From the FDA Drug Label
In patients with creatinine clearance less than or equal to 60 mL/min, the recommended initial dose of Cefepime Injection should be the same as in patients with CrCL greater than 60 mL/min except in patients undergoing hemodialysis.
Table 2: Recommended Dosing Schedule for Cefepime Injection in Adult Patients With Creatinine Clearance Less Than or Equal to 60 mL/min
Creatinine Clearance (mL/min) Recommended Maintenance Schedule 11–29 500 mg every24 hours, 500 mg every24 hours, 1 g every24 hours, 2 g every24 hours
For a patient with a creatinine clearance of 26, the recommended dose of Cefepime Injection is:
- 500 mg every 24 hours for mild to moderate infections
- 500 mg every 24 hours for moderate to severe infections
- 1 g every 24 hours for severe infections
Key considerations:
- The dose should be adjusted based on the severity of the infection and the patient's renal function.
- Cefepime Injection should be administered at the same time each day.
- The patient's renal function and response to treatment should be closely monitored. 1
From the Research
For patients with severe renal impairment (creatinine clearance of 26 ml/min) and a urinary tract infection, amoxicillin-clavulanate with dose adjustment is often the preferred antibiotic, as suggested by the most recent study 2. The recommended dosage would be amoxicillin-clavulanate 500/125 mg every 12 hours, with adjustments based on renal function. This antibiotic is effective against common UTI pathogens, including those producing extended-spectrum beta-lactamases (ESBLs), as shown in a recent study 3. Key considerations include:
- Local resistance patterns and specific pathogen identification, if available, to guide antibiotic choice.
- Dose adjustments to prevent drug accumulation and toxicity in patients with impaired kidney function.
- Alternative options, such as cefpodoxime or cephalexin, may also be considered with appropriate dose reductions.
- Fluoroquinolones, like ciprofloxacin, can be used with caution and dose adjustments, but are generally reserved as second-line options due to side effect concerns.
- Nitrofurantoin should be avoided in patients with creatinine clearance below 30 ml/min due to ineffective urinary concentrations and increased risk of toxicity.
- Adequate hydration and monitoring of renal function are crucial during treatment. Given the potential risks associated with trimethoprim-sulfamethoxazole, such as acute kidney injury and hyperkalaemia, especially in older patients or those taking renin-angiotensin system blockers 4, amoxicillin-clavulanate emerges as a safer alternative in the context of severe renal impairment.