Bedside Snapshot
- Use It For
- Febrile neutropenia (empiric); moderate to severe pneumonia; complicated UTI and pyelonephritis; skin infection; complicated intra-abdominal infection (with metronidazole)
- Adult Dose
- Febrile neutropenia: 2 g IV every 8 hr (max 2 g/dose)
- Severe UTI or skin infection: 2 g IV every 12 hr
- Pneumonia: 1–2 g IV every 8–12 hr
- Pediatric Dose
- 50 mg/kg IV every 8 hr (febrile neutropenia, Pseudomonas) or every 12 hr (other); not above adult dose. Not established under 2 months
- Onset / Duration
- IV: 30-min infusion, then every 8–12 hr (renal-adjusted); IM: mild to moderate UTI only, every 12 hr
- Do Not Give / Hold If
- Immediate hypersensitivity to cefepime, other cephalosporins, penicillins or other beta-lactams; CrCl 60 mL/min or less needs a dose reduction; stop for new confusion, myoclonus or seizure
- Watch For
- Neurotoxicity (encephalopathy, myoclonus, seizure, nonconvulsive status) in renal decline; anaphylaxis; hemolysis (positive Coombs); C. difficile diarrhea
- Reversal / Rescue
- No specific antidote: stop the drug and treat seizures per protocol. Hemodialysis removes cefepime (label); anaphylaxis per protocol
- Must Remember
- Renal dose check is the safety step: recalculate the dose with each creatinine change; a dose that was right on admission can cause neurotoxicity after acute kidney injury
Indications
Emergency & Prehospital
- Not a prehospital drug: Hospitals and inter-facility transfers are where you see cefepime. EMS carries it rarely, and the agency decides.
ED / ICU / Transport
- Febrile neutropenia (empiric): The label calls for monotherapy in neutropenic patients with fever. Monotherapy may not be appropriate for the high-risk patient: recent bone marrow transplant, hypotension at presentation, hematologic malignancy, or severe or prolonged neutropenia. The label has too little data to support cefepime alone in those patients (section 1.2). Escalate per oncology or infectious disease protocol
- Moderate to severe pneumonia: Inpatient empiric therapy. Cover Pseudomonas only when locally validated risk factors are present (ATS/IDSA 2019).
- Complicated urinary tract infection and pyelonephritis: Severe cases get the 2 g dose.
- Complicated intra-abdominal infection: Given with metronidazole to cover anaerobes.
- Skin and skin structure infection: Moderate to severe, uncomplicated cases.
Other Uses
- Uncomplicated and mild to moderate UTI: 0.5–1 g IV or IM. The IM route is labeled only for E. coli UTI.
Stewardship: Cefepime is for bacteria. The label limits it to infections proven or strongly suspected to be bacterial. Pair it with local antibiogram data. De-escalate when cultures allow.
Dosing & Administration
Doses vary by protocol; follow local protocols and medical direction.
Available Forms
- IV or IM vials: 1 g and 2 g single-dose vials (label)
- IV reconstitution: 1 g with 10 mL diluent gives about 100 mg/mL (withdraw 10.5 mL); 2 g with 10 mL gives about 160 mg/mL (withdraw 12.5 mL); then dilute in a compatible infusion fluid
- IM reconstitution (1 g vial only): 2.4 mL diluent gives about 280 mg/mL (withdraw 3.6 mL)
Adult Dosing
| Indication | Dose & Route | Repeat / Max | Notes |
|---|---|---|---|
| Febrile neutropenia (empiric) | 2 g IV | Every 8 hr; max 2 g/dose | Continue for 7 days or until neutropenia resolves (label). Renal dose table applies |
| Moderate to severe pneumonia | 1–2 g IV | Every 8–12 hr; max 2 g/dose | 10 days (label). Add Pseudomonas coverage only with locally validated risk factors (ATS/IDSA 2019); for P. aeruginosa, 2 g IV every 8 hr (label footnote) |
| Mild to moderate UTI, including pyelonephritis | 0.5–1 g IV or IM | Every 12 hr; max 1 g/dose | 7–10 days. IM is labeled only for uncomplicated or complicated UTI due to E. coli |
| Severe UTI, including pyelonephritis | 2 g IV | Every 12 hr; max 2 g/dose | 10 days (label) |
| Moderate to severe skin and skin structure infection (uncomplicated) | 2 g IV | Every 12 hr; max 2 g/dose | 10 days (label) |
| Complicated intra-abdominal infection | 2 g IV | Every 8–12 hr; max 2 g/dose | 7–10 days. Always with metronidazole (label); Pseudomonas: 2 g every 8 hr (label footnote). Highlights list every 12 hr; full Table 1 lists every 8–12 hr |
Pediatric Dosing
| Indication | Dose (per kg) & Route | Max Single / Max Total | Notes |
|---|---|---|---|
| Febrile neutropenia; moderate to severe pneumonia due to P. aeruginosa | 50 mg/kg IV every 8 hr | Not above adult dose (2 g/dose) | Label weight-based dosing applies up to 40 kg; over 40 kg use adult dosing. Complicated intra-abdominal infection is labeled for adults only |
| Pneumonia, UTI, uncomplicated skin infection | 50 mg/kg IV every 12 hr | Not above adult dose for the indication | Label usual pediatric dose; durations per the adult table |
| Under 2 months | Not established in children under 2 months | Not established | Label: safety and effectiveness are established from 2 months to 16 years |
Not established under 2 months: the label sets safety and effectiveness from 2 months to 16 years. For younger infants, use neonatal or infectious diseases guidance.
Use weight-based dosing for calculation checks.
Preparation & Administration
- Infusion: IV over approximately 30 minutes (label)
- Dilution: dilute reconstituted vials in a compatible infusion fluid; vials are compatible at 1–40 mg/mL (label); follow pharmacy compatibility guidance
- Y-site: Intermittent infusion through a Y-type set is allowed, and only with compatible solutions
- Separate lines: give separately from metronidazole, vancomycin, gentamicin, tobramycin, netilmicin and aminophylline (label)
- Ampicillin: do not add cefepime to ampicillin solutions above 40 mg/mL (label)
Dosing Notes:
- Renal dosing kicks in whenever creatinine clearance is 60 mL/min or less (see Special Populations).
- Once cultures and the clinical course allow, de-escalate. Reassess daily.
Contraindications & Precautions
Contraindications
- Immediate hypersensitivity reaction to cefepime, other cephalosporins, penicillins or other beta-lactam antibacterials (label section 4)
Precautions
- Penicillin or other beta-lactam allergy: Immediate reaction? That is a contraindication (above). Cross-hypersensitivity among beta-lactams may occur in up to 10% of patients with a penicillin allergy history. A non-immediate or remote history is a precaution. Assess the reaction history case by case before the first dose
- Renal impairment: Most neurotoxicity cases came from doses that were not reduced for creatinine clearance (CrCl) of 60 mL/min or less (label)
- Clostridioides difficile: Any diarrhea during or after therapy must be evaluated for C. difficile (label)
- Hemolysis: The label reports positive direct Coombs tests and hemolytic anemia.
Hold / Reassess If
- New confusion, aphasia, myoclonus, seizure or reduced consciousness (stop the drug and evaluate)
- CrCl falls to 60 mL/min or less: reduce the dose before the next dose
- Falling hemoglobin or positive direct Coombs test: discontinue per label and treat
- Hypersensitivity: discontinue and give supportive treatment (label)
Neurotoxicity trap: New encephalopathy or myoclonus in a patient on cefepime with rising creatinine is cefepime neurotoxicity until proven otherwise. Check the dose against CrCl. Do not wait for seizures to act.
Adverse Effects & Toxicity
Common
- Local reactions at the injection or infusion site (phlebitis about 1.3%)
- Rash (about 4% at the 2 g every 8 hr dose), diarrhea (about 3%), nausea (about 2%) and vomiting (about 1%) (label)
- Positive direct Coombs test (label)
Serious / Life-Threatening
| Effect | Recognition | Management |
|---|---|---|
| Neurotoxicity | Encephalopathy, aphasia, myoclonus, seizures or nonconvulsive status epilepticus; reduced consciousness; often in renal impairment | Stop cefepime; EEG; antiepileptic therapy; hemodialysis if needed (see below) |
| Anaphylaxis | Hypotension, bronchospasm, angioedema, urticaria | Stop the drug; epinephrine IM and anaphylaxis protocol |
| Hemolytic anemia | Falling hemoglobin, positive direct Coombs, jaundice | Discontinue per label; hemolysis workup |
| C. difficile infection | Diarrhea after antibiotic exposure | Test per protocol; treat per infectious diseases or institutional guidance |
Overdose & Toxicity Management
- Neurotoxicity: Stop the drug. Across 135 published cases in a 2017 systematic review, symptoms usually cleared within days. Clearing followed stopping the drug, antiepileptic treatment, or hemodialysis
- Dialysis: The label recommends hemodialysis, not peritoneal dialysis, to remove cefepime in overdose
- No specific antidote, so you rely on supportive care and getting the drug out of the body
Dosing error signal: In the 2017 review, roughly half of the neurotoxic patients received more than the FDA-approved guidance allowed for their renal function. About one in four developed neurotoxicity even on an appropriate dose.
Monitoring
| Parameter | When / How Often | Target / Act If |
|---|---|---|
| Clinical | Mental status and speech at every assessment, especially in older or renally impaired patients | New confusion, aphasia, myoclonus or seizure: stop cefepime and evaluate |
| Clinical | Allergy signs during the first dose and each new course | Hypotension, wheeze, angioedema or rash: stop and treat (anaphylaxis protocol) |
| Laboratory | Creatinine and eGFR or CrCl at least daily while acutely ill (local practice), and with any change in renal function | CrCl 60 mL/min or less: dose adjust (see renal table) |
| Laboratory | CBC with differential during therapy | Falling hemoglobin or positive direct Coombs: discontinue per label |
| Clinical | Stool pattern | New diarrhea after antibiotics: test for C. difficile per protocol |
| Drug levels | Not routinely measured in the label | Neurotoxicity risk rises with accumulation at low CrCl; clinical signs guide action |
Interactions & Compatibility
Clinically Significant Interactions
| Drug / Class | Effect | What To Do |
|---|---|---|
| Aminoglycosides (gentamicin, tobramycin) | Increased potential for nephrotoxicity and ototoxicity (label) | Monitor renal function and hearing; adjust per protocol |
| Potent loop diuretics (furosemide) | Nephrotoxicity reported when cephalosporins are given with potent diuretics (label) | Monitor creatinine and volume status |
| Laboratory tests | False-positive urine glucose with some copper-reduction methods; falling prothrombin activity (label) | Use glucose-oxidase urine glucose tests; monitor prothrombin time in renal or hepatic impairment, poor nutrition or prolonged therapy, and give vitamin K as indicated |
| Metronidazole | Used together for complicated intra-abdominal infection (label) | Dose each drug per its page; give through separate lines |
| Vancomycin | Often co-prescribed for MRSA coverage in sepsis and pneumonia | Give through separate lines (label); see vancomycin |
IV Compatibility
- Diluent: Use pharmacy-approved diluents. The label lists the compatible infusion fluids for reconstituted vials
- Separate line: do not run with metronidazole, vancomycin, gentamicin, tobramycin, netilmicin or aminophylline
- Ampicillin: not above 40 mg/mL in the same solution (label)
Before you hang it, confirm compatibility in an institutional resource.
Special Populations
- Pediatrics: Established from 2 months to 16 years. Weight-based dosing applies up to 40 kg (see the Pediatric Dosing table, not repeated here). For renal impairment, pediatric data are not available. The label recommends dose changes proportional to the adult renal table (CrCl 60 mL/min or less)
- Neonates: Under 2 months, safety and effectiveness are not established (label)
- Pregnancy: Cefepime-specific pregnancy data are limited. The label reports no cefepime pregnancy exposures from postmarketing experience. Animal reproduction studies in rats, mice and rabbits showed no adverse developmental outcomes. Treat serious infection. Do not withhold needed therapy
- Lactation: Cefepime passes into human milk at low concentrations (about 0.5 mcg/mL). The label has no data on effects on the breastfed infant. Weigh benefit against risk
- Older Adults: At usual adult doses, clinical efficacy and safety match younger adults (label). Renal decline with age is the main neurotoxicity risk, so dose by current creatinine clearance
- Renal Impairment: Once CrCl is 60 mL/min or less, adjust the dose. The table below shows how. On hemodialysis, every regimen except febrile neutropenia (including the 500 mg every 12 hr regimen, not shown) is 1 g on day 1, then 500 mg every 24 hr, given after dialysis. Febrile neutropenia is 1 g every 24 hr (label)
- Hepatic Impairment: No specific adjustment is established. The kidneys do most of the clearing (label)
- Obesity / Dosing Weight: Adult doses are fixed. Weight does not change them. Pediatric doses are weight-based up to 40 kg (label)
- Penicillin Allergy: See Contraindications & Precautions. Review the reaction history before you give the drug
| CrCl (mL/min) | 2 g every 8 hr regimen | 2 g every 12 hr regimen | 1 g every 12 hr regimen |
|---|---|---|---|
| Greater than 60 (no adjustment) | 2 g every 8 hr | 2 g every 12 hr | 1 g every 12 hr |
| 30 to 60 | 2 g every 12 hr | 2 g every 24 hr | 1 g every 24 hr |
| 11 to 29 | 2 g every 24 hr | 1 g every 24 hr | 500 mg every 24 hr |
| Less than 11 | 1 g every 24 hr | 500 mg every 24 hr | 250 mg every 24 hr |
| CAPD | 2 g every 48 hr | 2 g every 48 hr | 1 g every 48 hr |
| Hemodialysis | Febrile neutropenia: 1 g every 24 hr; give after dialysis on dialysis days, at the same time each day | Day 1: 1 g, then 500 mg every 24 hr; give after dialysis on dialysis days, at the same time each day | Day 1: 1 g, then 500 mg every 24 hr; give after dialysis on dialysis days, at the same time each day |
Continuous renal replacement therapy (CRRT) dosing is missing from the label excerpt reviewed for this page. Get it from pharmacy or nephrology. For the general approach, see the CRRT page.
Field & Transport Considerations
- Scope: Hospital and transfer staff give it. EMS rarely carries cefepime. Scope varies by state and agency protocol.
- Storage & Stability: Store vials the way the pharmacy label directs. Reconstituted solution and diluted infusion bags carry beyond-use times that pharmacy sets
- Carried Concentration: On the order, confirm the dose in grams (1 g vs 2 g) and the interval (every 8 hr vs every 12 hr). Renal function changes the interval.
- Infusions in Transport: The infusion runs IV over about 30 minutes. Plan around a long transfer so the next dose is not missed. Use a dedicated or separate line
- Handoff Essentials: time of the last dose and of the next dose; creatinine or CrCl used for dosing; mental status baseline; any allergy or reaction
Clinical Pearls
Renal dose check: Redo the math every time creatinine moves. The dose that was right on admission can turn neurotoxic within a day of acute kidney injury.
Encephalopathy is a drug question: New confusion, myoclonus or seizure on cefepime? Check the dose. Decide whether to stop. Get an EEG if one is available.
Cefepime vs piperacillin-tazobactam (ACORN): The randomized trial found no difference in acute kidney injury or death between arms. The cefepime arm had fewer days alive and free of delirium and coma: 11.9 vs 12.2 days, odds ratio 0.79.
Pseudomonas coverage: Add it only when locally validated risk factors are present, per the 2019 ATS/IDSA guideline. Cefepime is one of several options on that list.
Exam discriminator: On the exam, cefepime means fourth-generation with Pseudomonas activity. Ceftriaxone is third-generation, and it does not reliably cover Pseudomonas.
Pharmacology
Mechanism of Action
- Target: It binds penicillin-binding proteins and blocks bacterial cell wall synthesis. The effect is bactericidal
- Spectrum: Broad gram-negative activity, Pseudomonas included, plus gram-positive activity. Use it only for the labeled infections
- Neurotoxicity: Cefepime crosses the blood-brain barrier and antagonizes GABA in a concentration-dependent way. That is why renal dose errors cause encephalopathy and seizures (Payne 2017 review)
Pharmacokinetics
| Route | Infusion | Peak | Dosing interval |
|---|---|---|---|
| IV infusion | Over about 30 minutes | At end of infusion | Every 8–12 hr (renal-adjusted) |
- Half-life: about 2 hr in healthy volunteers; about 13.5 hr in hemodialysis patients (label)
- Elimination: principally renal; about 85% recovered unchanged in urine (label)
- Dialysis: about 68% of body cefepime is removed in a 3-hour hemodialysis session (label)
Names & Classification
- Generic Name
- Cefepime hydrochloride
- Brand Names
- Maxipime (US brand); generic cefepime from multiple manufacturers on DailyMed
- Pharmacologic Class
- Fourth-generation cephalosporin; beta-lactam
- Therapeutic Class
- Parenteral antibacterial
- Controlled Substance
- Not controlled
- ISMP High-Alert
- No
- Look-Alike / Sound-Alike
- None commonly reported; cephalosporin names share a prefix (cefepime, cefazolin, ceftriaxone), so read the full name on each order
References
- Hikma Pharmaceuticals USA Inc. (2025). Cefepime for injection, USP: Prescribing information (revised 6/2025). DailyMed, U.S. National Library of Medicine. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b9914e7e-13f6-42d4-9cbb-8c7ed1ce7a01
- Qian, E. T., Casey, J. D., Wright, A., et al. (2023). Cefepime vs piperacillin-tazobactam in adults hospitalized with acute infection: The ACORN randomized clinical trial. JAMA, 330(16), 1557–1567. https://doi.org/10.1001/jama.2023.20583
- Payne, L. E., Gagnon, D. J., Riker, R. R., et al. (2017). Cefepime-induced neurotoxicity: a systematic review. Critical Care, 21, 276. https://doi.org/10.1186/s13054-017-1856-1
- Metlay, J. P., Waterer, G. W., Long, A. C., et al. (2019). Diagnosis and treatment of adults with community-acquired pneumonia: An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine, 200(7), e45–e67. https://doi.org/10.1164/rccm.201908-1581ST
- Zafar, S. F., Park, H., Letourneau, A. R., et al. (2026). Strategies for safer cefepime use to prevent neurotoxicity using the electronic health record. Critical Care Explorations, 8(2), e1380. https://doi.org/10.1097/CCE.0000000000001380
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
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