From the FDA Drug Label
In patients with creatinine clearance less than or equal to 60 mL/min, the dose of cefepime for injection should be adjusted to compensate for the slower rate of renal elimination The recommended initial dose of cefepime for injection should be the same as in patients with normal renal function except in patients undergoing hemodialysis. The recommended doses of cefepime for injection in patients with renal impairment are presented in Table 11 In patients undergoing hemodialysis, approximately 68% of the total amount of cefepime present in the body at the start of dialysis will be removed during a 3-hour dialysis period. The dosage of cefepime for injection for hemodialysis patients is 1 g on Day 1 followed by 500 mg every 24 hours for the treatment of all infections except febrile neutropenia, which is 1 g every 24 hours Cefepime for injection should be administered at the same time each day and following the completion of hemodialysis on hemodialysis days
The recommended dose of cefepime for a patient with End-Stage Renal Disease (ESRD) is:
- 1 g on Day 1, then 500 mg every 24 hours thereafter for the treatment of all infections except febrile neutropenia
- 1 g every 24 hours for febrile neutropenia Cefepime should be administered following hemodialysis on hemodialysis days 1.
From the Research
For patients with end-stage renal disease (ESRD) on hemodialysis, cefepime should be dosed at 1 gram every 24 hours, with an additional 1 gram dose given after each hemodialysis session, as supported by the most recent study 2. This adjusted dosing is necessary because cefepime is primarily eliminated by the kidneys, and patients with ESRD have significantly reduced renal clearance of the drug. The post-dialysis dose is important because hemodialysis removes approximately 68% of cefepime from the bloodstream, potentially leading to subtherapeutic levels if not supplemented. For severe infections, some clinicians may use 2 grams every 24 hours with a 1 gram post-dialysis dose, but this higher dosing should be carefully considered based on the specific infection being treated and the patient's clinical status. It's also important to monitor for neurotoxicity, including seizures and encephalopathy, which can occur with cefepime, particularly in patients with renal impairment if doses are not appropriately adjusted, as noted in a study on cefepime-induced encephalopathy in ESRD patients 3. The first dose of cefepime should be a loading dose of 1-2 grams regardless of when dialysis is scheduled to ensure immediate therapeutic levels. Key considerations for dosing include:
- The patient's residual renal function, if any
- The severity and type of infection being treated
- The potential for neurotoxicity and the need for monitoring
- The use of high-flux hemodialysis membranes, which can affect cefepime clearance, as studied in patients on long-term hemodialysis 4, 5
- The clinical outcome and effectiveness of the treatment, as demonstrated in a retrospective study on post-dialysis cefepime therapy in patients on maintenance hemodialysis 6