Maxipime
cefepime hydrochloride
Pharmacologic class: Fourth-generation cephalosporin
Therapeutic class: Anti-infective
Pregnancy risk category B
Action
Interferes with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die. Active against gram-negative and gram-positive bacteria, with expanded activity against gram-negative bacteria. Exhibits minimal immunosuppressant activity.
Availability
Powder for injection: 500-mg vial, 1-g vial, 2-g vial; 1-g and 2-g piggyback bottles
Solution for injection (premixed): 1 g (50 ml in iso-osmotic dextrose), 2 g (100 ml in iso-osmotic dextrose)
Indications and dosages
➣ Urinary tract infections (UTIs) caused by Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis
Adults: 500 mg to 1g by I.V. infusion or I.M. q 12 hours for 7 to 10 days
➣ Severe UTIs caused by E. coli or K. pneumoniae; moderate to severe skin infections caused by Staphylococcus aureus or Streptococcus pyogenes
Adults: 2 g by I.V. infusion q 12 hours for 10 days
➣ Febrile neutropenia
Adults and children ages 2 months to 16 years: 2 g by I.V. infusion q 8 hours for 7 days
➣ Complicated intra-abdominal infections caused by alpha-hemolytic streptococci, E. coli, K. pneumoniae, Pseudomonas aeruginosa, Enterobacter species, or Bacteroides fragilis
Adults: 2 g by I.V. infusion q 12 hours for 7 to 10 days (given with metronidazole)
➣ Moderate to severe pneumonia caused by K. pneumoniae, P. aeruginosa, Enterobacter species, or Streptococcus pneumoniae
Adults: 1 to 2 g by I.V. infusion q 12 hours for 10 days
Dosage adjustment
• Renal impairment
Contraindications
• Hypersensitivity to cephalosporins or penicillins
Precautions
Use cautiously in:
• renal impairment, phenylketonuria
• history of GI disease
• elderly patients
• pregnant or breastfeeding patients
• children.
Administration
• Don't mix premixed solution with other drugs.
See Don't use flexible container in series connections because of risk of air embolism.
• Obtain specimens for culture and sensitivity testing as needed before starting therapy.
• Don't mix with ampicillin (at concentrations above 40 mg/ml), metronidazole, aminoglycosides, or aminophylline if ordered concurrently. Give each drug separately.
• For I.V. infusion, use small I.V. needle and infuse into large vein over 30 to 60 minutes.
• For I.M. administration, inject deep into large muscle.
Adverse reactions
CNS: headache, lethargy, paresthesia, syncope, seizures
CV: phlebitis, hypotension, palpitations, chest pain, vasodilation, thrombophlebitis
EENT: hearing loss
GI: nausea, vomiting, diarrhea, abdominal cramps, oral candidiasis, pseudomembranous colitis
GU: vaginal candidiasis, nephrotoxicity
Hematologic: lymphocytosis, eosinophilia, bleeding tendency, hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, agranulocytosis, bone marrow depression
Hepatic: hepatic failure, hepatomegaly
Musculoskeletal: arthralgia
Respiratory: dyspnea
Skin: urticaria, maculopapular or erythematous rash, redness, swelling, induration
Other: chills, fever, superinfection, pain at I.M. site, phlebitis at I.V. site, anaphylaxis, serum sickness
Interactions
Drug-drug. Aminoglycosides, loop diuretics: increased risk of nephrotoxicity
Probenecid: decreased excretion and increased blood level of cefepime
Drug-diagnostic tests. Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, bilirubin, blood urea nitrogen, creatinine, eosinophils, gamma-glutamyltransferase, lactate dehydrogenase: increased levels
Coombs' test, urinary 17-ketosteroids, nonenzyme-based urine glucose tests (such as Clinitest): false-positive results
Hemoglobin, platelets, white blood cells: decreased values
Drug-herbs. Angelica, anise, arnica, asafetida, bogbean, boldo, celery, chamomile, clove, danshen, fenugreek, feverfew, garlic, ginger, ginkgo, ginseng, horse chestnut, horseradish, licorice, meadowsweet, onion, papain, passionflower, poplar, prickly ash, quassia, red clover, turmeric, wild carrot, wild lettuce, willow: increased risk of bleeding
Patient monitoring
• Assess baseline CBC and kidney and liver function test results.
• Monitor for signs and symptoms of superinfection and other serious adverse reactions.
• Monitor for inflammation at infusion site.
• Be aware that cross-sensitivity to penicillins may occur.
Patient teaching
• Instruct patient to report reduced urinary output, persistent diarrhea, bruising, petechiae, or bleeding.
• Caution patient not to take herbs without consulting prescriber.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and herbs mentioned above.
cefepime
(seff-e-peem) cefepime,Maxipime
(trade name)Classification
Therapeutic: anti infectivesPharmacologic: fourth generation cephalosporins
Indications
- Uncomplicated skin and skin structure infections,
- Bone and joint infections,
- Uncomplicated and complicated urinary tract infections,
- Respiratory tract infections,
- Complicated intra-abdominal infections (with metronidazole),
- Septicemia.
Action
Therapeutic effects
- Enterobacter,
- Haemophilus influenzae (including β-lactamase-producing strains),
- Escherichia coli,
- Klebsiella pneumoniae,
- Neisseria,
- Proteus,
- Providencia,
- Pseudomonas aeruginosa,
- Serratia,
- Moraxella catarrhalis(including β-lactamase-producing strains).
Pharmacokinetics
Time/action profile
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| IM | rapid | 1–2 hr | 12 hr |
| IV | rapid | end of infusion | 12 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- seizures (↑ risk in renal impairment) (life-threatening)
- encephalopathy
- headache
Gastrointestinal
- pseudomembranous colitis (life-threatening)
- diarrhea
- nausea
- vomiting
Dermatologic
- rashes (most frequent)
- pruritis
- urticaria
Hematologic
- bleeding
- eosinophilia
- hemolytic anemia
- neutropenia
- thrombocytopenia
Local
- pain at IM site (most frequent)
- phlebitis at IV site (most frequent)
Miscellaneous
- allergic reactions including anaphylaxis (life-threatening)
- superinfection
- fever
Interactions
Drug-Drug interaction
Probenecid ↓ excretion and ↑ blood levels.Concurrent use of loop diuretics or aminoglycosides may ↑ risk of nephrotoxicity.Route/Dosage
Renal Impairment
Intramuscular Intravenous (Adults) (See Manufacturer's specific recommendations) CCr 30–60 mL/min—0.5–1 g every 24 hr or 2 g every 12–24 hr; CCr 11–29 mL/min—0.5–2 g every 24 hr; CCr <11 mL/min—250 mg–1 g every 24 hr.Availability (generic available)
Nursing implications
Nursing assessment
- Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
- Before initiating therapy, obtain a history to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.
- Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.
- Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue the drug and notify health care professional immediately if these symptoms occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
- Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.
- Lab Test Considerations: May cause positive results for Coombs' test in patients receiving high doses or in neonates whose mothers were given cephalosporins before delivery.
- May cause ↑ serum AST, ALT, bilirubin, BUN, and creatinine.
- May rarely cause leukopenia, neutropenia, thrombocytopenia, and eosinophilia.
Potential Nursing Diagnoses
Risk for infection (Indications, Side Effects)Diarrhea (Adverse Reactions)
Deficient knowledge, related to medication regimen (Patient/Family Teaching)
Implementation
- Intramuscular: Reconstitute IM doses with sterile or bacteriostatic water for injection, 0.9% NaCl, or D5W. May be diluted with lidocaine to minimize injection discomfort.
- Inject deep into a well-developed muscle mass; massage well.
- IM route should only be used for treatment of mild-to-moderate uncomplicated or complicated urinary tract infections due to Escherichia coli.
Intravenous Administration
- pH: 4.0–6.0.
- Intravenous: Monitor injection site frequently for phlebitis (pain, redness, swelling). Change sites every 48–72 hr to prevent phlebitis.
- If aminoglycosides are administered concurrently, administer in separate sites, if possible, at least 1 hr apart. If second site is unavailable, flush lines between medications.
- Intermittent Infusion: Reconstitute with 5 mL sterile water, 0.9% NaCl, or D5W for the 500-mg vial, or 10 mL for the 1-g or 2-g vials. Diluent: Dilute further in 50–100 mL of D5W, 0.9% NaCl, D10W, D5/0.9% NaCl, or D5/LR.Concentration: Maximum 40 mg/mL.
- Solution is stable for 24 hr at room temperature and 7 days if refrigerated.
- Rate: Administer over 20–30 min.
- Y-Site Compatibility: amikacin, amphotericin B lipid complex, ampicillin-sulbactam, anidulafungin, azithromycin, aztreonam, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium gluconate, carboplatin, carmustine, cyclophosphamide, cytarabine, dactinomycin, daptomycin, dexamethasone sodium phosphate, dexmedetomidine, docetaxel, doxacurium, doxorubicin liposome, eptifibatide, fenoldopam, fluconazole, fludarabine, fluorouracil, foscarnet, furosemide, gentamicin, granisetron, hetastarch, hydrocortisone sodium phosphate, hydrocortisone sodium succinate, hydromorphone, imipenem-cilastatin, insulin, ketamine, leucovorin, levofloxacin, linezolid, lorazepam, melphalan, mesna, methotrexate, methylprednisolone sodium succinate, metronidazole, milrinone, octreotide, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, piperacillin-tazobactam, potassium acetate, ranitidine, remifentanil, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, sufentanil, telavancin, thiotepa, ticarcillin-clavulanate, tigecycline, tirofiban, tobramycin, trimethoprim/sulfamethoxazole, vasopressin, zidovudine, zoledronic acid
- Y-Site Incompatibility: acetylcysteine, acyclovir, alemtuzumab, amphotericin B cholesteryl, amphotericin B colloidal, amphotericin B liposome, argatroban, caspofungin, chlorpromazine, ciprofloxacin, cisplatin, dacarbazine, daunorubicin, dexrazoxane, diazepam, diltiazem, diphenhydramine, dolasetron, doxorubicin hydrochloride, droperidol, enalaprilat, epirubicin, erythromycin, etoposide, etoposide phosphate, famotidine, filgrastim, floxuridine, ganciclovir, gemcitabine, haloperidol, hydroxyzine, idarubicin, ifosfamide, irinitecan, magnesium sulfate, mannitol, mechlorethamine, meperidine, metoclopramide, midazolam, mitomycin, mitoxantrone, nalbuphine, nesiritide, ondansetron, oxaliplatin, pantoprazole, pemetrexed, phenytoin, prochlorperazine, promethazine, quinupristin/dalfopristin, streptozocin, tacrolimus, theophylline, vecuronium, vinblastine, vincristine, vinorelbine, voriconazole
Patient/Family Teaching
- Advise patient to report signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy.
- Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional.
Evaluation/Desired Outcomes
- Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection.