including penicillinase-producing strains), S. pneumoniae, E. coli, Klebsiella, or Bacteroides (including B. fragilis).^{149 150 151 156}

Skin and Skin Structure Infections

Treatment of skin and skin structure infections caused by susceptible S. aureus (including penicillinase-producing strains), S. epidermidis, S. pyogenes (group A β-hemolytic streptococci), or other streptococci (except enterococci), E. coli, Klebsiella, P. mirabilis, Bacteroides (including B. fragilis), Clostridium, P. niger, or Peptostreptococcus.^{149 150 151 156}

Urinary Tract Infections (UTIs)

Treatment of UTIs caused by susceptible E. coli, Klebsiella, Morganella morganii, P. mirabilis, P. vulgaris, or Providencia (including P. rettgeri).^{149 150 151 156}

Gonorrhea and Associated Infections

Treatment of uncomplicated cervical, urethral, or rectal gonorrhea† caused by susceptible Neisseria gonorrhoeae in adults or adolescents.^{100 155} Drug of choice is IM ceftriaxone or oral cefixime.^{100 155} CDC considers IM† cefoxitin an alternative;^{100 155} does not appear to offer any advantage over IM ceftriaxone.¹⁰⁰

Mycobacterial Infections

Treatment of infections caused by Mycobacterium abscessus†¹⁵⁷ or M. fortuitum†;¹⁵⁷ used in conjunction with other antimycobacterial anti-infectives.¹⁵⁷

For serious skin, soft tissue, and bone infections caused by M. abscessus†, ATS and IDSA recommend a multiple-drug regimen of oral clarithromycin (or azithromycin) used in conjunction with parenteral anti-infectives (e.g., amikacin, cefoxitin, imipenem).¹⁵⁷ This multiple-drug regimen also used in treatment of M. abscessus lung disease;¹⁵⁷ however, anti-infectives may help control symptoms and disease progression, but long-term sputum conversion is unlikely.¹⁵⁷ In patients with focal infections and limited lung disease, curative therapy may be possible if surgical resection is used in conjunction with a multiple-drug treatment regimen.¹⁵⁷

Although optimum regimens not identified for treatment of M. fortuitum infections, ATS and IDSA recommend that pulmonary infections be treated with a regimen consisting of at least 2 anti-infectives selected based on results of in vitro susceptibility testing and tolerability (e.g., amikacin, clarithromycin, cefoxitin, ciprofloxacin or ofloxacin, a sulfonamide, imipenem, doxycycline).¹⁵⁷ In serious skin, bone, and soft tissue infections, ≥4 months of treatment with ≥2 anti-infectives active against the clinical isolate is necessary to provide a high likelihood of cure;¹⁵⁷ 6 months of treatment recommended for bone infections.¹⁵⁷ Surgery usually indicated for extensive disease, abscess formation, or when drug therapy is difficult.¹⁵⁷

Perioperative Prophylaxis

Perioperative prophylaxis in women undergoing gynecologic and obstetric surgery (e.g., vaginal, abdominal, or laparoscopic hysterectomy, cesarean section).^{106 115 136 148 149 150 151 156} A preferred agent for vaginal, abdominal, or laparoscopic hysterectomy.¹⁰⁶ Cefazolin generally preferred for perioperative prophylaxis in cesarean section;¹⁰⁶ doxycycline recommended for perioperative prophylaxis in abortion.¹⁰⁶

Perioperative prophylaxis in patients undergoing GI surgery (e.g., colorectal surgery, nonperforated appendectomy).^{106 115 127 148 149 150 151 156} A preferred agent for colorectal surgery and nonperforated appendectomy.^{106 115 127 148}

Cefoxitin Sodium Dosage and Administration

Administration

Administer by IV injection or infusion.^{149 150 151 156} Also has been given by IM injection†.¹⁰⁰

IV route preferred in patients with bacteremia, septicemia, or other severe or life-threatening infections, or in patients with lowered resistance resulting from debilitating conditions (e.g., malnutrition, trauma, surgery, diabetes, heart failure, malignancy), particularly with shock.^{149 150 151 156}

For solution and drug compatibility information, see Compatibility under Stability.

IV Injection

Reconstitution

Reconstitute vials containing 1 or 2 g of cefoxitin with 10 mL or 10 or 20 mL, respectively, of sterile water for injection to provide solutions containing approximately 95 or 180 or 95 mg/mL, respectively.¹⁵⁰

Rate of Administration

Inject appropriate dose of reconstituted solution directly into a vein over a 3- to 5-minute period or slowly into the tubing of a compatible IV solution.¹⁵⁰

IV Infusion

Other IV solutions flowing through a common administration tubing or site should be discontinued while cefoxitin is infused.^{149 151 156}

Reconstitution

Reconstitute vials containing 1 or 2 g of cefoxitin with 10 mL or 10–20 mL, respectively, of sterile or bacteriostatic water for injection, 0.9% sodium chloride injection, or 5% dextrose injection to provide solutions containing approximately 95 or 95–180 mg/mL, respectively.^{149 150} Further dilute the reconstituted solutions in 50 mL to 1 L of a compatible IV solution.¹⁵⁰

Reconstitute 10-g pharmacy bulk package with 43 or 93 mL of sterile or bacteriostatic water for injection, 0.9% sodium chloride injection, or 5% dextrose injection and then further dilute in 50 mL to 1 L of a compatible IV solution.¹⁵¹

Reconstitute (activate) commercially available Duplex drug delivery system containing 1 or 2 g of lyophilized cefoxitin and 50 mL of dextrose injection in separate chambers according to the manufacturer’s directions.¹⁴⁹

Thaw the commercially available premixed injection (frozen) at room temperature (25°C) or under refrigeration (5°C); do not thaw by immersion in a water bath or by exposure to microwave radiation.¹⁵⁶ A precipitate may have formed in the frozen injection, but should dissolve with little or no agitation after reaching room temperature.¹⁵⁶ Discard thawed injection if an insoluble precipitate is present or if container seals or outlet ports are not intact or leaks are found.¹⁵⁶ Do not use in series connections with other plastic containers, since such use could result in air embolism from residual air being drawn from the primary container before administration of fluid from the secondary container is complete.¹⁵⁶

Rate of Administration

Administer by intermittent or continuous IV infusion.^{149 151 156}

IM Injection†

Administer IM injections deeply into a large muscle, such as the upper outer quadrant of the gluteus maximus.^c Use aspiration to ensure needle is not in a blood vessel.^c

Reconstitution

IM injections are prepared by adding 2 mL of sterile water for injection or 0.5 or 1% lidocaine hydrochloride injection (without epinephrine) to each g of cefoxitin to provide solutions containing approximately 400 mg/mL.^c

Dosage

Available as cefoxitin sodium; dosage expressed in terms of cefoxitin.^{149 150 151 156}

Pediatric Patients

General Pediatric Dosage

IV

Children ≥3 months of age: 80–160 mg/kg daily given in 4–6 equally divided doses.^{149 150 151 156}

AAP recommends 80–100 mg/kg daily given in 3–4 equally divided doses for mild to moderate infections or 80–160 mg/kg daily given in 4–6 equally divided doses for severe infections in children >1 month of age.¹⁴⁷

Perioperative Prophylaxis

IV

Children ≥3 months of age: Manufacturers recommend 30–40 mg/kg given at induction of anesthesia (within 0.5–1 hour prior to incision), followed by 30–40 mg/kg every 6 hours for up to 24 hours.^{149 150 151 156}

Some clinicians recommend 20–40 mg/kg of cefoxitin given prior to induction of anesthesia.^{115 148}

Some clinicians recommend additional doses during the procedure (e.g., every 2–3 hours) if surgery is prolonged >4 hours or major blood loss occurs.^{106 115 121 148} Postoperative doses usually unnecessary and may increase risk of bacterial resistance.^{106 115 121 148}

Adults

General Adult Dosage

Uncomplicated Infections (Bacteremia Absent or Unlikely)

IV

1 g every 6–8 hours.^{149 150 151 156}

Moderately Severe or Severe Infections

IV

1 g every 4 hours or 2 g every 6–8 hours.^{149 150 151 156}

Infections Requiring Higher Dosage (e.g., Gangrene)

IV

2 g every 4 hours or 3 g every 6 hours.^{149 150 151 156}

Gonorrhea and Associated Infections†

Uncomplicated Urethral, Cervical, or Rectal Gonorrhea†

IM†

2 g as a single dose given with oral probenecid (1 g).^{100 155}

Pelvic Inflammatory Disease

IV

2 g every 6 hours;^{100 114 155} used in conjunction with IV or oral doxycycline (100 mg every 12 hours).^{100 114 155} Cefoxitin may be discontinued 24 hours after clinical improvement occurs and oral doxycycline (100 mg every 12 hours) continued to complete 14 days of treatment.¹⁰⁰

IM†

2 g as a single dose given with oral probenecid (1 g);^{100 114 155} followed by a 14-day regimen of oral doxycycline (100 mg twice daily) with or without oral metronidazole (500 mg twice daily).^{100 114 155}

Mycobacterium abscessus Infections†

IV

If used in initial combination regimens for treatment of serious skin, soft tissue, and bone infections (see Mycobacterial Infections under Uses), ATS and IDSA recommend up to 12 g daily given in divided doses for at least 2 weeks until clinical improvement.¹⁵⁷ At least 4 months of antimycobacterial treatment is necessary for treatment of serious skin and soft tissue infections; 6 months of antimycobacterial treatment recommended for bone infections.¹⁵⁷

Perioperative Prophylaxis

Gynecologic and Obstetric Surgery

IV

Hysterectomy (abdominal, vaginal, laparoscopic): Single 1- or 2-g dose given within 30–60 minutes prior to surgery.^{106 149 150 151 156} Although manufacturers also recommend additional 2-g doses every 6 hours (for up to 24 hours), ^{149 150 151 156} postoperative doses usually unnecessary and may increase risk of bacterial resistance.¹⁰⁶

Cesarean section: Single 1- or 2-g dose given within 30–60 minutes prior to surgery.^{106 149 150 151 156} Manufacturers recommend giving the dose as soon as the umbilical cord is clamped,^{149 150 151 156} but there is some evidence that giving the dose prior to skin incision is more effective than after clamping.¹⁰⁶ Although manufacturers state additional 2-g doses can be given at 4 and 8 hours after the initial dose,^{149 150 151 156} postoperative doses usually unnecessary and may increase risk of bacterial resistance.¹⁰⁶

Some clinicians recommend additional doses during the procedure (e.g., every 2–3 hours) if surgery is prolonged >4 hours or major blood loss occurs.^{106 115 121 148}

Colorectal Surgery, Appendectomy (Nonperforated), or Other GI Surgery

IV

Single 1- or 2-g dose given within 0.5–1 hour prior to incision.^{106 115}

Some clinicians recommend additional doses during the procedure (e.g., every 2–3 hours) if surgery is prolonged >4 hours or major blood loss occurs.^{106 115 121 148}

Although manufacturers state 2 g can be given every 6 hours after the procedure for up to 24 hours,^{149 150 151} postoperative doses usually unnecessary and may increase risk of bacterial resistance.^{106 121 148}

Prescribing Limits

Pediatric Patients

Maximum 12 g daily.^{149 150 151 156}

Adults

Maximum 12 g daily.^{149 150 151 156}

Special Populations

Renal Impairment

Dosage adjustments necessary in those with Cl_cr ≤50 mL/minute.^{149 150 151 156}

Adults with Cl_cr ≤50 mL/minute: Give an initial loading dose of 1–2 g followed by maintenance dosage based on Cl_cr (see Table 1).^{149 150 151 156}

Table 1. Maintenance Dosage for Adults with Renal Impairment149150151156

Clcr (mL/min)	Dosage
30–50	1–2 g every 8–12 h
10–29	1–2 g every 12–24 h
5–9	0.5–1 g every 12–24 h
<5	0.5–1 g every 24–48 h

Adults undergoing hemodialysis: Give a loading dose of 1–2 g after each dialysis period followed by maintenance dosage based on Cl_cr (see Table 1).^{149 150 151 156}

Pediatric patients with renal impairment: Make dosage adjustments similar to those recommended for adults.^{149 150 151 156}

Geriatric Patients

Cautious dosage selection because of age-related decreases in renal function.^{149 150 151 156} (See Renal Impairment under Dosage and Administration.)

Cautions for Cefoxitin Sodium

Contraindications

• 
  

  Known hypersensitivity to cefoxitin or cephalosporins.^{149 150 151 156}

  
  

Warnings/Precautions

Warnings

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible organisms with prolonged therapy.^{149 150 151 156} Careful observation of the patient is essential.^{149 150 151 156} Institute appropriate therapy if superinfection occurs.^{149 150 151 156}

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.^{149 150 151 156} C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) has been reported with nearly all anti-infectives, including cefoxitin, and may range in severity from mild diarrhea to fatal colitis.^{149 150 151 156}

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.^{149 150 151 156} Careful medical history is necessary since CDAD has been reported to occur as late as 2 months or longer after anti-infective therapy is discontinued.^{149 151 156}

If CDAD is suspected or confirmed, anti-infective therapy not directed against C. difficile may need to be discontinued.^{149 150 151 151 156} Some mild cases may respond to discontinuance alone.^{116 117 118 119 120 149 150 151} Manage moderate to severe cases with fluid, electrolyte, and protein supplementation, anti-infective therapy active against C. difficile (e.g., oral metronidazole or vancomycin), and surgical evaluation when clinically indicated.^{116 117 118 119 120 149 150 151 151 156}

Sensitivity Reactions

Hypersensitivity Reactions

Possible hypersensitivity reactions, including rash (maculopapular or erythematous), pruritus, fever, eosinophilia, urticaria, anaphylaxis, erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis.^{149 150 151 a 156}

If an allergic reaction occurs, discontinue cefoxitin and institute appropriate therapy as indicated (e.g., epinephrine, corticosteroids, and maintenance of an adequate airway and oxygen).^{149 150 151 156}

Cross-hypersensitivity

Partial cross-allergenicity among β-lactam antibiotics, including penicillins, cephalosporins, and cephamycins.^{149 150 151 156}

Prior to initiation of therapy, make careful inquiry concerning previous hypersensitivity reactions to cefoxitin, cephalosporins, penicillins, or other drugs.^{149 150 151 156} Cautious use recommended in individuals hypersensitive to penicillins.^{149 150 151 156 a} Avoid use in those who have had an immediate-type (anaphylactic) hypersensitivity reaction and administer with caution in those who have had a delayed-type (e.g., rash, fever, eosinophilia) reaction.^a

General Precautions

History of GI Disease

Use with caution in patients with a history of GI disease, particularly colitis.^{149 150 151 156} (See Superinfection/Clostridium difficile-associated Diarrhea and Colitis [CDAD] under Cautions.)

Laboratory Monitoring

Periodically assess organ system functions, including renal, hepatic, and hematopoietic, during prolonged therapy.^{149 150 151 156}

Patients with Diabetes

The commercially available Duplex delivery system containing 1 or 2 g of lyophilized cefoxitin and 50 mL of dextrose 2.2 or 4% injection should be used with caution in patients with overt or known subclinical diabetes mellitus or in patients with carbohydrate intolerance for any reason.¹⁴⁹

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of cefoxitin and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.^{149 150 151 156}

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.^{149 150 151 156} In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.^{149 150 151 156}

Sodium Content

Contains approximately 53.8 mg (2.3 mEq) of sodium per g of cefoxitin.^{149 150 151 156}

Specific Populations

Pregnancy

Category B.^{149 150 151 156}

Lactation

Distributed into milk in low concentrations; use with caution.^{149 150 151 156}

Pediatric Use

Safety and efficacy in infants <3 months of age have not been established.^{149 150 151 156}

Use of high doses in children ≥3 months of age have been associated with an increased incidence of eosinophilia and elevated serum AST concentration.^{149 150 151 156}

Cefoxitin reconstituted with bacteriostatic water for injection containing benzyl alcohol should not be used in infants.^{150 151} Benzyl alcohol as a preservative has been associated with toxicity in neonates; although these effects have not been demonstrated in infants >3 months of age, small infants in this age range may also be at risk for benzyl alcohol toxicity.^{150 151}

Geriatric Use

No overall differences in safety and efficacy in those ≥65 years of age compared with younger adults, but the possibility of increased sensitivity in some geriatric individuals cannot be ruled out.^{149 150 156}

Substantially eliminated by kidneys; risk of toxicity may be greater in those with impaired renal function.^{149 150 156} Select dosage with caution and consider monitoring renal function because of age-related decreases in renal function.^{149 150 156} (See Renal Impairment under Dosage and Administration.)

Renal Impairment

High and prolonged serum concentrations may occur.^{149 150 151 156}

Reduce dosage in those with Cl_cr ≤50 mL/minute.^{149 150 151 156} See Renal Impairment under Dosage and Administration.

Common Adverse Effects

Local reactions at the IV administration site (including thrombophlebitis), hypersensitivity reactions, diarrhea.^{149 150 151 156}

Interactions for Cefoxitin Sodium

Specific Drugs and Laboratory Tests

Drug or Test	Interaction	Comments
Aminoglycosides	Possible increased risk of nephrotoxicity149 150 151 Physical incompatibility if solutions directly mixed together149 150 151	Closely monitor renal function if used concomitantly149 150 151 Administer separately; do not admix149 150 151
Probenecid	Decreased renal excretion and higher and more prolonged serum concentrations of cefoxitin149 150 151
Tests for creatinine	High concentrations (>100 mcg/mL) may cause falsely elevated serum or urine creatinine values when the Jaffe reaction is used149 150 151	Avoid using blood samples for creatinine determinations if they were drawn from the patient within 2 hours after a cefoxitin dose149 150 151
Tests for glucose	Possible false-positive reactions in urine glucose tests using Clinitest, Benedict’s solution, or Fehling’s solution149 150 151 a	Use glucose tests based on enzymatic glucose oxidase reactions (e.g., Clinistix, Tes-Tape)149 150 151

Cefoxitin Sodium Pharmacokinetics

Absorption

Bioavailability

Not appreciably absorbed from the GI tract; must be administered parenterally.^c

Following IM administration in healthy adults, peak serum concentrations attained within 20–30 minutes.^c

Distribution

Extent

Widely distributed into body tissues and fluids, including ascitic, pleural, and synovial fluid.^c

Therapeutic concentrations may be obtained in bile if biliary obstruction is not present.^c

Diffuses poorly into CSF following IM or IV administration, even when meninges are inflamed.^c

Readily crosses the placenta^c and is distributed into milk in low concentrations.^c

Plasma Protein Binding

50–80%.^c

Elimination

Metabolism

≤2% of a dose is metabolized to descarbamylcefoxitin, which is microbiologically inactive.^c

Elimination Route

Rapidly eliminated in urine by glomerular filtration and renal tubular excretion.^c About 85% of a dose excreted unchanged in urine within 6 hours^c

Half-life

Adults with normal renal function: 0.7–1.1 hours.^c

Special Populations

Patients with renal impairment: Serum concentrations higher and serum half-life prolonged.^c Serum half-life averages 6.3 hours or 21.5 hours in adults with Cl_cr about 18 mL/min or 2 mL/min, respectively.^c

Geriatric adults 64–88 years of age with renal function normal for their age: 0.9–1.5 hours.^{149 150 151 156}

Stability

Storage

Parenteral

Powder for Injection or IV Infusion

2–25° C;^{150 151} avoid exposure to temperatures >50° C.^{150 151}

Powder and reconstituted solutions may darken; does not indicate loss of potency.^{150 151 156}

Reconstituted solutions for IV administration prepared using sterile or bacteriostatic water, 0.9% sodium chloride, or 5% dextrose are stable for 6 hours at room temperature or 1 week when refrigerated at <5°C.^{150 151}

Piggyback units containing 1 or 2 g of cefoxitin prepared using 5 or 10% dextrose or 0.9% sodium chloride are stable for 24 hours at room temperature or 1 week when refrigerated at <5°C.^c

Store commercially available Duplex drug delivery system containing 1 or 2 g of lyophilized cefoxitin and 50 mL of dextrose injection at 20–25°C (may be exposed to 15–30°C).¹⁴⁹ Following reconstitution (activation), use these IV infusions within 12 hours if stored at room temperature or within 7 days if stored in a refrigerator; do not freeze.¹⁴⁹

Injection (Frozen) for IV Infusion

-20°C or lower.¹⁵⁶ After thawing, stable for 24 hours at room temperature (25°C) or 21 days under refrigeration (2–8°C).¹⁵⁶

Do not refreeze after thawing.¹⁵⁶

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution Compatibility^HID

Compatible
Dextrose 5% in Ringer’s injection, lactated
Dextrose 5% in sodium chloride 0.2, 0.45, or 0.9%
Dextrose 5 or 10% in water
Invert sugar 10% in sodium chloride 0.9%
Invert sugar 5 or 10% in water
Ionosol B with dextrose 5% in water
Mannitol 5 or 10% in water
Normosol M in dextrose 5% in water
Ringer’s injection
Ringer’s injection, lactated
Sodium bicarbonate 5%
Sodium chloride 0.9%
Sodium lactate (1/6) M

Drug Compatibility

Admixture CompatibilityHID

Compatible
Amikacin sulfate
Cimetidine HCl
Clindamycin phosphate
Gentamicin sulfate
Kanamycin sulfate
Metronidazole HCl with sodium bicarbonate
Multivitamins
Sodium bicarbonate (Neut)
Tobramycin sulfate
Verapamil HCl
Vitamin B complex with C
Incompatible
Ranitidine HCl
Variable
Aztreonam
Metronidazole

Y-Site CompatibilityHID

Compatible
Acyclovir sodium
Amifostine
Amphotericin B cholesteryl sulfate complex
Aztreonam
Bivalirudin
Cyclophosphamide
Dexmedetomidine HCl
Diltiazem HCl
Docetaxel
Doxorubicin HCl liposome injection
Etoposide phosphate
Famotidine
Fluconazole
Foscarnet sodium
Gemcitabine HCl
Granisetron HCl
Hetastarch in lactated electrolyte injection (Hextend)
Hydromorphone HCl
Linezolid
Magnesium sulfate
Meperidine HCl
Morphine sulfate
Ondansetron HCl
Perphenazine
Propofol
Ranitidine HCl
Remifentanil HCl
Teniposide
Thiotepa
Incompatible
Fenoldopam mesylate
Filgrastim
Gatifloxacin
Hetastarch in sodium chloride 0.9%
Pentamidine isethionate
Variable
Vancomycin HCl

Actions and SpectrumActions

• 
  

  Cephamycin;^{149 150 151 a} sometimes classified with second generation cephalosporin based on spectrum of activity.^a

  
  


• 
  

  Usually bactericidal.^{149 150 151 a}

  
  


• 
  

  Like other β-lactam antibiotics, antibacterial activity results from inhibition of bacterial cell wall synthesis.^{149 150 151 a}

  
  


• 
  

  Spectrum of activity includes some gram-positive and -negative aerobic bacteria and some anaerobic bacteria; inactive against Chlamydia, fungi, and viruses.^a

  
  


• 
  

  Gram-positive aerobes: Active in vitro and in clinical infections against S. aureus (including penicillinase-producing strains), S. epidermidis, S. pneumoniae, S. pyogenes (group A β-hemolytic streptococci), and S. agalactiae (group B streptococci).^{149 150 151} Oxacillin-resistant staphylococci (methicillin-resistant staphylococci) and most enterococci (e.g., Enterococcus faecalis) are resistant.^{149 150 151}

  
  


• 
  

  Gram-negative aerobes: Active in vitro and in clinical infections against E. coli, H. influenzae, Klebsiella (including K. pneumoniae), M. morganii, N. gonorrhoeae, P. mirabilis, P. vulgaris, and Providencia (including P. rettgeri).^{149 150 151} Also active in vitro against Eikenella corrodens (non-β-lactamase-producing strains),^{149 150 151} K. oxytoca,^{149 150 151} Salmonella,^c and Shigella.^c Many strains of Enterobacter cloacae and most strains of Pseudomonas aeruginosa are resistant.^{149 150 151}

  
  


• 
  

  Anaerobes: Active in vitro and in clinical infections against Bacteroides distasonis, B. fragilis, B. ovatus, B. thetaiotaomicron, Clostridium (including C. perfringens but not C. difficile), Peptococcus niger, and Peptostreptococcus.^{149 150 151 c} Also active in vitro against Fusobacterium, Prevotella bivia,^{149 150 151} Propionibacterium.^c

  
  


• 
  

  Active in vitro against some mycobacteria, including Mycobacterium abscessus,¹⁵⁷ M. fortuitum,¹⁵⁷ and M. mucogenicum.¹⁵⁷ Has variable activity against M. smegmatis;¹⁵⁷ however, M. chelonae¹⁵⁷ and M. immunogenum¹⁵⁷ are resistant.

  
  

Advice to Patients

• 
  

  Advise patients that antibacterials (including cefoxitin) should only be used to treat bacterial infections; they do not treat viral infections (e.g., the common cold).^{149 150 151}

  
  


• 
  

  Importance of compl