Cefepime Dosing in Hemodialysis Patients
For patients on hemodialysis, cefepime should be administered at a dose of 1 g on day 1, followed by 500 mg every 24 hours after each hemodialysis session. 1
Pharmacokinetics of Cefepime in Hemodialysis
Cefepime is primarily eliminated by the kidneys, making dosage adjustment essential in patients with end-stage renal disease (ESRD) on hemodialysis. Key pharmacokinetic considerations include:
- Approximately 68% of cefepime is removed during a 3-hour hemodialysis session 1
- The interdialytic half-life is significantly prolonged (22 hours) compared to patients with normal renal function 2
- High-flux dialysis membranes can remove up to 72% of cefepime during a single session 2
Recommended Dosing Strategy
The FDA-approved dosing regimen for cefepime in hemodialysis patients is:
- Initial dose: 1 g on day 1
- Maintenance dose: 500 mg every 24 hours
- For febrile neutropenia: 1 g every 24 hours 1
Administration timing:
- Administer after completion of hemodialysis on dialysis days 1
- This timing prevents premature drug removal during dialysis and maintains therapeutic levels 3
Special Considerations
Residual Renal Function
- Patients with residual renal function may have lower pre-dialysis cefepime concentrations compared to anuric patients (9.25 mg/L vs. 15.6 mg/L) 4
- This may necessitate higher doses in patients with preserved diuresis when treating less susceptible pathogens 4
Infection Severity and Pathogen Susceptibility
For severe infections or less susceptible pathogens (e.g., Pseudomonas aeruginosa):
- Higher doses may be considered (1-2 g post-dialysis) 4
- The American Thoracic Society recommends adjusting frequency rather than dose to maintain efficacy while preventing toxicity 3
Monitoring Recommendations
- Monitor for signs of neurotoxicity, which can manifest as seizures, confusion, or encephalopathy 5
- Elderly patients may be more susceptible to cefepime-induced neurotoxicity, even at adjusted doses 5
- Therapeutic drug monitoring may be beneficial in patients showing signs of toxicity 3
Alternative Dosing Approach Based on Dialysis Schedule
Research suggests an alternative dosing strategy based on the interdialytic interval:
- For 48-hour intervals: 1 g post-dialysis
- For 72-hour intervals: 1.5 g post-dialysis 4
For less susceptible pathogens:
- For 48-hour intervals: 1.5 g post-dialysis
- For 72-hour intervals: 2 g post-dialysis 4
Potential Adverse Effects
- Neurotoxicity is a significant concern, particularly in elderly patients 5
- Symptoms may include seizures, encephalopathy, and altered mental status
- Risk factors include advanced age, higher doses, and uremic encephalopathy 5
- If neurotoxicity is suspected, discontinue cefepime and consider additional dialysis to enhance drug clearance 5
In summary, cefepime dosing in hemodialysis patients requires careful consideration of the dialysis schedule, infection severity, and patient factors. The FDA-approved regimen of 1 g on day 1 followed by 500 mg every 24 hours administered post-dialysis provides adequate coverage for most infections while minimizing toxicity risk.