Cefixime Dosing in Stage 3 Chronic Kidney Disease
For patients with stage 3 CKD (creatinine clearance 21-59 mL/min), reduce cefixime to 260 mg daily (13 mL of the 100 mg/5 mL suspension or 6.5 mL of the 200 mg/5 mL suspension). 1
Dosing Algorithm by Renal Function
Stage 3A CKD (CrCl 45-59 mL/min)
- Dose: 260 mg once daily 1
- Use 13 mL of 100 mg/5 mL suspension OR 6.5 mL of 200 mg/5 mL suspension 1
- The 200 mg/5 mL concentration is preferred for ease of administration 1
Stage 3B CKD (CrCl 30-44 mL/min)
- Dose: 260 mg once daily 1
- Same dosing as Stage 3A, as FDA labeling groups CrCl 21-59 mL/min together 1
Severe Renal Impairment (CrCl <30 mL/min)
Pharmacokinetic Rationale
The elimination half-life of cefixime increases from 3.7 hours in normal renal function to 12-14 hours when creatinine clearance falls below 20 mL/min. 2
- Peak serum concentrations (Cmax) are slightly elevated in renal impairment, reaching 2.27 mcg/mL at 8 hours (versus 2.50 mcg/mL at 2.83 hours in normal function) 2, 3
- Total body clearance decreases proportionally with declining creatinine clearance 2
- Only 40% of cefixime is renally excreted, with 60% undergoing hepatic clearance, which explains why dose reduction is less dramatic than with purely renally-cleared drugs 4, 5
Critical Safety Considerations
Neurotoxicity Risk
Beta-lactam antibiotics including cephalosporins can cause neurotoxicity in renal impairment, even with appropriate dose adjustments. 6, 7
- Monitor for confusion, encephalopathy, myoclonus, seizures, and status epilepticus 6, 7
- Cefixime has lower pro-convulsive activity compared to other cephalosporins like cefepime, but vigilance remains essential 6
- Neurotoxicity risk is particularly elevated in patients with chronic kidney disease 7
Dialysis Considerations
Neither hemodialysis nor peritoneal dialysis removes significant amounts of cefixime from the body. 1
- For hemodialysis patients: Use the 260 mg daily dose (same as CrCl 21-59 mL/min) 1
- No supplemental post-dialysis dose is required 1
- Timing of administration relative to dialysis is not critical given minimal drug removal 1
Practical Administration Points
Cefixime can be administered without regard to food, as meals do not affect absorption or peak concentrations. 4
- After reconstitution, suspension remains stable for 14 days at room temperature or refrigerated 1
- Shake well before each use 1
- For Streptococcus pyogenes infections, continue treatment for at least 10 days regardless of renal function 1
Common Pitfall to Avoid
Do not use normal dosing (400 mg daily) in stage 3 CKD. The FDA label explicitly requires dose reduction when creatinine clearance is below 60 mL/min 1. Research demonstrates that failure to adjust dosing results in drug accumulation, with serum levels remaining elevated (0.99 mcg/mL at 24 hours in severe renal impairment versus 0.10 mcg/mL in normal function) 3. This accumulation increases the risk of adverse effects, particularly neurotoxicity 6, 7.