CEFPODOXIME PROXETIL - AN APPRAISAL OF ITS USE IN ANTIBACTERIAL COST-CONTAINMENT PROGRAMS, AS STEPDOWN AND ABBREVIATED THERAPY IN RESPIRATORY-TRACT INFECTIONS

Cefpodoxime proxetil is an orally administered prodrug which is conver ted in vivo to the third generation cephalosporin cefpodoxime. Cefpodo xime has a similar spectrum of antibacterial activity to the parentera l cephalosporins ceftriaxone and defotaxime and a long elimination hal f-life, which allows once- or twice-daily administration. Cefpodoxime proxetil has proven efficacy in the treatment of community-acquired pn eumonia and upper respiratory tract, skin and soft tissue and urinary tract infections. It has been evaluated for use in cost-containment pr ogrammes, as stepdown (parenteral-to-oral conversion) therapy in the t reatment of community-acquired pneumonia and as abbreviated therapy in upper respiratory tract infections. Substituting oral for parenteral therapy can achieve considerable savings (in acquisition, delivery and labour costs). Moreover, oral administration has advantages for the p atient in terms of comfort and mobility, avoids the hazards of parente ral delivery and may allow earlier discharge from hospital, or even al low home treatment from the outset in low-risk patients. As hospitalis ation is usually the major cost component in treating serious infectio ns, considerable savings can be made in this way. Pharmacy-driven step down programmes in 2 US hospitals have achieved cost savings by target ing patients with community-acquired pneumonia for early conversion fr om intravenous ceftriaxone therapy to oral cefpodoxime proxetil. Costs were compared with those from a control group of patients who continu ed to receive intravenous ceftriaxone until physicians deemed that ora l therapy (with various agents) was appropriate. In one study, duratio n of parenteral therapy in the cefpodoxime proxetil group was reduced from 6.18 to 3.82 days and duration of hospitalisation was reduced fro m 10.06 to 6.23 days (p < 0.02), with corresponding hospitalisation co st reductions of $US7300 per patient. However, clinical trial data rel ating to the efficacy of cefpodoxime proxetil as stepdown therapy in p atients initially requiring parenteral antibacterials are lacking. Abb reviated (4- to 7-day) cephalosporin regimens appear to be as effectiv e as traditional 10-day penicillin regimens in the treatment of upper respiratory tract infections. Short regimens may improve patient compl iance and tolerability, thereby reducing the costs of adverse effects and treatment failures. Data from preliminary clinical studies suggest that a 5-day course of cefpodoxime proxetil is as effective as an 8-d ay course of amoxicillin/clavulanic acid in treating either acute otit is media or sinusitis, and as effective as a 10-day course of amoxicil lin/ clavulanic acid and more effective than a 10-day course of phenox ymethylpenicillin in the treatment of pharyngotonsillitis. Cefpodoxime proxetil tended to be better tolerated and was associated with better compliance than penicillin-based regimens. Indeed, a pharmacoeconomic study showed that a 10-day regimen of cefpodoxime proxetil was associ ated with lower costs for treating adverse effects and treatment failu res than a 10-day regimen of amoxicillin/clavulanic acid in the treatm ent of acute otitis media in children. A 5-day course of cefpodoxime p roxetil had a lower cost per patient treated per month free of recurre nce than a 10-day course of phenoxymethylpenicillin (non-generic) or a moxicillin/clavulanic acid in the treatment of recurrent pharyngotonsi llitis. Thus, evidence to date suggests that cefpodoxime proxetil has potential for use as stepdown therapy in community-acquired pneumonia and in abbreviated therapy courses in upper respiratory tract infectio ns. These preliminary observations require confirmation in well design ed studies.