What is the recommended dose and treatment regimen for cefepime in adults with pneumonia?

Cefepime Dosing for Pneumonia in Adults

For adults with community-acquired pneumonia (CAP), administer cefepime 1-2 g IV every 8-12 hours for 10 days; for severe CAP or when covering Pseudomonas aeruginosa, use 2 g IV every 8 hours. 1, 2

Community-Acquired Pneumonia (CAP)

Standard Dosing for Moderate to Severe CAP

• Cefepime 1-2 g IV every 8-12 hours for 10 days is the recommended regimen for moderate to severe pneumonia caused by S. pneumoniae, P. aeruginosa, K. pneumoniae, or Enterobacter species 1, 2
• The FDA-approved dosing specifically states this regimen for pneumonia in adults with normal renal function (creatinine clearance >60 mL/min) 2

When Pseudomonas Coverage is Required

• Use 2 g IV every 8 hours when P. aeruginosa is suspected or confirmed, as this provides optimal antipseudomonal coverage 1, 2
• The American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) guidelines recommend this higher dose specifically for empiric coverage of P. aeruginosa in CAP patients with locally validated risk factors 1

Combination Therapy Considerations

• Cefepime should NOT be used as monotherapy for CAP unless covering for P. aeruginosa specifically; standard CAP treatment requires a β-lactam PLUS either a macrolide or respiratory fluoroquinolone 1
• For severe CAP, combination therapy with a β-lactam plus macrolide OR β-lactam plus respiratory fluoroquinolone is mandatory 1

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

Low Risk for Multidrug-Resistant Organisms (MDRO)

• Cefepime 2 g IV every 8 hours can be used as monotherapy for HAP/VAP in patients with stable hemodynamics and low MDRO risk 1
• This dosing is consistent across multiple international guidelines 1

High Risk for MDRO or Unstable Hemodynamics

• Cefepime 2 g IV every 8 hours remains appropriate, but consider combination therapy with an aminoglycoside (gentamicin 5-7 mg/kg IV daily or amikacin 15-20 mg/kg IV daily) 1
• For P. aeruginosa coverage in unstable patients, the same cefepime dose should be combined with additional gram-negative coverage 1

Renal Dose Adjustments

Critical Dosing Modifications Based on Creatinine Clearance

• CrCl 30-60 mL/min: Reduce to 2 g IV every 12 hours (for severe infections) or 1 g IV every 24 hours (for moderate infections) 2
• CrCl 11-29 mL/min: Reduce to 2 g IV every 24 hours (for severe infections) or 1 g IV every 24 hours (for moderate infections) 2
• CrCl <11 mL/min: Reduce to 1 g IV every 24 hours (for severe infections) or 500 mg IV every 24 hours (for moderate infections) 2
• Hemodialysis patients: Give 1 g on Day 1, then 500 mg every 24 hours (1 g every 24 hours for febrile neutropenia); administer after dialysis on dialysis days 2

Administration Details

Infusion Duration

• Administer IV over approximately 30 minutes for standard dosing 2
• For critically ill patients with HAP/VAP, consider extended infusion over 4 hours (2 g every 12 hours) to optimize pharmacodynamic targets while minimizing neurotoxicity risk 3

Treatment Duration

Standard Duration

• 10 days for moderate to severe CAP 1, 2
• 7-10 days for HAP/VAP, depending on clinical response 1
• Duration may be shortened to 7 days in patients showing rapid clinical improvement, consistent with palliative care goals 4

Common Pitfalls to Avoid

Monotherapy Errors

• Do NOT use cefepime monotherapy for standard CAP without atypical pathogen coverage (macrolide or fluoroquinolone) unless specifically targeting P. aeruginosa 1
• Cefepime lacks activity against atypical pathogens (Mycoplasma, Chlamydophila, Legionella) that commonly cause CAP 5, 6

Dosing Frequency Mistakes

• Do NOT use every 12-hour dosing when treating P. aeruginosa pneumonia; the every 8-hour regimen is required for adequate coverage 1, 2
• Failure to adjust for renal impairment can lead to drug accumulation and neurotoxicity 2, 3

Resistance Considerations

• Cefepime is stable against many β-lactamases but can be hydrolyzed by extended-spectrum β-lactamases (ESBLs), though to a lesser extent than third-generation cephalosporins 5, 6
• Consider carbapenem therapy instead if ESBL-producing organisms are suspected based on local epidemiology 1

Therapeutic Drug Monitoring

• In critically ill patients, consider monitoring cefepime trough levels to maintain fCmin/MIC ratio ≥2.1 for optimal clinical outcomes while keeping Cmin <20 mg/L to avoid neurotoxicity 3, 7
• Patients with an fCmin/MIC <2.1 have significantly higher risk of clinical failure (OR=0.11,95% CI 0.02-0.67) 7