Prolonged Cefepime-Induced Neurotoxicity in a Patient with End-Stage Renal Disease

Abstract

Patient: Female, 86-year-old Final Diagnosis: Drug reaction Symptoms: Encephalopathy • seizure Medication: — Clinical Procedure: — Specialty: Neurology Objective: Unusual clinical course Background: Cefepime, a fourth-generation cephalosporin, has a known adverse effect of neurotoxicity. It occurs notably in patients with end-stage renal disease, but symptom resolution typically occurs within a median of 2 days following drug discontinuation. Case Report: We present a patient with end-stage renal disease on hemodialysis (TWThSat) who developed prolonged neurotoxicity lasting longer than 1 week complicated by nonconvulsive status epilepticus 2 days after cefepime discontinuation. She presented initially with a right upper-extremity arteriovenous graft infection from extended-spectrum beta-lactamase Escherichia coli , and was treated with cefepime. She eventually developed acute encephalopathy, and cefepime was discontinued. However, 2 days later, she developed seizures with worsened mental status. She was stabilized on levetiracetam and lorazepam, but developed hypotension in the Neurological Intensive Care Unit (Neuro-ICU), delaying hemodialysis. Hemodialysis was performed 6 days after cefepime discontinuation once she was stabilized, and her mental status improved 1 to 2 days after, with full improvement 20 days after admission. She was discharged on levetiracetam and meropenem. In addition, we review risk factors and symptomology of cefepime-induced neurotoxicity and discuss important management issues. Conclusions: Careful attention should be paid when administering cefepime to patients with end-stage renal disease. Patients showing signs of encephalopathy should not be on cefepime any longer, and more aggressive measures may be taken, such as prompt hemodialysis, assessment of cefepime blood levels, and electroencephalogram (EEG) to monitor for signs of seizures. Prolonging hemodialysis in patients with signs of cefepime neurotoxicity can pose a danger for more serious sequelae, such as status epilepticus. Close monitoring of patients at high risk of developing adverse events from cefepime administration can ensure patient safety and well-being.

Cefepime-induced encephalopathy in an older patient with polypharmacy and renal insufficiency: a case report

“…Reliable data strongly support the early initiation of hemodialysis to expedite removal of cefepime from the circulation, leading to accelerated recovery and a favorable prognosis. 12 , 19 , 23 , 28 , 29 …”

“…Reliable data strongly support the early initiation of hemodialysis to expedite removal of cefepime from the circulation, leading to accelerated recovery and a favorable prognosis. 12,19,23,28,29 Anticonvulsant therapy, primarily consisting of benzodiazepines along with alternatives such as phenobarbital, phenytoin, levetiracetam, and valproic acid, is occasionally administered to patients with CIN. However, benzodiazepines do not lead to immediate or permanent restoration of patients' mental state or EEG patterns, although EEG studies have demonstrated temporary suppression of generalized periodic discharges following benzodiazepine injection.…”

Cefepime Neurotoxicity in Patients With Normal Renal Function: An Overlooked Cause of Encephalopathy in the Intensive Care Unit

“…Renal impairment reduces the clearance of cefepime, leading to drug accumulation in the body and increasing susceptibility to neurotoxicity. 2 , 11 Even with renal dose adjustments, cefepime demonstrates notable adverse effects. In 2013, Fugate et al assessed 100 intensive care unit patients for neurotoxicity, identifying 15 likely cases of CIE and 7 definite cases.…”

Comparison of Cefepime with Piperacillin/Tazobactam Treatment in Patients with Hospital-Acquired Pneumonia

“…In many previous studies of piperacillin/tazobactam, the incidence of nephrotoxicity tended to increase, especially when this combination was used with vancomycin concomitantly [ 30 , 31 ]. Cefepime has been known to be associated with adverse neurologic effects [ 32 , 33 ] and an increased incidence of hospital-acquired Clostridioides difficile infection [ 34 ]. The well-known adverse effects of these two types of antibiotics differ, but these effects were not described among the KNHIS data.…”