Cefixime Dosing in CKD Stage 5
For patients with CKD stage 5 (creatinine clearance <10 mL/min), reduce cefixime to 200 mg once daily, or 8.6 mL of the 100 mg/5 mL suspension (4.4 mL of the 200 mg/5 mL suspension). 1
Dosing Algorithm by Renal Function
The FDA-approved dosing adjustments for cefixime are straightforward and based on creatinine clearance 1:
- CrCl ≥60 mL/min: Normal dose (400 mg daily)
- CrCl 21-59 mL/min: 260 mg daily (13 mL of 100 mg/5 mL suspension OR 6.5 mL of 200 mg/5 mL suspension)
- CrCl ≤20 mL/min OR continuous peritoneal dialysis: 172 mg daily (8.6 mL of 100 mg/5 mL suspension OR 4.4 mL of 200 mg/5 mL suspension)
Hemodialysis Considerations
Neither hemodialysis nor peritoneal dialysis removes significant amounts of cefixime from the body, so no supplemental dosing is required post-dialysis. 1, 2 This distinguishes cefixime from many other antibiotics that require post-dialysis supplementation 3.
Pharmacokinetic Rationale
The dose reduction is necessary because cefixime elimination half-life increases dramatically in severe renal impairment 4, 5:
- Normal renal function: t½ = 3-4 hours 2
- Moderate impairment (CrCl 30-60 mL/min): t½ = 4.15 hours 4
- Severe impairment (CrCl 10-30 mL/min): t½ = 11.05 hours 4
- CrCl <20 mL/min: t½ = 12-14 hours 5
Approximately 40% of cefixime is renally cleared, with the remaining 60% undergoing hepatic elimination 2. In severe renal failure, both renal and total body clearance decrease proportionally to creatinine clearance 5.
Critical Pitfalls to Avoid
Do not assume normal dosing is safe based on "normal" serum creatinine alone in elderly patients or those with reduced muscle mass, as this masks severe renal impairment 6. Always calculate actual creatinine clearance using the Cockcroft-Gault equation or measure GFR directly.
Do not substitute cefixime capsules for suspension in treating otitis media, as the suspension achieves higher peak blood levels at equivalent doses 1. However, for CKD stage 5 patients, either formulation is acceptable for non-otitis media indications.
Ensure all orders specifying milliliters include the concentration (100 mg/5 mL vs 200 mg/5 mL), as cefixime suspension is available in two strengths and dosing errors are common 1.
Duration of Therapy
For Streptococcus pyogenes infections, administer cefixime for at least 10 days regardless of renal function 1. For uncomplicated gonorrhea, a single 400 mg dose is standard in normal renal function, but this should be reduced to 200 mg in CKD stage 5 1.