Cefepime Dosing for Hemodialysis Patients
For patients on hemodialysis, administer cefepime 1 g on Day 1, followed by 500 mg every 24 hours for most infections (or 1 g every 24 hours for febrile neutropenia), given immediately after each dialysis session. 1
Standard Dosing Regimen
The FDA-approved dosing schedule for hemodialysis patients is straightforward and evidence-based:
- Initial dose: 1 g on Day 1
- Maintenance dose: 500 mg every 24 hours thereafter for most infections
- Febrile neutropenia: 1 g every 24 hours 1
Critical timing principle: Always administer cefepime immediately following hemodialysis completion, at the same time each day. 1 This prevents premature drug removal during dialysis (approximately 68% of cefepime is removed during a 3-hour dialysis session) and facilitates directly observed therapy. 1
Alternative Three-Times-Weekly Dosing
For outpatient management with thrice-weekly dialysis schedules, higher post-dialysis doses can be used:
- Before 48-hour intervals: 1 g for highly susceptible pathogens; 1.5 g for less susceptible organisms like Pseudomonas aeruginosa 2
- Before 72-hour intervals: 1.5 g for highly susceptible pathogens; 2 g for less susceptible organisms 2
This approach maintains trough levels above EUCAST breakpoints for most pathogens (>1 mg/L) and has demonstrated good clinical outcomes. 2 However, patients with residual renal function may require higher initial doses with subsequent monitoring. 2
Critical Safety Considerations
Neurotoxicity risk: Hemodialysis patients, particularly elderly individuals, are at increased risk for cefepime-associated neurotoxicity even at recommended doses. 3, 4
- Advanced age and uremic encephalopathy increase susceptibility to neurotoxic effects 3
- Patients with severe renal dysfunction receiving higher doses may face greater neurotoxicity risk 4
- Most neurotoxicity manifests as altered mental status 4
- Consider monitoring neurological status closely, especially in very elderly patients 3
Important caveat: In very old hemodialysis patients or those with severe metabolic encephalopathy, consider using doses lower than the standard 1 g/day recommendation, or alternative agents like cefotaxime, ceftriaxone, or meropenem that have different elimination pathways. 3
Monitoring Parameters
- Administer at consistent times following dialysis 1
- Monitor for neurological changes, particularly altered mental status 3, 4
- For infections with less susceptible pathogens or patients with residual renal function, consider measuring pre-dialysis trough levels to ensure adequate drug exposure 2
- If neurotoxicity develops, discontinue cefepime immediately and consider urgent hemodialysis to enhance drug clearance 3