What is the recommended dose of cefepime for a patient with End-Stage Renal Disease (ESRD) and gram-negative bacteremia?

Cefepime Dosing in End-Stage Renal Disease (ESRD) with Gram-Negative Bacteremia

For patients with ESRD and gram-negative bacteremia, cefepime should be dosed at 1 gram intravenously every 24 hours. 1

Dosing Rationale and Considerations

The FDA-approved drug labeling for cefepime provides clear guidance for dosing in patients with renal impairment. According to the official prescribing information:

• For patients with creatinine clearance less than 11 mL/min (which includes ESRD patients), the recommended dose for severe infections is 1 gram every 24 hours 1
• For patients on hemodialysis, cefepime should be administered following hemodialysis sessions 1

Hemodialysis Considerations

For patients on hemodialysis specifically, the dosing regimen should be:

• 1 gram on day 1, followed by 500 mg every 24 hours thereafter for most infections
• 1 gram every 24 hours for febrile neutropenia 1

Approximately 68% of cefepime is removed during a 3-hour hemodialysis session, making post-dialysis administration critical to maintain therapeutic levels 1.

Safety Concerns in ESRD

Cefepime requires careful dosing in ESRD patients due to several important safety considerations:

• Neurotoxicity risk: ESRD patients have a 7.5% incidence of cefepime-induced encephalopathy, even with adjusted doses 2
• Pre-existing CNS conditions: Patients with pre-existing central nervous system morbidity are at significantly higher risk for cefepime-induced neurotoxicity 2
• Advanced age: Very elderly ESRD patients may be more sensitive to neurotoxicity, even at reduced doses 3

Alternative Antibiotics for ESRD Patients

When treating gram-negative infections in ESRD patients, consider these alternatives if clinically appropriate:

• First-line options that don't require dose adjustment: Doxycycline, clindamycin, azithromycin, and linezolid 4
• For gram-negative coverage: Ceftazidime or ceftriaxone may be safer alternatives as they have both hepatic and renal excretion pathways 3
• For severe infections: Consider meropenem as an alternative with similar spectrum but potentially less neurological toxicity 3

Monitoring Recommendations

For ESRD patients receiving cefepime:

1. Monitor neurological status closely for signs of encephalopathy (confusion, altered mental status, myoclonus, seizures)
2. Consider therapeutic drug monitoring when available
3. Administer dose after hemodialysis on dialysis days
4. Maintain consistent timing of administration

Special Considerations

• In very elderly ESRD patients, consider using even lower doses (such as 500 mg daily) due to increased sensitivity to neurotoxic effects 3
• For patients with pre-existing CNS conditions, consider alternative antibiotics with less neurotoxicity potential 2
• For patients on continuous kidney replacement therapy (CKRT), dosing may need to be individualized based on effluent flow rates 5

By following these dosing recommendations and monitoring protocols, you can effectively treat gram-negative bacteremia in ESRD patients while minimizing the risk of adverse effects.