Version November 2024
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms): IV: 2.5 g (cefepime 2 g and enmetazobactam 500 mg) every 8 hours. Switch to an appropriate oral regimen once symptoms improve, if culture and susceptibility results allow. Total duration of therapy ranges from 5 to 14 days; for patients with symptomatic improvement within the first 48 to 72 hours of therapy, some experts recommend shorter courses of 5 to 10 days (or 7 to 10 days if therapy is completed with cefepime and enmetazobactam) (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Altered kidney function:
Note: Kidney function may be estimated using the MDRD formula.
eGFR 60 to 129 mL/minute: IV: No dosage adjustment necessary.
eGFR 30 to 59 mL/minute: IV: 1.25 g (cefepime 1 g and enmetazobactam 250 mg) every 8 hours.
eGFR 15 to 29 mL/minute: IV: 1.25 g (cefepime 1 g and enmetazobactam 250 mg) every 12 hours.
eGFR <15 mL/minute: IV: Loading dose: 1.25 g (cefepime 1 g and enmetazobactam 250 mg) on day 1 of treatment, followed by 625 mg (cefepime 500 mg and enmetazobactam 125 mg) every 24 hours thereafter.
Augmented renal clearance (eGFR ≥130 mL/minute): Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Young patients (<55 years of age) admitted post trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies (Ref).
eGFR ≥130 mL/minute: IV: No dosage adjustment necessary; however, infusion time should be extended to 4 hours.
Hemodialysis, intermittent (thrice weekly): IV: Dialyzable (cefepime: 30%; enmetazobactam: 35%): Loading dose: 1.25 g (cefepime 1 g and enmetazobactam 250 mg) on day 1 of treatment, followed by 625 mg (cefepime 500 mg and enmetazobactam 125 mg) every 24 hours thereafter. Administer after dialysis on dialysis days.
There are no dosage adjustments provided in the manufacturer's labeling; however, dosage adjustment unlikely due to minimal metabolism.
Refer to adult dosing.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Adverse reactions reported in adults. Also see Cefepime.
>10%: Hepatic: Increased serum transaminases (20%; including increased serum alanine aminotransferase, increased serum aspartate aminotransferase)
1% to 10%:
Gastrointestinal: Diarrhea (4%), nausea (1%), vomiting (2%)
Hematologic & oncologic: Anemia (3%)
Hepatic: Increased serum bilirubin (7%)
Hypersensitivity: Hypersensitivity reaction (2%)
Infection: Injection-site reaction (≤5%; including hematoma at injection site, inflammation at injection site, injection-site phlebitis, pain at injection site, rash at injection site [erythematous], venous thrombosis at injection site)
Nervous system: Headache (5%)
<1%:
Endocrine & metabolic: Hyperkalemia, hypocalcemia
Gastrointestinal: Clostridioides difficile colitis, eructation
Hematologic & oncologic: Eosinophilia, prolonged partial thromboplastin time, thrombocytopenia
Hepatic: Increased serum alkaline phosphatase
Nervous system: Dizziness, restlessness
Renal: Increased blood urea nitrogen, increased serum creatinine
Respiratory: Epistaxis
Frequency not defined:
Cardiovascular: Chest pain
Gastrointestinal: Abdominal pain, gastroenteritis
Genitourinary: Urinary retention
Infection: Bacterial infection, fungal infection
Nervous system: Insomnia
Respiratory: Pneumonia
Postmarketing: Gastrointestinal: Clostridioides difficile-associated diarrhea
Hypersensitivity to cefepime, enmetazobactam, any component of the formulation, or other beta-lactam antibacterial drugs.
Concerns related to adverse effects:
• Elevated INR: May be associated with increased INR, especially in patients who are nutritionally deficient, are receiving prolonged treatment, or have hepatic or kidney disease.
• Hypersensitivity: Hypersensitivity reactions have been reported. Serious, occasionally fatal hypersensitivity reactions (including anaphylaxis), and serious skin reactions have been reported in patients receiving beta-lactams. Question patients about previous hypersensitivity reactions to other cephalosporins, penicillins, or other beta-lactams; cross-sensitivity has been reported. Discontinue the drug and institute appropriate supportive measures if an allergic reaction occurs.
• Neurotoxicity: Severe neurological reactions (some fatal) have been reported, including encephalopathy, aphasia, myoclonus, seizures, and nonconvulsive status epilepticus. Risk may be increased in the presence of kidney impairment; ensure dose is adjusted for kidney function and discontinue therapy if patient develops neurotoxicity; effects are often reversible upon discontinuation of cefepime.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including Clostridioides difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Kidney impairment: Use with caution in patients with kidney impairment (CrCl ≤60 mL/minute); dosage adjustments recommended.
• Seizure disorders: Use with caution in patients with a history of seizure disorder.
Exblifep: FDA approved February 2024; anticipated availability is currently unknown.
IV: Administer by IV infusion over 2 hours. In patients with eGFR ≥130 mL/minute, extend infusion time to 4 hours.
Urinary tract infection, complicated (pyelonephritis or urinary tract infection with systemic signs/symptoms): Treatment of complicated urinary tract infections, including pyelonephritis, caused by susceptible Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis, and Enterobacter cloacae complex in patients ≥18 years of age.
Cefepime and enmetazobactam may be confused with ceftazidime and avibactam.
None known.
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Aminoglycosides: Cephalosporins may enhance the nephrotoxic effect of Aminoglycosides. Cephalosporins may decrease the serum concentration of Aminoglycosides. Risk C: Monitor therapy
Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification
BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination
BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy
Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination
Fecal Microbiota (Live) (Oral): May diminish the therapeutic effect of Antibiotics. Risk X: Avoid combination
Fecal Microbiota (Live) (Rectal): Antibiotics may diminish the therapeutic effect of Fecal Microbiota (Live) (Rectal). Risk X: Avoid combination
Furosemide: May enhance the nephrotoxic effect of Cephalosporins. Risk C: Monitor therapy
Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies): Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors (Anti-PD-1, -PD-L1, and -CTLA4 Therapies). Risk C: Monitor therapy
Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy
Mycophenolate: Antibiotics may decrease serum concentrations of the active metabolite(s) of Mycophenolate. Specifically, concentrations of mycophenolic acid (MPA) may be reduced. Risk C: Monitor therapy
Probenecid: May increase the serum concentration of Cephalosporins. Risk C: Monitor therapy
Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification
Vitamin K Antagonists (eg, warfarin): Cephalosporins may enhance the anticoagulant effect of Vitamin K Antagonists. Risk C: Monitor therapy
Adverse events were not observed in animal reproduction studies using cefepime. Maternal body weight was reduced in animal reproduction studies using enmetazobactam.
Refer to the cefepime monograph for additional information.
Cefepime is present in breast milk; excretion of enmetazobactam is not known.
According to the manufacturer, the decision to breastfeed during therapy should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and the benefits of treatment to the mother.
Refer to the cefepime monograph for additional information.
Kidney function; in patients with changing kidney function, monitor serum creatinine and eGFR at least daily.
Cefepime binds to penicillin-binding proteins, which inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, inhibiting cell wall synthesis.
Enmetazobactam is a beta-lactamase inhibitor that protects cefepime from degradation by certain serine beta-lactamases (eg, extended spectrum beta-lactamases).
Distribution: Vdss: Cefepime: 20.02 L; Enmetazobactam: 25.26 L.
Protein binding: Cefepime: 20%; Enmetazobactam: Negligible.
Metabolism: Minimally metabolized.
Half-life elimination: Cefepime: 2.7 ± 1.1 hours; Enmetazobactam: 2.6 ± 1.1 hours.
Excretion: Urine: Cefepime: 85% (unchanged); Enmetazobactam: 90% (unchanged).
Altered kidney function: Dose-normalized systemic exposures of cefepime and enmetazobactam were higher at all levels of kidney impairment compared to subjects with CrCl ≥90 mL/minute. Increased cefepime and enmetazobactam clearance has been observed in patients with eGFR ≥130 mL/minute.
Anti-infective considerations:
Parameters associated with efficacy:
Cefepime (in combination with enmetazobactam): Time dependent; associated with time free drug concentration (fT) > minimum inhibitory concentration (MIC), goal: 40% to 70% fT > MIC (Bernhard 2020; Craig 1995; Craig 1998; Hong 2023).
Enmetazobactam (in combination with cefepime): Time dependent; associated with fT > threshold, goal: ≥20% to 45% fT > 2 mg/L (Bernhard 2020; Johnson 2020).
Expected drug concentrations in patients with normal renal function:
Adults:
IV: 2-hour infusion, cefepime 2 g and enmetazobactam 500 mg every 8 hours, steady state:
Cmax (peak): Cefepime 99.8 ± 26.4 mg/L; enmetazobactam 19.8 ± 6.3 mg/L.
AUC: Cefepime 379.5 ± 123.3 mg•hour/L; enmetazobactam 75.3 ± 30.8 mg•hour/mL.
Postantibiotic effect: Generally little to no cefepime postantibiotic effect occurs (magnitude of effect varies based on the organism) (Craig 1991; Craig 1995).
Parameters associated with toxicity: Neurotoxicity (eg, confusion, altered consciousness, seizures) is associated with elevated cefepime Cmin (trough) concentrations and risk increases with increasing cefepime Cmin; however, a specific Cmin associated with neurotoxicity has not been well established (Boschung-Pasquier 2020; Huwyler 2017; Lamoth 2010; Payne 2017). In 2 small studies, cefepime Cmin of ≥22 mg/L and >35 mg/L were associated with neurotoxicity (Huwyler 2017; Lamoth 2010). In a study assessing cefepime therapeutic drug monitoring in adults, Cmin <7.7 mg/L resulted in no neurotoxicity, Cmin ≥12 mg/L was associated with a 25% probability of neurotoxicity, Cmin ≥16 mg/L was associated with a 50% probability of neurotoxicity, and Cmin ≥38.1 mg/L was always associated with neurotoxicity (Boschung-Pasquier 2020). A meta-analysis found a cefepime trough level of >20 mg/L puts patients at risk for cefepime-induced neurotoxicity (Maan 2022). Parameters associated with enmetazobactam toxicity are unknown.
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
