What is the recommended dose of Cefepime (Cefepime) for a patient with suspected Hospital-Acquired Pneumonia (HAP) and impaired renal function, specifically a Creatinine Clearance (CrCl) of 20?

Cefepime Dosing for HAP with CrCl 20 mL/min

For a patient with suspected hospital-acquired pneumonia and a creatinine clearance of 20 mL/min, administer cefepime 1 gram IV every 24 hours (for standard HAP coverage) or 2 grams IV every 24 hours (if high mortality risk or recent IV antibiotics within 90 days). 1

Renal Dose Adjustment Algorithm

The FDA-approved dosing for cefepime in renal impairment follows a structured approach based on creatinine clearance 1:

• For CrCl 11-29 mL/min (which includes your patient with CrCl 20):
  • Standard dose (2g q8h in normal renal function) → 2g IV every 24 hours 1
  • Moderate dose (2g q12h in normal renal function) → 1g IV every 24 hours 1
  • Lower dose (1g q12h in normal renal function) → 500mg IV every 24 hours 1
  • Lowest dose (500mg q12h in normal renal function) → 500mg IV every 24 hours 1

HAP-Specific Dosing Considerations

Risk Stratification Determines Intensity

• Low mortality risk without MRSA factors: Use 1g IV every 24 hours (adjusted from standard 2g q12h) 2, 1

• High mortality risk OR recent IV antibiotics: Use 2g IV every 24 hours (adjusted from standard 2g q8h) 2, 1

  • High mortality risk includes: need for ventilatory support or septic shock 2, 3
  • Recent IV antibiotics defined as: within prior 90 days 2, 3

Infusion Considerations

• Administer each dose over approximately 30 minutes 1
• Extended infusions (4 hours) may optimize pharmacodynamics in critically ill patients, though this is based on research data rather than FDA labeling 4

Critical Safety Concerns with Renal Impairment

Neurotoxicity Risk

Patients with CrCl <30 mL/min are at significant risk for cefepime accumulation and neurotoxicity, even with appropriate dose adjustment. 5

• Neurotoxic symptoms include: confusion, muscle jerks, non-convulsive status epilepticus 5
• Target trough concentrations: maintain Cmin <20 mg/L (or <35 mg/L depending on treatment target) to minimize neurotoxicity 4
• Strongly consider therapeutic drug monitoring (TDM) in patients with CrCl <30 mL/min to adjust dosing and prevent toxicity 4, 5

Monitoring Parameters

• Monitor for neurological symptoms closely, especially confusion or myoclonus 5
• If neurotoxicity suspected, check cefepime levels if available and consider discontinuation 5
• Reassess renal function regularly as changes will require further dose adjustments 1

Pharmacodynamic Targets

• For pathogens with MIC ≤4 mg/L: The adjusted renal dosing achieves adequate time above MIC (T>MIC ≥50%) 5
• For pathogens with MIC ≥8 mg/L: Standard renal-adjusted dosing may be inadequate, and TDM becomes even more critical 5
• The 2g every 24 hours regimen provides appropriate coverage for most HAP pathogens in this renal function range 4

Additional HAP Management

• Add MRSA coverage (vancomycin or linezolid) if patient has prior IV antibiotics within 90 days, high MRSA prevalence unit (>20%), or high mortality risk 2, 3
• Consider combination therapy with a second antipseudomonal agent (fluoroquinolone or aminoglycoside) if high mortality risk 2, 3
• Obtain cultures before initiating antibiotics 3