Does cefepime provide coverage against Streptococcus species such as Streptococcus pneumoniae, group A Streptococcus (Streptococcus pyogenes), and group B Streptococcus (Streptococcus agalactiae)?

Does Cefepime Cover Streptococcus Species?

Yes, cefepime provides excellent coverage against most clinically relevant Streptococcus species, including Streptococcus pneumoniae (including penicillin-resistant strains), Streptococcus pyogenes (group A strep), and Streptococcus agalactiae (group B strep), making it a reliable option for empiric therapy when streptococcal infections are suspected. 1

FDA-Approved Spectrum Against Streptococci

• The FDA label explicitly lists cefepime as active against Streptococcus pneumoniae, Streptococcus pyogenes (group A), and viridans group streptococci for clinical infections 1
• Streptococcus agalactiae (group B) is also listed as having in vitro susceptibility, though with less extensive clinical trial data 1

Comparative Activity Against Streptococcal Species

Streptococcus pneumoniae (Including Resistant Strains)

• Cefepime demonstrates in vitro activity against penicillin-sensitive, penicillin-intermediate, and penicillin-resistant S. pneumoniae that is similar to cefotaxime and ceftriaxone 2
• In a multicenter study of 197 nosocomial streptococcal bloodstream isolates, cefepime inhibited 100% of S. pneumoniae isolates at ≤8 μg/mL, and was approximately eightfold more potent than ceftazidime 3
• Among 42 penicillin-resistant streptococcal isolates (MIC >0.12 μg/mL), 100% were inhibited by cefepime at ≤8 μg/mL, compared to only 48% for ceftazidime 3

Group A and Group B Streptococci

• Cefepime shows superior activity against streptococci compared to any other drug tested in comparative studies 4
• Against Streptococcus pyogenes (group A), all 19 clinical isolates tested were highly susceptible 4
• Against Streptococcus agalactiae (group B), all 36 clinical isolates demonstrated susceptibility 4

Viridans Group Streptococci

• Cefepime inhibited 83% of viridans group streptococci at ≤0.5 μg/mL and 100% at ≤8 μg/mL in nosocomial bloodstream isolates 3
• This is particularly important for febrile neutropenic patients with oral mucositis, where viridans streptococci are common pathogens 5

Clinical Guideline Support for Streptococcal Coverage

• The Infectious Diseases Society of America (IDSA) guidelines for febrile neutropenia explicitly state that monotherapy regimens including cefepime provide excellent coverage of viridans streptococci 5
• Cefepime monotherapy is considered adequate for febrile neutropenia in patients with oral mucositis, precluding the need for vancomycin addition specifically for streptococcal coverage 5
• The American Thoracic Society guidelines note that cefepime is active against drug-resistant S. pneumoniae (DRSP), though it is not listed as a primary agent for community-acquired pneumonia due to broader-than-necessary spectrum 5

Rank Order of Cephalosporin Activity

• Among cephalosporins tested against 197 streptococcal bloodstream isolates, the rank order was: ceftriaxone > cefepime > ceftazidime 3
• Cefepime and ceftriaxone were identified as the superior cephalosporins for empiric coverage of streptococcal bloodstream infections 3

Important Clinical Considerations

When Cefepime Is Appropriate for Streptococcal Coverage

• Febrile neutropenia with suspected streptococcal infection (particularly viridans group in patients with mucositis) 5
• Nosocomial pneumonia where both Gram-negative and streptococcal coverage is needed 2
• Polymicrobial infections requiring broad Gram-negative and Gram-positive coverage 6

When Alternative Agents May Be Preferred

• Community-acquired pneumonia without risk factors for Pseudomonas: Use ceftriaxone, cefotaxime, or high-dose amoxicillin rather than cefepime to avoid unnecessarily broad Gram-negative coverage 5
• Methicillin-resistant staphylococci or enterococci: Cefepime has no activity against these organisms; vancomycin or linezolid is required 1, 4

Common Pitfalls to Avoid

• Do not assume cefepime is inferior to third-generation cephalosporins for streptococci – its activity is comparable to ceftriaxone and superior to ceftazidime 2, 3
• Do not use cefepime for enterococcal coverage – like all cephalosporins, it lacks clinically meaningful activity against Enterococcus species 1, 4
• Do not use cefepime for methicillin-resistant staphylococci – only methicillin-susceptible S. aureus is covered 1, 6
• Avoid using cefepime as first-line monotherapy for uncomplicated community-acquired pneumonia – narrower-spectrum agents like ceftriaxone are preferred to minimize selection pressure for resistant Gram-negative organisms 5