What is the recommended dosing of Cefepime (Cefepime) for Hospital-Acquired Pneumonia (HAP)?

Cefepime Dosing for Hospital-Acquired Pneumonia

For hospital-acquired pneumonia (HAP), administer cefepime 1-2 grams intravenously every 8-12 hours in patients with normal renal function, with the specific dose and interval determined by disease severity and risk factors for multidrug-resistant pathogens. 1

Standard Dosing Regimens

Low to Moderate Risk HAP

• Cefepime 2 grams IV every 8 hours is the recommended dose for empiric monotherapy in patients without risk factors for multidrug-resistant (MDR) pathogens 1, 2
• This regimen provides adequate coverage for methicillin-sensitive Staphylococcus aureus (MSSA) and common gram-negative organisms 3, 2

High-Risk HAP or Severe Disease

• Cefepime 2 grams IV every 8 hours should be combined with a second antipseudomonal agent (fluoroquinolone or aminoglycoside) when treating late-onset disease or patients with risk factors for MDR pathogens 1
• Risk factors requiring dual coverage include: hospitalization ≥5 days, recent antibiotic use within 90 days, admission from healthcare facility, or need for mechanical ventilation 1, 2

Optimized Administration Strategy

Extended Infusion for Critically Ill Patients

• Administer cefepime 2 grams over 3-4 hours every 8 hours rather than standard 30-minute infusions in critically ill patients to maximize time above MIC 4, 5
• This prolonged infusion strategy is particularly important for organisms with MICs of 4-8 mg/L, as it increases the probability of achieving 50-100% fT>MIC 4

Alternative Dosing Interval

• Cefepime 2 grams every 12 hours (4-hour infusion) may be optimal for patients with normal renal function (CrCl 90-130 mL/min) when targeting organisms with MIC ≤4 mg/L, balancing efficacy with reduced neurotoxicity risk 4

Renal Dose Adjustments

Critical caveat: Cefepime requires mandatory dose adjustment based on creatinine clearance to prevent neurotoxicity 4, 6

• CrCl >50 mL/min: 2 grams every 8-12 hours (standard dose) 1
• CrCl 30-50 mL/min: Reduce frequency or dose based on severity
• CrCl 10-30 mL/min: Consider 0.75 grams continuous infusion over 24 hours for MIC ≤8 mg/L, maintaining trough <35 mg/L 4
• Hemodialysis patients: Reduced dosing schedule necessary; consider therapeutic drug monitoring 2, 4

Combination Therapy Requirements

When to Add MRSA Coverage

• Add vancomycin 15 mg/kg every 12 hours (target trough 15-20 mcg/mL) or linezolid 600 mg every 12 hours when MRSA prevalence exceeds 20% in your ICU or patient has prior MRSA colonization 1, 2

When to Add Second Antipseudomonal Agent

• Combine cefepime with ciprofloxacin 400 mg IV every 8 hours, levofloxacin 750 mg IV daily, or aminoglycoside for ventilated patients, septic shock, or confirmed Pseudomonas bacteremia 1, 7, 2
• Dual antipseudomonal coverage prevents emergence of resistance and improves outcomes in severe HAP 7

Critical Pitfalls to Avoid

• Never use fluoroquinolone monotherapy for Pseudomonas infections in ventilated patients—resistance develops rapidly 7
• Do not delay initial empiric therapy while awaiting cultures, as inappropriate initial treatment significantly increases mortality (24.7% vs 16.2%) 1
• Avoid using the same antibiotic class the patient received in the prior 90 days, as this predisposes to resistance 1
• Monitor for neurotoxicity in patients with renal dysfunction or when trough levels exceed 20-35 mg/L; therapeutic drug monitoring is recommended in critically ill patients 4
• Check local antibiogram patterns—if institutional Pseudomonas susceptibility to cefepime is <90%, consider alternative β-lactam or add aminoglycoside 7

Duration and De-escalation

• Continue combination therapy for 3-5 days, then de-escalate to monotherapy based on culture results and clinical response 7
• Narrow therapy once susceptibilities are available—if MSSA is confirmed, switch to oxacillin, nafcillin, or cefazolin rather than continuing broad-spectrum coverage 2