• Third Generation Cephalosporins in More Detail

  • Cefotaxime Therapeutic Uses (Continued)

    • Intra‑abdominal infections

      • In perforated appendicitis, diverticulitis with abscess, or secondary peritonitis without severe sepsis or high ESBL risk, cefotaxime plus metronidazole is an effective combination which targets Enterobacterales and anaerobes respectively.

      • SBP is typically on monomicrobial infection due to enteric-type bacteria such as Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis.

      • Guidelines for Spontaneous Bacterial Peritonitis (SBP) and other intra‑abdominal infections identify cefotaxime as a standard third‑generation cephalosporin option, especially in community‑acquired settings.^6,7,8,9

       

      Intra-abdominal Infections

      References (1) EASL clinical practice guidelines in the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome and sclerosis. European Association for the Study of the Liver. Clinical Practice Guidelines. Volume 53, Issue 3, 397-417. September 2010. https://www.journal-of-hepatology.eu/article/S0168-8278(10)00478-2/fulltext (2) Runyon B Management of Adult Patients with Ascites Due to Cirrhosis: An Update. AASLD Practice Guidelines. Hepatology, June 2009. 2087-2107. https://gastroliver.medicine.ufl.edu/files/2012/07/Ascites-Update6-2009.pdf (3) Fernandez J Navasa M Planas R Montoliu S Monfort D Soriano G Vila C Pardo A Quintero E Vargas V Such J Genes P Arroya V Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improved survival and cirrhosis. Randomized Controlled Trial. Gastroenterology. 2007 September;133(3): 818-824. https://pubmed.ncbi.nlm.nih.gov/17854593/ (4) Thevenot T Elkrief L Bureau C Di Martino V Weil D Desmarets M et al. Effect of rifaximin in patients with severe cirrhosis and ascites: A randomized double-blind placebo-controlled trial. Journal of Hepatology. Have volume 83, Issue 6. 1320-3027. December, 2025. https://www.journal-of-hepatology.eu/article/S0168-8278(25)02318-9/fulltext (5) Li P Szeto C Piraino B Arteaga J Fan S Figueiredo A Fish D Goffin E Kim Y-L Salzer W Strruiji K Teitelbaum I Johnson D. ISPD Peritonitis Recommendations: 2016 Update on Prevention and Treatment Perit Dial Int. . 2016 September-October;36(5): 41-508. https://pmc.ncbi.nlm.nih.gov/articles/PMC5033625/ (6) Sartelli M et al The management of inter-abdominal infections from the global perspective: 2017 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg. 2017 July 10:12:29. https://pubmed.ncbi.nlm.nih.gov/28702076/ (7) Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1–76. Surg Infect (Larchmt). 2017 January;18(1): 1-76. https://pubmed.ncbi.nlm.nih.gov/28085573/ (8) Weiss G, Steffanie W, Lippert H. Peritonitis: main reason of severe sepsis in surgical intensive care. Zentralbl Chir. 2007;132(2):130–137. [Peritonitis: main reason of severe sepsis and surgical intensive care] https://pubmed.ncbi.nlm.nih.gov/17516319/

     

    • Skin and soft‑tissue infections^8,10

      • Cefotaxime can be used for moderate to severe cellulitis or soft‑tissue infections when streptococci and some staphylococci are implicated, particularly if a Gram‑negative component is suspected post‑surgery or in diabetics.

      • For pure MSSA infections, narrower agents such as cefazolin are preferred, but cefotaxime is useful when broader coverage is needed while cultures are pending.

      References (1) Stevens D Bisno A Chambers H Dellinger E Goldstein E Gorbach S Hirschmann J Kaplan S Montoya J Wade J Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10–e52. https://academic.oup.com/cid/article/59/2/e10/2895845 (2) Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–337. https://pubmed.ncbi.nlm.nih.gov/27434444/ (3) Eron L Lipsky B Low D Nathwani D Tice A Volturo G Managing skin and soft tissue infections: expert panel recommendations on key decision points. J Antimicrob Chemother. 2003;52(Suppl 1):i3–i17. https://pubmed.ncbi.nlm.nih.gov/14662806/ (4) Wong C Khin L Heng K Tan K Low C The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32(7):1535–1541. https://pubmed.ncbi.nlm.nih.gov/15241098/ (5) Sartelli M, Guirao X, Hardcastle T et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg. 2018;13:58. https://pubmed.ncbi.nlm.nih.gov/30564282/ (6)  Misiakos EP, Bagias G, Patapis P, Sotiropoulos D, Kanavidis P, Machairas A. Current concepts in the management of necrotizing fasciitis. Front Surg. 2014;1:36. https://pubmed.ncbi.nlm.nih.gov/25593960/ (7) Goh T, Goh L Ang C Wong C. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–e125. https://bjssjournals.onlinelibrary.wiley.com/doi/full/10.1002/bjs.9371

     

    • Bone and Joint Infections^8,10

      • In osteomyelitis or septic arthritis caused by susceptible streptococci or Gram‑negative bacilli, cefotaxime achieves therapeutic bone and synovial levels and is often part of combination therapy.

        • Osteomyelitis of the first Toe

          Attribution Osteomyelitis of the first toe. James Heilman, MD, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons (May 29, 2016)

           

        • Osteomyelitis of the first Toe

          Attribution Septic arthritis the left hip joint with melioidosis https://commons.wikimedia.org/wiki/File:Septic_arthritis_of_left_hip_joint_with_melioidosis.jpg This file is licensed under the Creative Commons Attribution 4.0 Unported license.

        • Cefuroxime is commonly selected when polymicrobial infections or Gram‑negative coverage are concerns, with targeted agents added for staphylococci or anaerobes as indicated.

        • Bone & Joint Infections

          Comparative overview of Osteomyelitis and Septic Arthritis

          References (1)  Lew D  Waldvogel F  Osteomyelitis. Lancet. 2004;364(9431): 369–379.  https://www.sciencedirect.com/science/article/abs/pii/S0140673604167275 (2) Berbari E  Kanj S  Kowalski T  et al. Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. Clin Infect Dis. 2015;61(6):e26–e46. https://www.idsociety.org/globalassets/idsa/practice-guidelines/2015-infectious-diseases-society-of-america-idsa-clinical-practice-guidelines-for-the-diagnosis-and-treatment-of-native-vertebral-osteomyelitis-in-adults.pdf (3) Horowitz D Katzap E  Horowitz S  Bhavsar M  Approach to septic arthritis. Am Fam Physician. 2011;84(6)653–660. https://pubmed.ncbi.nlm.nih.gov/21916390/ (4) Mathews C Weston VC Jones A Field M  Coakley G. Bacterial septic arthritis in adults. Lancet. 2010;375(9717):846–855.  https://www.thelancet.com/article/S0140-6736(09)61595-6/abstract (5) Li H Rombach I Zambellas R et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA Trial). N Engl J Med. 2019;380(5):425–436. https://www.nejm.org/doi/full/10.1056/NEJMoa1710926 (6) Cierny G Mader J Penninck JJ A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003;(414):7–24. https://journals.lww.com/clinorthop/citation/2003/09000/the_classic__a_clinical_staging_system_for_adult.3.aspx (7) Kowalski T Lappe J Berbari E Vertebral osteomyelitis and native joint infections. In: Bennett J Dolin R Blaser M eds. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 9th ed. Elsevier; 2020:1328–1345. https://shop.elsevier.com/books/mandell-douglas-and-bennetts-principles-and-practice-of-infectious-diseases/bennett/978-0-323-48255-4 (8) Arnold J Bradley J Osteoarticular Infections in Children. Infect Dis Clin North Am. 2015;29(3):557–574. https://pubmed.ncbi.nlm.nih.gov/26311358/

       

      • Gynecologic and Pelvic Infections^{8,10,11,12,13}  

        • Cefotaxime has been used in pelvic inflammatory disease and postpartum endometritis to cover Gram‑negative rods and streptococci.

          • Other more current regimens based on ceftriaxone is often recommended, as describe in references 12,13 and in the table below.

        • Cefuroxime was often combined with metronidazole and doxycycline (or azithromycin) targeting anaerobes and Chlamydia trachomatis.

          • Such multi‑drug approaches take into account the polymicrobial character of upper genital tract infections.

        Pelvic Inflammatory Disease

        References (1) Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, MMWR Recomm Rep. 2021. https://pmc.ncbi.nlm.nih.gov/articles/PMC8344968/ (2) Ross J, Guaschino S, Cusini M, Jensen J. 2017 Int J STD AIDS. 2018;29(2):108-114. European International Union against Sexually Transmitted Infections (IUSTI) guideline for the management of pelvic inflammatory disease. https://iusti.org/wp-content/uploads/2019/12/IUSTIPIDGuideline2017.pdf (3) Curry A, Williams T, Penny ML. Am Fam Physician. Pelvic inflammatory disease: diagnosis, management, and prevention. https://www.aafp.org/pubs/afp/issues/2019/0915/p357.html (4) Haggerty CL, Ness RB. Epidemiology, pathogenesis, and treatment of pelvic inflammatory disease. Expert Rev Anti Infect Ther. https://www.tandfonline.com/doi/abs/10.1586/14787210.4.2.235 (5) Weström L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility: a cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopic results. Sex Transm Dis.  https://europepmc.org/article/med/1411832/reload=0 (6) Savaris RF, Fuhrich DG, Duarte RV, Franik S, Ross J. Antibiotic therapy for pelvic inflammatory disease. https://pubmed.ncbi.nlm.nih.gov/32820536/ (7) Trent M. Pelvic inflammatory disease. Pediatr Rev. 2013;34(4):163-172. https://publications.aap.org/pediatricsinreview/article-abstract/34/4/163/34778/Pelvic-Inflammatory-Disease?redirectedFrom=fulltext

February, 2026