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 Table 11: Recommended Dosing Schedule for Cefepime for Injection in Adult Patients (Normal Renal Function, Renal Impairment, and Hemodialysis)
The recommended dosage of cefepime for treating Acinetobacter pneumonia in a patient with Acute Kidney Injury (AKI) is not directly stated in the label. However, for patients with renal impairment, the dose should be adjusted based on creatinine clearance.
- For creatinine clearance greater than 60 mL/min, the normal recommended dosing schedule applies.
- For creatinine clearance 30 to 60 mL/min, the recommended dose is 1 g every 24 hours for pneumonia.
- For creatinine clearance 11 to 29 mL/min, the recommended dose is 0.5 to 1 g every 24 hours.
- For creatinine clearance less than 11 mL/min, the recommended dose is 250 to 500 mg every 24 hours. There is no information about sulbactam in the provided label, so no recommendation can be made for its use in this context 1.
From the Research
For Acinetobacter pneumonia in a patient with acute kidney injury (AKI), the recommended dosage of cefepime-sulbactam is typically 1-2g cefepime with 1g sulbactam every 12-24 hours, adjusted based on the severity of kidney dysfunction, as supported by the most recent study 2.
Key Considerations
- The dosage should be individualized based on creatinine clearance, with more significant reductions needed as kidney function worsens.
- Therapeutic drug monitoring is advisable when available to ensure adequate drug levels while minimizing toxicity.
- This combination is effective against Acinetobacter because sulbactam has intrinsic activity against this pathogen and also inhibits beta-lactamases that would otherwise inactivate cefepime.
- Treatment duration typically ranges from 7-14 days depending on clinical response.
- It's essential to reassess kidney function regularly during treatment as both improvement or deterioration would warrant dosage adjustments.
- Concurrent supportive care for AKI is also necessary while treating the pneumonia.
Rationale
The study by 2 highlights the effectiveness of cefiderocol for the treatment of bloodstream infections due to carbapenem-resistant Acinetobacter baumannii, and although it does not directly address cefepime-sulbactam, it implies the importance of considering renal function in the treatment of such infections.
Adjustments for AKI
- For mild to moderate AKI, dosing every 12 hours may be appropriate.
- Severe AKI might require extending the interval to 24 hours or reducing the dose.
Monitoring and Support
- Regular reassessment of kidney function is crucial.
- Concurrent supportive care for AKI is necessary.
- Therapeutic drug monitoring can help minimize toxicity and ensure adequate drug levels.