What is the recommended dosing for Cefepime (Cefepime) in the treatment of cellulitis?

Cefepime Dosing for Cellulitis

Cefepime is not a first-line agent for typical cellulitis and should be reserved for specific clinical scenarios such as nosocomial infection, healthcare-associated cellulitis, or when broader gram-negative coverage is required.

Standard Dosing Regimens

For adults requiring cefepime for cellulitis treatment, the recommended dosing is:

• Standard dose: 1-2 g IV every 12 hours 1, 2
• For severe infections or suspected resistant organisms: 2 g IV every 8-12 hours 1, 2
• Duration: Typically 5-7 days, though this may be extended if clinical improvement is inadequate 1, 3

The pharmacokinetics support twice-daily dosing, with an elimination half-life of approximately 2 hours and primarily renal elimination (85% excreted unchanged in urine) 2, 4.

Pediatric Dosing

For children requiring cefepime:

• Infants >14 days and children ≤40 kg: 50 mg/kg IV every 12 hours 1
• Neonates ≤14 days: 30 mg/kg IV every 12 hours 1
• Maximum daily dose should not exceed adult dosing on a per-kilogram basis 1

Clinical Context: When to Use Cefepime for Cellulitis

Cefepime is appropriate in these specific scenarios:

• Nosocomial or healthcare-associated cellulitis: Use cefepime 100-150 mg/kg/day divided every 8-12 hours (up to 6 g/day) in combination with vancomycin and gentamicin for empiric coverage 1
• Early prosthetic material infection or vascular catheter-associated cellulitis: Cefepime or ceftazidime should be combined with vancomycin and gentamicin 1
• Suspected gram-negative involvement: When cellulitis occurs in the context of immunocompromise, diabetes with chronic wounds, or water exposure 1

Important caveat: For typical community-acquired cellulitis without these risk factors, beta-lactams targeting streptococci and methicillin-susceptible S. aureus (such as cephalexin, cefazolin, or nafcillin) remain the preferred agents 1, 3.

Dosing Adjustments for Renal Impairment

Cefepime requires dose adjustment in renal dysfunction due to its predominantly renal elimination:

• CrCl 30-60 mL/min: Consider 2 g every 24 hours for adequate coverage 5
• CrCl <30 mL/min: Further dose reduction required based on specific creatinine clearance 2

Administration Considerations

• Standard infusion: 30-60 minutes 2, 6
• Prolonged or continuous infusion: May be beneficial in critically ill patients or infections with higher MIC organisms to optimize time above MIC (target: 70% of dosing interval with free drug concentration above MIC) 1, 2
• In ICU patients with preserved renal function or augmented renal clearance, higher doses (>4 g/day) may be required to achieve pharmacodynamic targets 1

Critical Monitoring Points

• Neurotoxicity risk: Particularly in patients with renal impairment receiving cefepime; monitor for altered mental status, confusion, or seizures 2
• Therapeutic drug monitoring: Consider in critically ill patients, those with life-threatening infections, or when treating more resistant pathogens 2
• Clinical response: Assess for improvement within 48-72 hours; lack of response should prompt re-evaluation for deeper infection, abscess, or alternative diagnosis 1, 3

Common Pitfalls to Avoid

• Don't use cefepime as first-line for uncomplicated community-acquired cellulitis when narrower-spectrum agents like cephalexin or cefazolin are appropriate 1, 3
• Don't forget to adjust dosing for renal function to avoid neurotoxicity 2
• Don't overlook underlying conditions such as tinea pedis, venous insufficiency, or lymphedema that predispose to cellulitis recurrence 1, 3
• Don't continue unnecessarily beyond clinical cure - 5 days is often adequate for uncomplicated cases if improvement has occurred 1, 3