Antibiotic · Beta-lactam · Cephalosporin
Cefepime (Maxipime)
Also called Maxipime
Indications
- Moderate to severe pneumonia, including Pseudomonas (label)
- Empiric therapy for febrile neutropenia, 2 g every 8 h (label)
- Complicated intra-abdominal infection, with metronidazole (label)
- Urinary tract and uncomplicated skin infections (label)
- Empiric gram-negative and Pseudomonas coverage in sepsis and hospital-acquired pneumonia; post-neurosurgical meningitis (off-label)
Dosing
| Where | Dose |
|---|---|
| Antimicrobials | Cefepime: Reduce at CrCl 60 or less; neurotoxicity (confusion, myoclonus, nonconvulsive seizures) in AKI |
On the quick cards
- Sepsis, source unknownEmpiric Antibiotics: Broad coverage until the source declares itself
- Neutropenic feverEmpiric Antibiotics: ANC under 500, or expected below 500 within 48 h, with 38.3 °C once or 38.0 °C for an hour
- AntimicrobialsRenal Dosing: Adjust, or no change
Mechanism of action
Cefepime is a fourth-generation cephalosporin that binds penicillin-binding proteins and blocks cell-wall synthesis (label), so dividing bacteria lyse; killing depends on time above the MIC. Its positively charged N-methylpyrrolidinium group makes it a zwitterion that crosses gram-negative porins quickly and binds chromosomal AmpC beta-lactamases poorly, keeping it active against many AmpC producers. ESBLs and carbapenemases hydrolyze it. In the brain, beta-lactams antagonize GABA-A receptors, the likely basis of its neurotoxicity.
Pharmacology
- Infectious: gram-negative rods including Pseudomonas, plus MSSA and streptococci; no activity against MRSA, enterococci or Bacteroides, hence metronidazole for abdominal infection
- CNS: encephalopathy, myoclonus, seizures and nonconvulsive status epilepticus, mostly with unadjusted doses in renal impairment (label); fewer delirium- and coma-free days than piperacillin-tazobactam (11.9 vs 12.2 of 14; ACORN 2023)
- Renal: stage 3 AKI 7.0% vs 7.5% with piperacillin-tazobactam (ACORN 2023)
- Hematologic: positive Coombs test without hemolysis 16.2%; falling prothrombin activity (label)
- Skin and local: rash 1.1%, phlebitis 1.3% (label)
Pharmacokinetics
| Half-life | About 2 h (label) |
|---|---|
| Distribution | Vd about 18 L at steady state (label) |
| Protein binding | About 20% (label) |
| Metabolism | Minor: under 1% of the dose appears in urine as N-methylpyrrolidine (label) |
| Elimination | About 85% unchanged in urine (label) |
| Renal dosing | Adjust at CrCl 60 mL/min or less (label) |
| Dialysis | A 3-h session removes about 68%; 1 g on day 1, then 500 mg daily for most infections (label) |
| Infusion | Over about 30 min (label); extended infusion off-label |
Chemistry
- Cephalosporin, C₁₉H₂₄N₆O₅S₂ for the cefepime moiety (label), with an aminothiazolyl methoxyimino side chain at C-7 and a quaternary N-methylpyrrolidinium at C-3
- Supplied as cefepime hydrochloride mixed with L-arginine, which sets the reconstituted pH at 4–6 (label)
Adverse effects and cautions
In the one-pagers
- Meningitis and EncephalitisEmpiric antibiotics and dexamethasone: Neurosurgery, EVD, shunt, penetrating trauma: Vancomycin + cefepime, ceftazidime or meropenem 2 g q8h
- Acute Kidney InjuryNephrotoxins and ICU causes: Adding piperacillin-tazobactam raises creatinine, partly pseudo-AKI; ACORN 2023 found no AKI difference vs cefepime
- Oncologic EmergenciesNeutropenic fever: Antipseudomonal β-lactam within 60 min of triage (ASCO/IDSA 2018): cefepime, piperacillin-tazobactam or meropenem
- Neuro: ICP and StrokeEVD management: leveling, drainage, clamping, infection: Ventriculitis complicates roughly 5–10% of drains; risk rises with IVH or SAH, CSF leak, frequent access and days in place. The NCS 2016 EVD consensus recommends antimicrobial-impregnated catheters, one periprocedural antibiotic dose rather than continuous prophylaxis, CSF sampling only when clinically indicated, and no routine catheter exch
- Sepsis and Septic Shock BundleHour-1 bundle element by element: Underfilled bottles are the commonest cause of false-negative cultures. Give the beta-lactam first: cefepime and meropenem can be pushed over 3–5 min where policy allows, while vancomycin runs 1–2 h. Loading doses are full regardless of renal function because sepsis expands the volume of distribution. Epinephrine, metformin, liver failure and seizures raise lactat
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Sources
- FDA label: Cefepime for Injection (Hospira, 2024)
- Qian 2023 (ACORN trial)
For education and exam preparation only. Follow your institution’s protocols. Typical adult values for study. Follow the order, the label and your institution's protocols.