Cefepime Dosing on Non-Dialysis Days in Hemodialysis Patients
No, you should not increase the Sunday dose to 2 grams—in fact, you should not administer cefepime at all on Sunday. For anuric end-stage renal disease patients receiving hemodialysis four times weekly (Monday, Wednesday, Friday, Saturday), cefepime should be given only immediately after each dialysis session, with no doses on non-dialysis days 1, 2.
Core Dosing Principle for Hemodialysis Patients
The fundamental strategy is to maintain full individual doses while extending the dosing interval, never reducing the milligram amount per administration. 3, 1
- For severe infections requiring 2 g dosing, administer the full 2 g dose after each dialysis session (four times weekly in your schedule: Monday, Wednesday, Friday, Saturday) 1, 2
- The interdialytic half-life of cefepime is approximately 22 hours, allowing therapeutic levels to persist between dialysis sessions 2
- Approximately 68-72% of cefepime is removed during a 3-hour high-flux hemodialysis session 1, 2
Why No Dosing on Sunday
Administering cefepime on non-dialysis days leads to dangerous drug accumulation and neurotoxicity. 4, 5, 6
- Cefepime is almost exclusively cleared by the kidneys; in anuric patients, there is essentially no elimination between dialysis sessions 1, 4
- Even with "renal-adjusted" dosing, patients with end-stage renal disease frequently develop cefepime-induced neurotoxicity, manifesting as non-convulsive status epilepticus, delirium, myoclonus, and altered mental status 4, 5, 6
- The risk of neurotoxicity persists even when doses are adjusted according to manufacturer guidelines, because metabolite accumulation occurs regardless 4, 6
Correct Dosing Schedule for Your Patient
For a patient dialyzed Monday, Wednesday, Friday, and Saturday:
- Monday: 2 g IV immediately after dialysis 1, 2
- Tuesday: No dose 1
- Wednesday: 2 g IV immediately after dialysis 1, 2
- Thursday: No dose 1
- Friday: 2 g IV immediately after dialysis 1, 2
- Saturday: 2 g IV immediately after dialysis 1, 2
- Sunday: No dose 1
Post-Dialysis Timing is Critical
Always administer cefepime immediately following hemodialysis completion, never before. 1, 3
- Pre-dialysis administration results in premature drug removal during the dialysis session, leading to subtherapeutic levels and treatment failure 3, 1
- Post-dialysis administration ensures the full therapeutic dose is retained between sessions 3, 1
- This timing also facilitates directly observed therapy and improves adherence monitoring 3
Therapeutic Drug Monitoring Considerations
Measure trough cefepime levels immediately before the next dialysis session to verify adequate exposure without excessive accumulation. 2
- Target trough levels of 20-25 mg/L provide coverage above the MIC₉₀ for most pathogens while minimizing neurotoxicity risk 2
- Peak levels of 150-170 mg/L are expected immediately after a 2 g dose 2
Common Pitfall to Avoid
The most dangerous error is attempting to "bridge" non-dialysis days with additional doses. This practice invariably leads to drug accumulation and neurotoxicity in anuric patients, even when using reduced doses 4, 5, 6. The extended interdialytic half-life (22 hours) maintains therapeutic levels throughout the 48-72 hour intervals between your patient's dialysis sessions 2.