What is the recommended dosing and length of therapy for cefepime (Cefepime) in a paraplegic patient with a suprapubic catheter (suprapubic cath), normal renal function, and E. coli bacteremia, who is also growing E. coli in their urine, with resistance to cefazolin (Cefazolin), ceftriaxone (Ceftriaxone), and trimethoprim/sulfamethoxazole (Bactrim), but sensitive to cefepime (Cefepime)?

Cefepime Dosing and Duration for E. coli Bacteremia in a Paraplegic Patient with Suprapubic Catheter

For this paraplegic patient with E. coli bacteremia and catheter-associated UTI with normal renal function, administer cefepime 2 g IV every 8 hours for 14 days, and replace the suprapubic catheter as soon as feasible.

Dosing Regimen

Cefepime 2 g IV every 8 hours is the appropriate dose for severe complicated urinary tract infections and bacteremia. 1

• The FDA-approved dosing for severe complicated UTI due to E. coli is 2 g IV every 12 hours, but for bacteremia with a urinary source in a catheterized patient, the more aggressive every-8-hour regimen is warranted 1
• Standard dosing of 1-2 g every 12 hours may be inadequate for bacteremia, particularly when the MIC approaches 8 μg/mL, as mortality rates increase significantly at this threshold 2
• Patients with bacteremia due to gram-negative organisms treated with cefepime at MIC ≥8 μg/mL had a mortality rate of 54.8%, compared to 24.1% for MIC <8 μg/mL 2
• The every-8-hour dosing provides superior pharmacodynamic target attainment for serious bloodstream infections 2

Duration of Therapy

Treat for 14 days total from the first negative blood culture, assuming the suprapubic catheter is replaced and blood cultures clear within 72 hours. 3

• For catheter-associated bacteremia with a retained or delayed catheter change, 14 days is the standard duration for uncomplicated gram-negative bacteremia 3
• If bacteremia persists >72 hours after catheter removal or appropriate therapy initiation, extend treatment to 4-6 weeks due to concern for endovascular infection or metastatic complications 3
• The 7-10 day duration listed in the FDA label applies to uncomplicated UTI without bacteremia; bacteremia requires longer treatment 1

Critical Management Steps

Catheter Management

The suprapubic catheter must be replaced as soon as possible—ideally within 24-48 hours of starting antibiotics. 3, 4

• Retained infected catheters serve as a nidus for persistent bacteremia and biofilm formation 3
• In spinal cord injury patients with long-term catheters and bacteremia, catheter retention is associated with treatment failure and recurrent infection 3
• Do not wait indefinitely for catheter change—coordinate urgent replacement even if it requires procedural scheduling 4

Monitoring for Treatment Response

Obtain repeat blood cultures 48-72 hours after starting cefepime to document clearance of bacteremia. 3

• Persistent positive blood cultures at 72 hours indicate complicated infection requiring extended therapy (4-6 weeks) 3
• Monitor for clinical improvement: defervescence within 48-72 hours, resolution of hemodynamic instability, and improved mental status 3
• If fever or positive blood cultures persist beyond 72 hours despite appropriate antibiotics and catheter change, investigate for metastatic complications including endocarditis, epidural abscess, or suppurative thrombophlebitis 3

Special Considerations for Paraplegic Patients

Asymptomatic Bacteriuria vs. True Infection

• This patient has true symptomatic infection (bacteremia), not asymptomatic bacteriuria, so treatment is absolutely indicated 3, 4
• Asymptomatic bacteriuria is nearly universal in patients with long-term suprapubic catheters (approaching 100% prevalence) and should not be treated 3, 4
• The presence of bacteremia distinguishes this case from asymptomatic colonization and mandates aggressive treatment 3

Renal Function Monitoring

• Verify normal renal function with creatinine clearance calculation before using standard dosing 1
• If creatinine clearance is 30-60 mL/min, reduce to 2 g every 12 hours; if 11-29 mL/min, reduce to 1 g every 24 hours 1
• Paraplegic patients may have reduced muscle mass affecting creatinine-based estimates, so consider cystatin C if available 1

Common Pitfalls to Avoid

Do not use the 7-10 day duration listed for uncomplicated UTI—this patient has bacteremia requiring 14 days minimum. 3, 1

Do not delay catheter replacement waiting for "sterile urine"—the catheter itself perpetuates infection and must be changed during treatment. 3, 4

Do not assume clinical improvement means adequate treatment—document negative blood cultures before shortening therapy. 3

Do not use cefepime 1 g every 12 hours for bacteremia—this dosing is inadequate and associated with treatment failure. 1, 2