Cefepime Dosing for Acute Bacterial Meningitis
IDSA Guidelines Do Not Specifically Recommend Cefepime for Bacterial Meningitis
The IDSA guidelines and current standard-of-care protocols recommend ceftriaxone or cefotaxime as the preferred third-generation cephalosporins for bacterial meningitis, not cefepime (a fourth-generation cephalosporin). 1, 2
Standard Empiric Therapy According to Guidelines
Adults <60 Years
- Ceftriaxone 2 grams IV every 12 hours (total 4 grams daily) is the recommended empiric therapy 1, 2
- Alternative: Cefotaxime 2 grams IV every 6 hours 2
- Add vancomycin 15-20 mg/kg IV every 12 hours if penicillin-resistant pneumococci are suspected 2
Adults ≥60 Years
- Ceftriaxone 2 grams IV every 12 hours PLUS amoxicillin 2 grams IV every 4 hours to cover Listeria monocytogenes 1, 2
- Add vancomycin if resistant pneumococci are suspected 2
Pediatric Patients
- Ceftriaxone 50 mg/kg IV every 12 hours (maximum 4 grams daily) 1
- For neonates 22-60 days: Ceftriaxone 50 mg/kg once daily for bacteremia/UTI, but use ampicillin plus ceftazidime for meningitis 1
Why Cefepime Is Not Standard for Meningitis
While cefepime has been studied in pediatric bacterial meningitis with comparable efficacy to cefotaxime (75% cure rate vs 78% with comparators), it is not included in current IDSA or UK Joint Specialist Societies guidelines as a first-line agent 3, 4. The guidelines consistently recommend third-generation cephalosporins (ceftriaxone/cefotaxime) over fourth-generation agents for this indication 5, 1, 2.
If Cefepime Were to Be Used (Based on Research Data)
Should clinical circumstances require cefepime use, the research-supported dosing would be:
Pediatric Dosing
- 50 mg/kg/dose IV every 8 hours for children 2 months to 14 years 3, 4
- This achieved CSF concentrations 55-95 times greater than the MIC of causative pathogens 4
- Clinical cure rates of 75% and bacterial eradication rates of 92-97% depending on pathogen 3
Adult Dosing (Extrapolated)
- No specific adult dosing for meningitis is established in guidelines
- Standard severe infection dosing would be 2 grams IV every 8 hours, but this is not guideline-supported for meningitis
Treatment Duration by Pathogen
- Pneumococcal meningitis: 10-14 days (longer if delayed response or resistance) 6
- Meningococcal meningitis: 5-7 days 6
- Haemophilus influenzae: 10 days 6
- Listeria monocytogenes: 21 days 6
- Enterobacteriaceae: 21 days 6
Critical Clinical Pitfall
Do not substitute cefepime for ceftriaxone/cefotaxime in bacterial meningitis without compelling clinical justification. The overwhelming guideline consensus supports third-generation cephalosporins as the standard of care, with decades of clinical experience and superior guideline support 5, 1, 2. If cefepime must be used due to drug shortages or specific resistance patterns, infectious disease consultation is strongly advised.