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

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.