Cefpodoxime found inferior to ciprofloxacin as cystitis treatment

Cefpodoxime is not an effective treatment option for acute uncomplicated cystitis, a new study concluded.
In a double-blind trial, researchers randomized 300 women, ages 18 to 55, with acute uncomplicated cystitis to three days of treatment with either cefpodoxime or ciprofloxacin. Patients were given 250 mg of ciprofloxacin orally twice daily or 100 mg of cefpodoxime proxetil orally twice daily. Overall clinical cure, defined as not requiring more antibiotics at a 30-day follow-up visit, was the primary outcome.
In an intent-to-treat analysis in which patients lost to follow-up (who totaled 32) were considered cured, the clinical cure rate was 93% for ciprofloxacin compared to 82% for cefpodoxime (difference, 11%; 95% CI, 3% to 18%). When the patients lost to follow-up were assumed to not be cured, the cure rates were 83% for ciprofloxacin versus 71% for cefpodoxime (difference, 12%; 95% CI, 3% to 21%). An even greater difference was seen in microbiological cure rate: 96% for ciprofloxacin and 81% for cefpodoxime (difference, 15%; 95% CI, 8% to 23%). More women in the cefpodoxime group were also found to have vaginal colonization with Escherichia coli at their follow-up visit (40% vs. 16%).
The study authors concluded that cefpodoxime did not meet their clinical criteria for noninferiority to ciprofloxacin (which was set at a 10% margin before the study began). The research was undertaken, they explained, because although fluoroquinolones such as ciprofloxacin are highly efficacious for acute cystitis, guidelines have recommended that the drugs be reserved for more serious conditions to slow the development of fluoroquinolone resistance. Cefpodoxime was thought to have potential as a safe and effective fluoroquinolone-sparing option, but the findings of this study do not support its use as a first-line treatment, the authors concluded.
The risk of gram-negative extended-spectrum beta-lactamase resistance is another potential concern about cefpodoxime, the researchers noted. Given these limitations of the drug, they recommended that physicians follow existing guidelines and consider nitrofurantoin, trimethoprim-sulfamethoxazole and fosfomycin as treatments for uncomplicated cystitis before resorting to fluoroquinolones or beta-lactams. The study was published in the Feb. 8 Journal of the American Medical Association.