What is the recommended dose of cefepime (Cefepime) for ventilator-associated pneumonia (VAP)?

Cefepime Dosing for Ventilator-Associated Pneumonia

For VAP, administer cefepime 2 g IV every 8 hours as the standard empiric dose for patients with normal renal function, with dose adjustments required based on creatinine clearance in patients with renal impairment. 1

Standard Dosing Regimen

• Cefepime 2 g IV every 8 hours is the recommended dose for empiric treatment of VAP in patients with normal renal function 1
• This dose should be used as part of combination therapy when empiric coverage for multidrug-resistant pathogens is indicated 1

Renal Function-Based Dose Adjustments

Critical consideration: Serum creatinine alone may not accurately reflect renal function in critically ill patients—measured creatinine clearance should guide dosing when possible 2

• Dose adjustments are mandatory in patients with renal impairment to prevent neurotoxicity while maintaining efficacy 3
• For patients with creatinine clearance 10-30 mL/min, significantly reduced doses (as low as 0.75 g continuous infusion over 24 hours) may be sufficient for organisms with MIC ≤8 mg/L 3

Extended Infusion Strategies

For optimal pharmacodynamic target attainment, consider extended infusions rather than standard bolus dosing:

• Extended 3-4 hour infusions of 2 g every 8 hours improve the probability of achieving 50% fT>MIC and reduce risk of neurotoxicity (target Cmin <20 mg/L) 3, 4
• For patients with normal renal function (CrCl 90-130 mL/min), 2 g IV every 12 hours infused over 4 hours may be optimal at MIC of 4 mg/L 3
• Extended infusions are particularly important when treating organisms with higher MICs (16-32 mg/L) 4

Combination Therapy Requirements

Cefepime should NOT be used as monotherapy for empiric VAP treatment:

• Must be combined with an agent from a different class (aminoglycoside, fluoroquinolone, or polymyxin) for empiric double gram-negative coverage in high-risk patients 1
• Add MRSA coverage (vancomycin 15 mg/kg IV every 8-12 hours OR linezolid 600 mg IV every 12 hours) if risk factors present 1
• Never use aminoglycosides as the sole antipseudomonal agent 1

Therapeutic Drug Monitoring

Strongly consider TDM in critically ill VAP patients to optimize efficacy and minimize neurotoxicity:

• Target trough concentrations <20 mg/L for safety (neurotoxicity risk) while maintaining 50% fT>MIC for efficacy 3
• For more aggressive targets (100% fT>MIC), maintain Cmin <35 mg/L to avoid toxicity 3
• TDM is especially important in patients with fluctuating renal function, liver cirrhosis, or other critical illness-related pharmacokinetic alterations 2

Common Pitfalls to Avoid

• Do not rely solely on serum creatinine for dose adjustment—measured creatinine clearance provides more accurate assessment in critically ill patients 2
• Avoid standard bolus infusions when treating organisms with MIC ≥8 mg/L—extended infusions significantly improve target attainment 3, 4
• Do not continue empiric double coverage once susceptibilities are known—de-escalate to monotherapy for susceptible P. aeruginosa unless patient has septic shock 1
• Watch for neurotoxicity (confusion, seizures, encephalopathy), particularly in patients with renal dysfunction or when trough levels exceed 20 mg/L 3, 2

Alternative Antipseudomonal Agents

If cefepime is contraindicated or ineffective, alternative antipseudomonal beta-lactams include:

• Piperacillin-tazobactam 4.5 g IV every 6 hours 1
• Ceftazidime 2 g IV every 8 hours 1
• Meropenem 1 g IV every 8 hours 1
• Imipenem 500 mg IV every 6 hours 1