ACP HospitalistCefepime-induced Neurotoxicity

An elderly patient exhibited signs of cognitive disarray, which emerged three days subsequent to a hospital discharge following osteomyelitis treatment.

An elderly man’s confusion post-osteomyelitis treatment prompts an exploration into the potential neurotoxic effects of cefepime, a frequently used fourth-generation cephalosporin, especially in patients with renal dysfunction.

Key Points:

• The patient was an 87-year-old male who presented confusion and decreased responsiveness three days after being discharged from an osteomyelitis treatment involving IV cefepime.
• Despite not having cefepime levels obtained, the improvement of the patient’s mental status after the antibiotic change to ertapenem indicated cefepime-induced neurotoxicity.
• Cefepime-induced neurotoxicity can occur in up to 0.15% of all patients and 15% of ICU patients, with symptoms typically delayed by a median of four days from treatment initiation.
• One primary risk factor for cefepime-induced neurotoxicity is renal dysfunction which increases the unbound, active form of cefepime in the blood.

Additional Points:

• Cefepime neurotoxicity mechanism involves the competitive inhibition of the γ-aminobutyric acid (GABA) receptor, which can lower the seizure threshold and lead to encephalopathy.
• The blood-brain barrier can be disrupted by renal dysfunction, sepsis, uremia, or prior central nervous system infection, allowing for greater penetration of cefepime, from 10% in normal conditions up to 45%.
• Cefepime toxicity treatment includes stopping the offending agent, managing seizure activity with antiepileptics, and in some cases, initiating hemodialysis.

Conclusion:

• The connection between cefepime and neurotoxicity, especially in patients with renal impairment, emphasizes the importance of monitoring cefepime levels in high-risk patients.

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Did You Know?
Neurotoxicity affects up to 15% of people over the age of 60, with polypharmacy and pre-existing neurological and renal conditions significantly increasing the risk.