Cefuroxime

What it is

Cefuroxime is a second-generation cephalosporin antibiotic. Swallowed, it is given as cefuroxime axetil, an ester that is broken down by esterases in the gut wall and blood into cefuroxime itself. It also exists as cefuroxime sodium for injection, and as a small single-use injection put into the front of the eye at the end of cataract surgery. The oral tablets are approved in the United States for eight infections, from throat and ear infections to early Lyme disease.

What the research says

The evidence differs sharply between its approved uses. In group A streptococcal sore throat it eradicated the bacterium in 94.2% of children against 84.1% for penicillin V. In children's acute otitis media a five-day course matched eight or ten days of amoxicillin/clavulanate. In early Lyme disease it matched doxycycline in a randomised trial. But in the one placebo-controlled trial we could find, in 82 children with respiratory symptoms and imaging evidence of sinusitis, a ten-day course gave no benefit at all. Its largest single piece of outcome evidence is off-label: the ESCRS randomised trial of intracameral cefuroxime at cataract surgery, stopped early because endophthalmitis fell from 23 cases in 6862 patients to 5 in 6836. Against this, cefuroxime is one of the oral antibiotics most strongly linked to community-acquired Clostridioides difficile infection.

Evidence grade: Well established.

How it works

Drug class: Second-generation cephalosporin beta-lactam antibacterial; the oral form, cefuroxime axetil, is an ester prodrug hydrolysed to cefuroxime

Cefuroxime kills bacteria by blocking the construction of their cell wall, so the wall fails and the cell bursts. It holds up against some of the beta-lactamase enzymes that destroy penicillins. Bacteria become resistant by hydrolysing it with beta-lactamases, by altering the penicillin-binding proteins it targets, by letting less of it in, and by pumping it out. (Source 1)

What it is used for

• A randomised, evaluator-blinded multicentre trial in 385 evaluable children found higher bacterial eradication and symptom resolution than penicillin V. The label notes that efficacy in preventing rheumatic fever was not established in the trials. Evidence: established. (Source 2)
• An open-label randomised multicentre trial in 716 children aged 6 to 36 months with tympanocentesis-confirmed otitis media with effusion found a 5-day cefuroxime axetil course equivalent to 8 or 10 days of amoxicillin/clavulanate, with less drug-related diarrhoea than the 10-day comparator. Nobody was blinded, and equivalence means the shorter course was not shown to be worse. Evidence: established. (Source 3)
• Most sinusitis trials compared cefuroxime against another antibiotic rather than against placebo. The one placebo-controlled randomised trial we reached, in children with imaging-confirmed sinusitis, found no clinical benefit from a 10-day course. Evidence: disputed. (Source 4)
• A randomised investigator-blinded trial found cefuroxime axetil 500 mg twice daily for 20 days gave satisfactory outcomes in 93% against 88% for doxycycline, with the difference's confidence interval spanning zero. A smaller paediatric trial against amoxicillin found all 43 children did well. Evidence: established. (Source 5)
• These indications rest on comparative trials against other antibiotics rather than against placebo, so they show cefuroxime is not worse than alternatives rather than that treatment beats no treatment. We did not retrieve outcome trials for each of them in this pass. Evidence: limited. (Source 6)
• The ESCRS randomised trial of over 16,000 patients was stopped early because endophthalmitis was about five times more common without intracameral cefuroxime. Observational studies and a meta-analysis covering over 900 000 eyes agree. The harm is dilution and compounding error, which can cause retinal toxicity. Evidence: established. (Source 7)
• A pooled analysis of prophylaxis trials covering 12,446 patients reported no difference between cefazolin and cefuroxime, ceftriaxone or cefamandole, so there is no demonstrated advantage for cefuroxime here - though the analysis publishes no pooled estimate or confidence interval, so equivalence is not established either. Second-generation cephalosporin prophylaxis has been linked to Clostridioides difficile in orthopaedic surgery. Evidence: limited. (Source 8)

Interactions

• Food (a meal) (pharmacokinetic study): Food increases how much cefuroxime gets into the blood from the oral prodrug. A volunteer study measured the rise: absolute bioavailability went from 0.35 and 0.32 in fasting men and women up to 0.45 and 0.41 after food. This is the opposite direction to most antibiotic food interactions. (Source 9)
• Antacids, H2 blockers such as ranitidine, and proton pump inhibitors (label): Anything that raises stomach pH lowers the amount of cefuroxime absorbed and cancels out the benefit of taking it with food. The label says to separate short-acting antacids by at least 1 hour before or 2 hours after, and to avoid H2 antagonists and proton pump inhibitors altogether. A volunteer study measured the effect directly. (Source 10)
• Probenecid (label): Probenecid blocks the kidney tubule transporters that clear cefuroxime, so blood levels rise. The label advises against taking the two together. (Source 11)
• Urine and blood glucose tests (label): Cefuroxime can make a copper-reduction urine glucose test read falsely positive and a ferricyanide blood glucose test read falsely negative. This matters for anyone with diabetes who self-monitors with older methods. Creatinine assays by the alkaline picrate method are unaffected. (Source 12)
• Alcohol (label): We found no trial, pharmacokinetic study or case series describing a cefuroxime-alcohol interaction. The disulfiram-like reaction that some cephalosporins cause belongs to the ones carrying a methyltetrazolethiol side chain, such as cefotetan, and we found no such report for cefuroxime. Nothing in the label's drug interactions section mentions alcohol. (Source 13)
• Calcium, iron, magnesium and zinc supplements (pharmacokinetic study): We found no pharmacokinetic study showing that mineral supplements chelate cefuroxime the way they do tetracyclines and fluoroquinolones, and the label's drug interactions section does not list them. One study of a different mechanism, amlodipine's effect on peptide-transporter beta-lactams, found no change in cefuroxime pharmacokinetics at all. Limit: The source contradicts itself in the sentence quoted: it reports "no significant differences" and then prints "(P < .05)", which is the threshold for a difference being significant. A null result cannot be supported by P < .05, and the published abstract almost certainly means P > .05. We have kept the quotation as the journal printed it. What the study supports is that amlodipine did not measurably change cefuroxime levels; the p-value as printed should not be relied on. The abstract also contains the typo "They authors conclude", which is the source's. (Source 14)

Stopping it

• Courses are fixed and short, and there is no withdrawal syndrome or taper in the literature we searched. The question is instead how short a course can be: in acute otitis media a 5-day course of cefuroxime axetil matched 8 or 10 days of amoxicillin/clavulanate in 716 children, so stopping earlier did not cost cure. (Source 3)
• Not every duration is interchangeable. The label states that safety and effectiveness have not been established for courses shorter than 10 days in acute exacerbations of chronic bronchitis. (Source 15)
• Stopping is immediate rather than tapered where an allergic reaction occurs, and the label instructs discontinuation and appropriate therapy. (Source 16)
• Diarrhoea after stopping is not automatically a sign that all is well: Clostridioides difficile diarrhoea has been reported more than two months after the antibiotic was taken, and ongoing antibiotics not aimed at C. difficile may need to be stopped if it is suspected. (Source 17)

What goes wrong

The same meta-analysis found that dosing errors, not the drug itself at the correct dose, caused most of the eye toxicity seen with cefuroxime. (Source 18)

• Meta-analysis, Low certainty.
• Size: seventeen studies with over 900 000 eyes.
• Who: cataract surgery patients receiving intracameral antibiotics.
• How long: postoperative.
• Result: no rate given for toxicity; dosing errors accounted for the majority of cefuroxime toxicities, while standard doses showed minimal or no toxicity events.
• Funding: not stated in the abstract.

Dosing errors led to the majority of toxicities with cefuroxime. Although rare, vancomycin was associated with toxic retinal events.

A systematic review of 32 reports found retinal toxicity after intracameral cefuroxime at both high and standard doses, typically presenting as macular oedema or serous retinal detachment. (Source 19)

• Systematic review, Low certainty.
• Size: 32 of 51 screened articles met inclusion criteria.
• Who: patients receiving intraocular cefuroxime injections during cataract surgery, across different ethnic groups.
• How long: not stated; typically noticed on the first day after surgery.
• Result: no pooled incidence; risk factors reported were overdose, blood-retinal barrier disruption and anterior-posterior chamber connection; most eyes recovered visual acuity but a minority did not.
• Funding: not stated.

Retinal toxicity can be caused by both high and standard doses of cefuroxime injections in different ethnic groups, with risk factors including overdose, blood-retinal barrier disruption, anterior and posterior chamber connection.

A systematic review of the risks of intracameral cefuroxime found that the incidence of toxicity from compounding or dilution errors is simply unknown. (Source 20)

• Systematic review, Very low certainty.
• Size: not stated in the abstract.
• Who: patients receiving intracameral cefuroxime for endophthalmitis prophylaxis, including those with penicillin allergy.
• How long: not applicable.
• Result: Level 2a evidence supports use in penicillin-allergic patients; incidence and risk of ocular toxicity from compounding or dilutional errors unknown; the link to toxic anterior segment syndrome is not established.
• Funding: not stated.

Compounding or dilutional errors are associated with ocular toxicity, but the incidence and risk of this occurrence are unknown.

Cefuroxime is among the oral antibiotics most strongly associated with community-acquired Clostridioides difficile infection, at about four and a half times the odds seen with doxycycline. (Source 21)

• Cohort study, Moderate certainty.
• Size: 36,626,794 unique patients who received outpatient antibiotics, of whom 11,607 (0.03%) developed community-acquired C. difficile infection.
• Who: adults with an outpatient antibiotic prescription in the IBM MarketScan databases between 2008 and 2020.
• How long: outcome counted within 90 days of the prescription.
• Result: relative to doxycycline, adjusted odds ratios were clindamycin 8.81 (95% CI 7.76 to 10.00), cefdinir 5.86 (95% CI 5.03 to 6.83), cefuroxime 4.57 (95% CI 3.87 to 5.39) and fluoroquinolones 4.05 (95% CI 3.58 to 4.59); the absolute risk across all antibiotics was 0.03%.
• Funding: not stated in the abstract; retrospective claims-database cohort, so confounding by indication cannot be excluded.

There were 36,626,794 unique patients who received outpatient antibiotics, including 11,607 (0.03%) who developed CA-CDI. Relative to doxycycline, the antibiotics conferring the highest risks for CA-CDI were clindamycin (adjusted odds ratio [aOR], 8.81; 95% confidence interval [CI], 7.76 to 10.00), cefdinir (aOR, 5.86; 95% CI, 5.03 to 6.83), cefuroxime (aOR, 4.57; 95% CI, 3.87 to 5.39), and fluoroquinolones (aOR, 4.05; 95% CI, 3.58 to 4.59).

In the registration programme of 912 subjects on multiple-dose tablets, diarrhoea affected 4% and nausea or vomiting 3%, and 2.2% stopped the drug because of side effects. (Source 22)

• Official position, Certainty not rated.
• Size: 912 subjects treated with 125 to 500 mg twice daily in multiple-dose clinical trials.
• Who: adults and adolescents in the multiple-dose registration trials of 7 to 10 days' duration.
• How long: 7 to 10 days.
• Result: diarrhoea 4%, nausea/vomiting 3%, transient AST and ALT elevation 2% each, transient LDH elevation 1%, eosinophilia 1%; 20 subjects (2.2%) discontinued, and 85% of those did so because of gastrointestinal disturbances; no placebo arm is reported for these rates.
• Funding: manufacturer data reproduced in the FDA-approved label, effective 5 August 2026.

In multiple-dose clinical trials, 912 subjects were treated with cefuroxime axetil (125 to 500 mg twice daily). It is noted that 125 mg twice daily is not an approved dosage. Twenty (2.2%) subjects discontinued medication due to adverse reactions.

In the 20-day Lyme disease regimen the side effects were commoner than in short courses: diarrhoea in 10.6% and a Jarisch-Herxheimer reaction in 5.6%. (Source 22)

• Official position, Certainty not rated.
• Size: two multicentre trials of cefuroxime axetil 500 mg twice daily for 20 days.
• Who: patients treated for early Lyme disease.
• How long: 20 days.
• Result: diarrhoea 10.6%, Jarisch-Herxheimer reaction 5.6%, vaginitis 5.4%.
• Funding: manufacturer data reproduced in the FDA-approved label, effective 5 August 2026.

Two multicenter trials assessed cefuroxime axetil 500 mg twice daily for 20 days. The most common drug-related adverse experiences were diarrhea (10.6%), Jarisch-Herxheimer reaction (5.6%), and vaginitis (5.4%).

In the head-to-head Lyme trial, cefuroxime axetil caused more diarrhoea and more Jarisch-Herxheimer reactions than doxycycline, while doxycycline caused the photosensitivity. (Source 5)

• Randomized trial, Moderate certainty.
• Size: 63 patients given cefuroxime axetil and 60 given doxycycline; 55 and 51 evaluable at one month.
• Who: patients with erythema migrans.
• How long: 20 days of therapy.
• Result: Thirty percent of patients treated with cefuroxime axetil and 32% of those treated with doxycycline had one or more drug-related adverse events; diarrhoea 21% versus 7% (P = 0.035); Jarisch-Herxheimer reactions 29% versus 8% (P = 0.005); photosensitivity 0% versus 15% (P = 0.001)
• Funding: not stated in the abstract.

Doxycycline was associated with more photo-sensitivity reactions (15% compared with 0%; P = 0.001) and cefuroxime axetil with more diarrhea (21% compared with 7%; P = 0.035) and Jarisch-Herxheimer reactions (29% compared with 8%; P = 0.005).

Rare but serious reactions reported after marketing include anaphylaxis, Stevens-Johnson syndrome, toxic epidermal necrolysis, haemolytic anaemia, pancytopenia, seizure, encephalopathy and hepatitis. (Source 23)

• Official position, Certainty not rated.
• Size: not applicable; spontaneous reports from a population of uncertain size.
• Who: people taking cefuroxime axetil after approval.
• How long: not stated.
• Result: no rates can be estimated; the label states that frequency and causality cannot reliably be established from voluntary reports.
• Funding: FDA-approved labelling, effective 5 August 2026.

Skin and Subcutaneous Tissue Disorders Angioedema, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, urticaria.

People with a history of penicillin allergy have had severe reactions to cephalosporins, and cefuroxime axetil is contraindicated after any known beta-lactam hypersensitivity. (Source 16)

• Official position, Certainty not rated.
• Size: not applicable.
• Who: people with a history of beta-lactam hypersensitivity or sensitivity to multiple allergens.
• How long: not stated.
• Result: no rate given; the label describes serious and occasionally fatal anaphylactic reactions with beta-lactams including cefuroxime axetil.
• Funding: FDA-approved labelling, effective 5 August 2026.

There have been reports of individuals with a history of penicillin hypersensitivity who have experienced severe reactions when treated with cephalosporins.

What the evidence supports

In children with group A streptococcal pharyngitis, cefuroxime axetil eradicated the bacterium more often than penicillin V. (Source 2)

• Randomized trial, Moderate certainty.
• Size: 385 evaluable patients.
• Who: children aged 2 to 13 years with acute pharyngitis and a positive throat culture for group A beta-haemolytic streptococci.
• How long: 10 days of therapy, with cultures 4 to 8 days and 19 to 25 days after completion.
• Result: eradication 244 of 259 (94.2%) with cefuroxime versus 106 of 126 (84.1%) with penicillin (P = 0.001); complete resolution of signs and symptoms 238 of 259 (91.9%) versus 102 of 126 (81.0%) (P = 0.001); drug-related adverse events 7.0% versus 3.2% (P = 0.078)
• Funding: not stated in the abstract; multicentre, randomised, evaluator-blinded.

Of the 385 evaluable patients, GABHS were eradicated from 244 of 259 (94.2%) cefuroxime-treated patients and 106 of 126 (84.1%) penicillin-treated patients (P = 0.001).

In an open-label randomised trial, a five-day course of cefuroxime axetil matched eight or ten days of amoxicillin/clavulanate in children aged 6 to 36 months with otitis media with effusion diagnosed by tympanocentesis. (Source 3)

• Randomized trial, Moderate certainty.
• Size: 716 children randomised (252 cefuroxime axetil, 255 amoxicillin/clavulanate for 10 days, 209 for 8 days)
• Who: children aged 6 to 36 months with acute otitis media with effusion diagnosed by tympanocentesis and culture.
• How long: 5 days of cefuroxime axetil versus 8 or 10 days of amoxicillin/clavulanate, with follow-up 21 to 28 days after the course.
• Result: clinical cure 175 of 203 (86%), 181 of 205 (88%) and 145 of 164 (88%); maintained cure at follow-up 74%, 70% and 79%; drug-related diarrhoea 18% in the 10-day amoxicillin/clavulanate group versus 10% in the other two.
• Funding: not stated in the abstract; open-label, randomised, multicentre.

Limit of this finding: The trial was open-label: nobody was blinded, which matters most for a judgement like "clinical cure". It was also an equivalence trial, so the result is that the shorter course was not shown to be worse, not that it was better.

In the clinically evaluable population, the proportions of patients with clinical cure at posttreatment were 175 of 203 (86%), 181 of 205 (88%) and 145 of 164 (88%) in the CAE, A/CA-10 and A/CA-8 groups, respectively, demonstrating equivalence among the three treatments.

That otitis media trial was open-label, comparing a short five-day cefuroxime axetil course against amoxicillin/clavulanate given for eight or ten days. (Source 24)

• Randomized trial, Low certainty.
• Size: not stated in this section of the abstract.
• Who: children with acute otitis media with effusion.
• How long: 5 days of cefuroxime axetil versus 8 or 10 days of amoxicillin/clavulanate.
• Result: an open, randomised, multicentre comparison of a 5-day course against 8-day and 10-day comparator regimens.
• Funding: not stated in the abstract.

Limit of this finding: Open-label means neither the families nor the clinicians were blinded, and the comparator arms ran for different lengths of time. Equivalence in an unblinded trial is weaker evidence than it sounds.

This open, randomized, multicenter study compared the clinical efficacy of a short 5-day course of cefuroxime axetil (CAE) suspension with that of amoxicillin/clavulanate (A/CA) suspension for 8 or 10 days.

The Lyme disease indication is limited by the label to adults and to children aged 13 and older, for erythema migrans caused by Borrelia burgdorferi. (Source 25)

• Official position, Certainty not rated.
• Size: not applicable.
• Who: adult patients and paediatric patients aged 13 and older.
• How long: not stated in this section.
• Result: approved for early Lyme disease (erythema migrans) caused by susceptible strains of Borrelia burgdorferi; the tablets are not approved for this use in younger children.
• Funding: FDA-approved labelling, effective 5 August 2026.

Cefuroxime axetil tablets are indicated for the treatment of adult patients and pediatric patients (aged 13 and older) with early Lyme disease (erythema migrans) caused by susceptible strains of Borrelia burgdorferi.

In early Lyme disease, cefuroxime axetil gave the same satisfactory outcome rate as doxycycline, at one month and again at one year. (Source 5)

• Randomized trial, Moderate certainty.
• Size: 63 patients given cefuroxime axetil and 60 given doxycycline; 55 and 51 evaluable at one month.
• Who: patients with erythema migrans at three university referral centres and one private practice.
• How long: 20 days of oral therapy, with clinical evaluations to 12 months after treatment.
• Result: satisfactory outcome 51 of 55 (93%) with cefuroxime axetil versus 45 of 51 (88%) with doxycycline (difference 5%, 95% Cl -5% to 14%); at one year 43 of 48 (90%) versus 35 of 38 (92%) (difference -2%, Cl -12% to 7%)
• Funding: not stated in the abstract.

A satisfactory clinical outcome (success or improvement) was achieved in 51 of 55 (93%) evaluable patients treated with cefuroxime axetil and in 45 of 51 (88%) patients treated with doxycycline (difference, 5%, 95% Cl, -5% to 14%).

The doses compared in that Lyme trial were cefuroxime axetil 500 mg twice daily and doxycycline 100 mg three times daily, both for 20 days. (Source 26)

• Randomized trial, Moderate certainty.
• Size: 63 patients on cefuroxime axetil and 60 on doxycycline.
• Who: patients with erythema migrans.
• How long: 20 days.
• Result: cefuroxime axetil 500 mg twice daily versus doxycycline 100 mg three times daily.
• Funding: not stated in the abstract.

Patients were treated orally for 20 days with either cefuroxime axetil, 500 mg twice daily (63 patients), or doxycycline, 100 mg three times daily (60 patients).

In a preliminary report with follow-up still incomplete, the randomised ESCRS cataract surgery study was stopped early after endophthalmitis proved almost five times as common in the groups not given intracameral cefuroxime. (Source 7)

• Randomized trial, Moderate certainty.
• Size: 13 698 patients with complete follow-up records at the time of the preliminary report, from a study recruiting about 16,000.
• Who: patients having phacoemulsification cataract surgery at 24 ophthalmology units in nine European countries, from September 2003.
• How long: a randomised study halted early, before all follow-up procedures were complete.
• Result: total endophthalmitis 23 cases in 6862 patients without cefuroxime versus 5 cases in 6836 with it (OR 4.59, 95% CI 1.74-12.08, P = .002); for proven infective cases OR 5.32 (95% CI 1.55-18.26, P = .008); levofloxacin drops gave a smaller, non-significant reduction.
• Funding: European Society of Cataract and Refractive Surgeons multicentre study.

Limit of this finding: This is explicitly a preliminary report: the investigators stopped the study early because they judged it unethical to continue, and they say twice that follow-up was not complete and further cases might still be reported. Trials stopped early for benefit tend to overstate the size of the effect, so read the almost-fivefold figure as the direction of the finding rather than a precise number. The fuller 2007 analysis of the same study is reported separately.

If total reported cases of endophthalmitis are considered, the incidence rate observed in those treatment groups not receiving cefuroxime prophylaxis (23 cases in 6862 patients) was almost 5 times as high (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.74-12.08; P = .002) as that in the groups receiving this treatment (5 cases in 6836 patients).

In the full ESCRS analysis, going without intracameral cefuroxime carried a 4.92-fold higher risk of postoperative endophthalmitis. (Source 27)

• Randomized trial, Moderate certainty.
• Size: 16 603 patients recruited; twenty-nine presented with endophthalmitis, 20 classified as proven infective.
• Who: cataract surgery patients at 24 ophthalmology units in Austria, Belgium, Germany, Italy, Poland, Portugal, Spain, Turkey and the United Kingdom.
• How long: prospective randomised partially masked multicentre study.
• Result: absence of intracameral cefuroxime at 1 mg in 0.1 mL normal saline associated with a 4.92-fold increase in risk (95% CI 1.87-12.9); clear corneal incisions 5.88-fold (95% CI 1.34-25.9); silicone intraocular lens optic 3.13-fold (95% CI 1.47-6.67)
• Funding: European Society of Cataract and Refractive Surgeons multicentre study.

The absence of an intracameral cefuroxime prophylactic regimen at 1 mg in 0.1 mL normal saline was associated with a 4.92-fold increase (95% confidence interval [CI], 1.87-12.9) in the risk for total postoperative endophthalmitis.

The ESCRS study recruited 16 603 patients into a prospective, randomised, partially masked, two-by-two factorial comparison of intracameral cefuroxime and perioperative levofloxacin drops. (Source 28)

• Randomized trial, Moderate certainty.
• Size: 16 603 patients.
• Who: cataract surgery patients at twenty-four ophthalmology units in nine European countries.
• How long: prospective randomised partially masked multicentre study.
• Result: 2 x 2 factorial design with intracameral cefuroxime and topical perioperative levofloxacin factors, giving 4 treatment groups; odds ratios estimated by multivariable logistic regression.
• Funding: European Society of Cataract and Refractive Surgeons multicentre study.

Limit of this finding: Partially masked, not double-blind: this was a surgical prophylaxis study and the surgeons knew what they injected. The risk figures come from multivariable logistic regression, not from a simple randomised comparison of two arms.

A prospective randomized partially masked multicenter cataract surgery study recruited 16 603 patients. The study was based on a 2 x 2 factorial design, with intracameral cefuroxime and topical perioperative levofloxacin factors resulting in 4 treatment groups.

A French single-centre before-and-after series found endophthalmitis fell from 1.238% to 0.044% after intracameral cefuroxime was introduced. (Source 29)

• Cohort study, Low certainty.
• Size: 5115 patients; 2289 received cefuroxime and 2826 did not.
• Who: patients having cataract surgery at Dupuytren Hospital, Limoges, between April 2003 and June 2008; injections began in June 2006.
• How long: postoperative infections recorded at 8 days and 1 month.
• Result: 35 (1.238%) of 2826 without cefuroxime versus 1 (0.044%) of 2289 with cefuroxime (P<.0001); no allergic reaction reported.
• Funding: no author reported a financial or proprietary interest.

Limit of this finding: This is not a randomised comparison. Cefuroxime injections simply began part-way through a single hospital's surveillance of cataract surgery, so the two groups are different time periods and anything else that changed over those years - technique, materials, infection control - could contribute to the difference. The journal's own abstract labels the design 'Clinical trials', which is misleading.

The incidence of endophthalmitis was 35 (1.238%) of 2826 patients without intracameral cefuroxime and 1 (0.044%) of 2289 patients with intracameral cefuroxime; the difference was statistically significant (P<.0001).

The French study was a before-and-after surveillance series at one hospital, not a randomised comparison: injections simply began in June 2006 within a cohort operated on between April 2003 and June 2008. (Source 30)

• Cohort study, Low certainty.
• Size: a single-centre prospective surveillance cohort; the number is reported in the results section.
• Who: patients having cataract surgery at one French ophthalmology department.
• How long: surgery from April 2003 to June 2008, with injections starting in June 2006 and infections recorded at 8 days and 1 month.
• Result: no randomisation and no concurrent control group; preoperative, intraoperative and infection data were collected prospectively.
• Funding: no author reported a financial or proprietary interest.

Limit of this finding: Because the comparison is between earlier and later calendar periods at one hospital, it cannot separate the effect of the injection from anything else that changed over five years. It supports the randomised evidence; it does not stand alone.

Patients having cataract surgery between April 2003 and June 2008 were included in a survey of operative-site infection. Intracameral cefuroxime injections started in June 2006.

Pooling studies of over 900 000 eyes, intracameral antibiotics cut endophthalmitis fivefold, and adding topical antibiotics on top added nothing. (Source 18)

• Meta-analysis, Low certainty.
• Size: seventeen studies with over 900 000 eyes.
• Who: patients having phacoemulsification cataract surgery.
• How long: postoperative endophthalmitis incidence.
• Result: OR 0.20 (95% CI 0.13 to 0.32; P<0.00001) favouring intracameral antibiotics; weighted endophthalmitis incidence 0.0332% with cefuroxime, 0.0153% with moxifloxacin and 0.0106% with vancomycin; no difference between intracameral plus topical and intracameral alone (P>0.3)
• Funding: not stated in the abstract; mostly observational studies, low to moderate risk of bias.

Seventeen studies with over 900 000 eyes were included, which favoured the use of intracameral antibiotics at the end of cataract surgery (OR 0.20; 95% CI 0.13 to 0.32; P<0.00001). The average weighted postoperative endophthalmitis incidence rates with intracameral cefuroxime, moxifloxacin and vancomycin were 0.0332%, 0.0153% and 0.0106%, respectively.

Taking cefuroxime axetil after food raises how much of it reaches the blood, from about a third of the dose to a little under half. (Source 9)

• Blood level study, Low certainty.
• Size: two studies in male and female volunteers.
• Who: healthy fasting and non-fasting male and female volunteers given 1 g cefuroxime axetil orally against intravenous cefuroxime.
• How long: single dose.
• Result: absolute bioavailability fasting 0.35 (range 0.26-0.44) in men and 0.32 (0.23-0.41) in women; after food 0.45 (0.34-0.55) in men and 0.41 (0.29-0.51) in women; no sex difference in pharmacokinetics.
• Funding: not stated in the abstract.

The mean (and range) absolute bioavailability of cefuroxime axetil in the first study was 0.35 (0.26-0.44) in male volunteers and 0.32 (0.23-0.41) in female volunteers. In the second study, the bioavailability was significantly greater when cefuroxime axetil was given after food: 0.45 (0.34-0.55) in males and 0.41 (0.29-0.51) in females.

A crossover study against intravenous cefuroxime put the food effect at 36% of a fasting 500 mg dose absorbed against 52% of a fed dose. (Source 31)

• Blood level study, Low certainty.
• Size: 12 normal male volunteers.
• Who: healthy male volunteers in a six-way randomised crossover trial.
• How long: single doses of 125, 250, 500 (twice) and 1000 mg orally plus 500 mg intravenously.
• Result: 36 per cent of the fasting and 52 per cent of the fed 500 mg dose absorbed; mean peak plasma concentration 43 per cent greater after the fed dose.
• Funding: not stated in the abstract.

Based on a comparison of the AUC for the oral and intravenous data, 36 per cent of the fasting and 52 per cent of the fed 500 mg doses were absorbed. The mean peak plasma concentration was 43 per cent greater after the fed dose than the fasting dose.

What the evidence does not support

In the one placebo-controlled trial we could find, cefuroxime axetil gave no clinical benefit to children with respiratory illness and imaging evidence of sinusitis. (Source 4)

• Randomized trial, Low certainty.
• Size: eighty-two children enrolled; 72 (88%) completed follow-up.
• Who: children aged 4 to 10 years with acute respiratory symptoms and ultrasonography findings of acute rhinosinusitis, confirmed on plain radiographs in 90% of those followed up.
• How long: 10 days of treatment; complete cure assessed at 2 weeks.
• Result: difference in complete cure by day 14 was 6% (95% confidence interval -16% to 29%); difference in escaping prolonged disease and complications 7% (-9% to 24%)
• Funding: not stated in the abstract.

The proportion of children completely cured by day 14 was similar in both groups (difference 6%, 95% confidence interval -16% to 29%). Similarly, there was no significant difference in the proportions of children who escaped prolonged disease and complications between the groups (difference 7%, -9% to 24%).

That placebo-controlled sinusitis trial was small and double-blind, randomising children to cefuroxime axetil 125 mg twice daily or placebo for 10 days. (Source 32)

• Randomized trial, Low certainty.
• Size: eighty-two children aged 4 to 10 years.
• Who: children aged 4 to 10 years with acute respiratory symptoms and ultrasound findings suggestive of acute rhinosinusitis.
• How long: 10 days.
• Result: cefuroxime axetil in 125 mg capsules twice a day for 10 days versus placebo; primary outcomes complete cure at 2 weeks and absence of prolonged symptoms or complications.
• Funding: not stated in the abstract.

The children received either cefuroxime axetil in 125-mg capsules twice a day for 10 d or placebo. Main outcome measures were complete cure in 2 wk and absence of prolonged symptoms or complications.

A pooled analysis of prophylaxis trials reported no difference in surgical site infections between cefazolin and cefuroxime, cefamandole or ceftriaxone, but published no pooled effect estimate, no confidence interval and no count of included trials. (Source 8)

• Meta-analysis, Very low certainty.
• Size: 12,446 patients; 6327 received cefazolin and 6119 received cefamandole, cefuroxime or ceftriaxone.
• Who: surgical patients in clinical trials of antibiotic prophylaxis across several disciplines.
• How long: surgical site infection outcomes.
• Result: no pooled risk ratio or odds ratio, no confidence interval and no heterogeneity statistic are reported; the authors state only that cefazolin is as effective as cefuroxime, cefamandole and ceftriaxone.
• Funding: not stated in the abstract; the analysis reports no number of included trials and its search covered only PubMed, Google Scholar and ClinicalTrials.gov, with no Embase, no Cochrane CENTRAL and no stated language or date limits.

Limit of this finding: Read this as an absence of a demonstrated difference, not as proof of equivalence. The abstract gives no pooled estimate, no confidence interval and no count of the trials it combined, so there is no way to tell whether the analysis was large enough to detect a difference. Its search covered only PubMed, Google Scholar and ClinicalTrials.gov, which is an incomplete search for a review of this kind.

A total of 12,446 patients were included in the study. Among these patients, 6327 patients received cefazolin and 6119 patients received cefamandole, cefuroxime, or ceftriaxone. Our analysis showed that cefazolin is as effective as cefuroxime, cefamandole, and ceftriaxone in preventing surgical site infections.

Amlodipine raised cephalexin exposure but had no measurable effect on cefuroxime axetil, which is a documented absence of an interaction rather than a hazard. (Source 14)

• Blood level study, Low certainty.
• Size: twenty-four healthy men.
• Who: healthy male volunteers in a four-treatment crossover design with a 14-day washout.
• How long: single doses; cefuroxime axetil 500 mg alone and 2 hours after amlodipine 5 mg.
• Result: for cephalexin, geometric mean ratios 1.38 (90% CI 1.32-1.45) for AUC and 1.27 (1.18-1.36) for Cmax; no significant differences in cefuroxime pharmacokinetic parameters between treatments.
• Funding: not stated in the abstract.

Limit of this finding: The source contradicts itself in the sentence quoted: it reports "no significant differences" and then prints "(P < .05)", which is the threshold for a difference being significant. A null result cannot be supported by P < .05, and the published abstract almost certainly means P > .05. We have kept the quotation as the journal printed it. What the study supports is that amlodipine did not measurably change cefuroxime levels; the p-value as printed should not be relied on. The abstract also contains the typo "They authors conclude", which is the source's.

In contrast, no significant differences were found in the pharmacokinetic parameters of CXM between treatments (P < .05).

Where the evidence is mixed

A small randomised paediatric trial found cefuroxime axetil and amoxicillin both acceptable for children with erythema migrans, but was too small to show a difference. (Source 33)

• Randomized trial, Very low certainty.
• Size: forty-three children randomised (13 to amoxicillin, 15 to each cefuroxime axetil arm); 39 completed 12 months of follow-up.
• Who: children aged 6 months to 12 years with erythema migrans.
• How long: 20 days of treatment, followed to 1 year.
• Result: total resolution of erythema migrans at the end of treatment in 67% of the amoxicillin group, 92% of the low-dose cefuroxime group and 87% of the high-dose cefuroxime group; resolution of constitutional symptoms in 100%, 69% and 87%.
• Funding: not stated in the abstract; randomised but unblinded.

The number of patients in this trial was not sufficient to demonstrate a statistically significant difference between the 3 groups; however, both amoxicillin and cefuroxime axetil seem to be safe, efficacious treatments for children with early LD.

In a six-volunteer study, food increased absorption of the cefuroxime ester, the opposite of what food and reduced stomach acidity did to the comparator prodrug bacampicillin. (Source 34)

• Blood level study, Low certainty.
• Size: 6 healthy volunteers.
• Who: healthy volunteers in an intraindividual comparison of four regimens, each separated by 7 drug-free days.
• How long: single doses, with blood sampled to 10 hours and urine collected for 10 hours.
• Result: absorption of the cefuroxime ester was enhanced after a meal; by contrast food and reduced gastric acidity each lowered bacampicillin bioavailability and did so additively; the indexed abstract stops before reporting what reduced acidity alone did to cefuroxime.
• Funding: not stated in the abstract.

Limit of this finding: The version of this abstract carried by the indexing databases is cut off at 250 words, and the sentence that would have reported the effect of reduced stomach acidity on cefuroxime itself falls after the cut. What can be read is that food increased absorption of the cefuroxime ester. Six volunteers is a very small study and these are blood and urine levels, not infection outcomes.

In contrast, the absorption of the cefuroxime ester was enhanced postprandially. This may be rationalized in terms of delayed gastric emptying and gastrointestinal transit which allows more complete dissolution or prolonged residence at the most favourable site of absorption in the intestine.

Where the research disagrees

Whether cefuroxime axetil actually helps acute bacterial sinusitis, an approved indication

• The FDA-approved label, regulatory position based on comparative trials against other antibiotics, label effective 5 August 2026: Acute bacterial maxillary sinusitis (adults and pediatric patients) (1.3) (Source 6)
• Kristo and colleagues, in the only placebo-controlled trial we reached, randomised, double-blind, placebo-controlled trial of 82 children with imaging-confirmed sinusitis: The proportion of children completely cured by day 14 was similar in both groups (difference 6%, 95% confidence interval -16% to 29%). (Source 4)

Whether intracameral cefuroxime is safe enough to give routinely

• The intracameral antibiotic meta-analysis, meta-analysis of 17 studies covering over 900 000 eyes, mostly observational: Dosing errors led to the majority of toxicities with cefuroxime. (Source 18)
• The 2025 systematic review of retinal toxicity, systematic review of 32 publications: Retinal toxicity can be caused by both high and standard doses of cefuroxime injections in different ethnic groups, with risk factors including overdose, blood-retinal barrier disruption, anterior and posterior chamber connection. (Source 19)
• The systematic review of the risks of intracameral cefuroxime, systematic review with level-of-evidence grading: Compounding or dilutional errors are associated with ocular toxicity, but the incidence and risk of this occurrence are unknown. (Source 20)

How much

• Reference intake: Dosing is set by the prescriber. As a position, the current FDA-approved label gives, for adults and adolescents 13 years and older, 250 mg every 12 hours for 10 days for mild-to-moderate pharyngitis or tonsillitis and for acute bacterial maxillary sinusitis, and 250 mg or 500 mg every 12 hours for 10 days for acute bacterial exacerbations of chronic bronchitis. The tablets may be taken with or without food. (Source 15)
• Upper limit: No upper limit is set as a toxicological threshold. The highest single dose in the approved regimens is 1,000 mg, used once for uncomplicated gonorrhoea. The label notes that the percentage of subjects stopping the drug for adverse reactions was similar at daily doses of 1,000, 500 and 250 mg, but that gastrointestinal adverse reactions became more common at the higher recommended doses. (Source 22)
• Studied: Cefuroxime axetil 500 mg twice daily for 20 days in early Lyme disease, against doxycycline 100 mg three times daily. (Source 26)
• Studied: A 5-day course of cefuroxime axetil suspension in children with tympanocentesis-confirmed acute otitis media with effusion. (Source 3)
• Studied: Cefuroxime axetil 125 mg capsules twice a day for 10 days against placebo in children aged 4 to 10 years with imaging evidence of sinusitis. (Source 32)
• Studied: Intracameral cefuroxime 1 mg in 0.1 mL normal saline injected at the end of cataract surgery in the ESCRS trial. (Source 27)

A common belief, and what the research shows

The belief: Antibiotics should be taken on an empty stomach, so cefuroxime tablets should be taken away from food.

What the research shows: The opposite is true for this one. Food increases absorption of the oral prodrug. One volunteer study found that "the bioavailability was significantly greater when cefuroxime axetil was given after food: 0.45 (0.34-0.55) in males and 0.41 (0.29-0.51) in females", and a crossover study against intravenous dosing found that "36 per cent of the fasting and 52 per cent of the fed 500 mg doses were absorbed." The current US label for the tablets says they may be given with or without food, but acid-suppressing drugs do cancel the food advantage: "Administration of drugs that reduce gastric acidity may negate the food effect of increased absorption of cefuroxime axetil when administered in the postprandial state."

Questions and answers

What is it?

Cefuroxime is a second-generation cephalosporin antibiotic. The tablet form is cefuroxime axetil, an ester that is not itself the active drug: enzymes in the gut wall and blood split it to release cefuroxime. There are also injectable forms, including a tiny 1 mg dose injected into the front of the eye during cataract surgery. (Source 35)

What does it do in the body?

It kills bacteria by stopping them building their cell wall, so the cell cannot hold itself together. It survives some of the beta-lactamase enzymes that break down penicillins, which is why it covers organisms penicillin misses. Bacteria escape it by making stronger beta-lactamases, by changing the proteins it binds, by reducing permeability, or by pumping it out. (Source 1)

Is it good or bad for you?

It depends entirely on the infection. In streptococcal sore throat it eradicated the bacterium more often than penicillin V. In early Lyme disease it matched doxycycline. In children with imaging-confirmed sinusitis it beat placebo by nothing at all. And it is one of the oral antibiotics most strongly linked to community-acquired Clostridioides difficile infection, at 4.57 times the odds seen with doxycycline. (Source 21)

How do you get more of it?

This is not something to want more of. It comes as tablets, an oral suspension and injections, and the amount is fixed by the prescription. One thing does change how much reaches the blood: taking the tablet after a meal raises absorption from about a third of the dose to a little under half. (Source 9)

If it is harmful, what reduces it?

If an allergic reaction occurs the drug is stopped at once. If diarrhoea develops, the label's instruction is to evaluate for Clostridioides difficile, because treatment with antibacterials alters the colon's normal flora and lets C. difficile overgrow, and ongoing antibiotics not directed against it may need to be stopped. There is no antidote. (Source 17)

Why might someone be low in it or missing it?

The question does not apply in its usual sense: cefuroxime is a manufactured antibiotic, not something the body holds. The people who cannot have it are those with known hypersensitivity to it or to another beta-lactam, including penicillins and other cephalosporins, where it is contraindicated outright. (Source 36)

Which whole foods contain it or feed it?

No food contains cefuroxime. Food does matter to it, though, and in an unusual direction: eating before the dose increases absorption rather than reducing it. In one crossover study 36% of a fasting 500 mg dose was absorbed against 52% of a fed dose, and the peak blood level was 43% higher after food. Antacids and acid-suppressing drugs cancel that advantage. (Source 31)

What happens if you do not have it?

It depends which infection is left untreated. In children with imaging evidence of sinusitis, going without it made no measurable difference. In cataract surgery, the preliminary report of the ESCRS randomised study found about five times the rate of endophthalmitis without the intracameral injection, 23 cases in 6862 patients compared with 5 in 6836. In early Lyme disease the trial that compared it with doxycycline recorded no late Lyme arthritis in either group after one month. (Source 7)

How can you test for it?

There is no routine blood level test. What gets tested is whether the bacterium causing the infection is susceptible: a culture with susceptibility testing. The label says that where culture and susceptibility data exist they should guide the choice, and that where they do not, local resistance patterns should. A separate caution is that cefuroxime can distort older urine and blood glucose tests. (Source 37)

References

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