Cephalosporins Are Not Created Equal

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Cephalosporins Are Not Created Equal Just the other day I found where a pharmacist had discontinued cefepime off a patient's profile because a post-op order had included starting cefazolin post-op for three doses.  This particular patient had pseudomonas positive cultures, and I scratched my head trying to figure out why the cefepime was stopped.

Well...

Our computer system flags cephalosporins as duplicates regardless of what generation and what is being treated.  It is much too easy as a pharmacist to just allow the computer system to do all the thinking, but if you have an archaic computer system as many hospitals I have seen, well...

So here's a cephalosporin refresher.  Maybe some tips to help you remember things about each generation and why cefepime is not the same as cefazolin.  NEVER ever.

Some hints to just memorize I use:  (I did not create these)

How to remember the names of the MC used drugs third generation Cephalosporins? Easy. Third Generation–>cef-Tazidime,cefo-Taxime, and cef-Triaxone. All of them start with CEF (they are Cephalosporins) and have the letter T in their name, right after CEF. There is an exception of that rule. Cef-oTeTan is a second generation Cephalosporin, starts with CEF and has the letter T in its name. It can’t be easier than that. Second generation=IInd. generation–>double T in the name of Cef-oTeTan.

1st: zolin, lexin are dying.

cefazolin, cephalexin, cephradine

2nd: actor fox, u rocks (most don't enter CNS)

actor: cefaclor, fox: cefoxitin, u rocks: cefuroxime

A Fox has a Furry Face ie ceFOXitin, ceFURoxime ceFAClor

3rd: tazi tri taxi enter CNS, opera no CNS

tazi: ceftazidime, tri: ceftriaxone, taxi: cefotaxime

oper: cefoperazone (doesn't enter CNS, from kaplan)

4th:  cefepime

From the fpnotebook.com:

  1. General
    1. Spectrum changes from first to third generation
      1. First Generation: Better Gram Positive Cocci coverage
      2. Third Generation: Better Gram Negative Rod coverage
  2. Contraindications
    1. Drug allergy to other Cephalosporin
    2. Type I Hypersensitivity Reaction to a Penicillin
      1. Less than 10% of those who report Penicillin Allergy actually have a Penicillin Allergy
      2. Penicillin Allergy has only a 1% risk of cross-reactivity with Cephalosporins (previously thought to be 10%)
        1. Herbert (2000) West J Med 172(5): 341
      3. Penicillin Anaphylaxis confers a 0.001% risk of Anaphylaxis to Cephalosporins
        1. Apter (2006) Am J Med 119(4):354.e11-9
      4. Cross reactivity appears limited to First Generation Cephalosporins and Penicillins
        1. Second and Third Generation Cephalosporins have minimal to no allergy cross reactivity
        2. Campagna (2012) J Emerg Med 42(5): 612-20
  3. Class: First Generation Cephalosporins
    1. Oral Agents
      1. Cephalexin (Keflex)
      2. Cephradine (Velosef)
      3. Cefadroxil (Duricef)
    2. Parenteral Agents
      1. Cefazolin (Ancef)
    3. Organisms covered
      1. Gram Positive Cocci
      2. EKP Gram Negative Bacteria
  4. Class: Second Generation Cephalosporins
    1. Second Generation Broad-spectrum Cephalosporins
      1. Oral Agents
        1. Loracarbef (Lorabid)
        2. Cefprozil (Cefzil)
        3. Cefuroxime (Ceftin, Zinacef)
        4. Cefaclor (Ceclor)
      2. Organisms Covered
        1. Gram Positive Cocci
        2. EKP Gram Negative Bacteria
        3. Gram Negative Coccobacilli
    2. Second Generation Anti-anaerobe Cephalosporins
      1. Parenteral Agents
        1. Cefoxitin
        2. Cefotetan
        3. Cefamandole
      2. Organisms Covered
        1. Bacteroides fragilis
  5. Class: Third Generation Cephalosporins
    1. Third Generation Broad-Spectrum Cephalosporins
      1. Oral agents
        1. Cefixime (Suprax)
          1. Only indication is for Gonorrhea
        2. Cefpodoxime (Vantin)
          1. Does not cover Enterobacter or pseudomonas
      2. Parenteral agents
        1. Cefotaxime (Claforan)
        2. Ceftizoxime (Cefizox)
        3. Ceftriaxone (Rocephin)
      3. Organisms Covered
        1. Gram Positive Cocci
        2. EKP Gram Negative Bacteria
        3. ESP Gram Negative Bacteria
        4. No Pseudomonas activity
    2. Third Generation Anti-Pseudomonal Cephalosporins
      1. Agents
        1. Ceftazidime (Fortaz)
      2. Organisms Covered
        1. Pseudomonas
        2. EKP Gram Negative Bacteria
        3. ESP Gram Negative Bacteria
        4. Poor Gram Positive Cocci coverage
        5. No Coccobacilli coverage
    3. Fourth Generation Cephalosporins --Cefepime -  is a fourth-generation cephalosporin antibiotic developed in 1994. Cefepime has an extended spectrum of activity against Gram-positive and Gram-negative bacteria, with greater activity against both Gram-negative and Gram-positive organisms than third-generation agents.Cefepime is usually reserved to treat moderate-severe nosocomial pneumonia, infections caused by multi-resistant microorganisms (e.g.Pseudomonas aeruginosa) and empirical treatment of febrile neutropenia.[3]

      Cefepime has good activity against important pathogens including Pseudomonas aeruginosa, Staphylococcus aureus, and multiple drug resistant Streptococcus pneumoniae. A particular strength is its activity against Enterobacteriaceae. Whereas other cephalosporins are degraded by many plasmid- and chromosome-mediated beta-lactamases, cefepime is stable and is a front line agent when infection with Enterobacteriaceae is known or suspected.

So there you go.

 

Don't go discontinuing a broad spectrum cephalosporin used to treat a multi-resistant microorganism like Pseudomonas for a puny mostly gram positive post surgical cefazolin for they are not equal.

And that would be an awesome song lyric!