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Fourth-Generation Cephalosporin Pregnancy: Use only if clearly indicated — limited human data; likely safe (cephalosporin class generally considered low-risk in pregnancy)

Cefepime (Surgical — Broad-Spectrum Cover)

Brand names: Maxipime

Adult dose

Dose: Severe surgical infection: 1–2 g IV every 8–12 hours; Empirical post-operative fever: 2 g IV every 8 hours; Neutropenic fever (post-surgical oncology): 2 g IV every 8 hours
Route: IV (30-minute infusion) or IM
Frequency: Every 8–12 hours
Max: 6 g/day
Fourth-generation cephalosporin — broader gram-negative cover than third-generation (active against Pseudomonas, Enterobacter, Citrobacter). Suitable for hospital-acquired post-surgical infections where Pseudomonas or AmpC-producing organisms are suspected. Not active against MRSA or Enterococcus.

Paediatric dose

Dose: 50 mg/kg
Route: IV
Frequency: Every 8 hours
Max: 2 g per dose (6 g/day)
Paediatric febrile neutropenia: 50 mg/kg IV every 8 hours (max 2 g per dose). Neonates: specialist guidance — limited pharmacokinetic data.

Dose adjustments

Renal

Dose reduction required: eGFR 30–60: 1–2 g every 12–24h; eGFR 11–29: 0.5–1 g every 24h; eGFR <10: 0.25–0.5 g every 24h. Haemodialysis: supplemental dose post-dialysis.

Hepatic

No dose adjustment required.

Paediatric weight-based calculator

Paediatric febrile neutropenia: 50 mg/kg IV every 8 hours (max 2 g per dose). Neonates: specialist guidance — limited pharmacokinetic data.

Clinical pearls

  • Cefepime neurotoxicity: a clinically underrecognised complication — presents as confusion, myoclonus, non-convulsive seizures, and encephalopathy; almost exclusively in patients with renal impairment receiving standard doses without adjustment; EEG shows triphasic waves; reversible on discontinuation or dose correction. MHRA 2012 warning emphasises dose adjustment in renal failure
  • AmpC beta-lactamase producing organisms (Enterobacter, Citrobacter, Serratia): cefepime is stable against AmpC — preferred over third-generation cephalosporins (which can induce AmpC de-repression) for treating suspected AmpC-producing infections in post-surgical HAI
  • Post-operative infection spectrum considerations: abdominal surgery — add metronidazole for anaerobic cover; orthopaedic: add vancomycin if MRSA colonised; urosurgery: cefepime alone often adequate for gram-negative coverage

Contraindications

  • Hypersensitivity to cephalosporins
  • History of severe immediate hypersensitivity to penicillin (cross-reactivity ~1–2% — use with caution)

Side effects

  • Neurotoxicity — cefepime encephalopathy (unique risk: non-convulsive status epilepticus, encephalopathy, myoclonus, especially in renal impairment if dose not adjusted)
  • Diarrhoea (C. difficile — as with all antibiotics)
  • Hypersensitivity reactions
  • Phlebitis (IV site)
  • Elevated LFTs

Interactions

  • Aminoglycosides (additive nephrotoxicity and ototoxicity — space administration, do not mix in same line)
  • Probenecid (reduces renal tubular secretion — increased cefepime levels)
  • Loop diuretics (additive nephrotoxicity at high doses)

Monitoring

  • Renal function (creatinine, eGFR) before and during therapy
  • Signs of neurotoxicity (confusion, myoclonus) in renally impaired patients
  • CBC (neutropenia with prolonged use)
  • Culture and sensitivity results — de-escalate when organism identified

Reference: BNFc; BNF 90; MHRA Drug Safety Update 2012 (cefepime neurotoxicity); PHE Antimicrobial Stewardship Guidelines; IDSA Febrile Neutropenia Guidelines 2011; BNFc. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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