Encephalopathy Induced by High Plasma and Cerebrospinal Fluid Ceftriaxone Concentrations in a Hemodialysis Patient

Abstract

Encephalopathy is a rare side effect of cephalosporin treatment. We herein present a case of encephalopathy induced by ceftriaxone, a third-generation cephalosporin, in a patient with renal failure. An 86-year-old woman on maintenance hemodialysis received ceftriaxone for Helicobacter cinaedi bacteremia. Her mental status deteriorated during antibiotic treatment, and an electroencephalogram revealed triphasic waves predominantly in the frontal area. Her consciousness improved after the discontinuation of the antibiotic due to the suspicion of ceftriaxone-induced encephalopathy. This is the first reported case of encephalopathy associated with high plasma and cerebrospinal fluid ceftriaxone concentrations, and provides significant evidence for a causal relationship between the administration of ceftriaxone and the onset of encephalopathy.

Why Did the Patient Not Show Any Neurological Symptoms on the Day of the Higher Serum Concentration of Ceftriaxone?

“…A previous pharmacokinetic study revealed lower serum concentrations of ceftriaxone among hemodialysis patients (2) in comparison to the concentration recorded in this patient (>100 μg/mL) (1). Additionally, the cerebrospinal concentration (10.2 μg/mL) of ceftriaxone in this encephalopathic patient was higher in comparison to meningitis patients (median 3.52 μg/mL), whose blood-brain barrier might be more permeable, allowing medicines to penetrate more easily from blood into the cerebrospinal fluid (3).…”

Review: Other Helicobacter species

“…The infecting strain showed resistance to macrolides and quinolones which represent the first-line antibiotic therapy for Campylobacter-like infections. 22 In the latter case, high plasma and cerebrospinal fluid ceftriaxone concentrations induced an encephalopathy in the hemodialysis patient. 13 21 Other reported cases include a secondary infection following a vascular access device placement, 13 chemotherapy (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone), 10 or cephalosporin treatment (ceftriaxone).…”

“…21 Other reported cases include a secondary infection following a vascular access device placement, 13 chemotherapy (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone), 10 or cephalosporin treatment (ceftriaxone). 22 In the latter case, high plasma and cerebrospinal fluid ceftriaxone concentrations induced an encephalopathy in the hemodialysis patient. 22 Anti-cancer chemotherapy and systemic steroids have been shown to be independent risk factors for recurrent H. cinaedi-induced bacteremia; however, evidence would suggest that selective digestive decontamination with kanamycin could potentially be a strategy to prevent recurrence of infectious bacteremia.…”

“…22 In the latter case, high plasma and cerebrospinal fluid ceftriaxone concentrations induced an encephalopathy in the hemodialysis patient. 22 Anti-cancer chemotherapy and systemic steroids have been shown to be independent risk factors for recurrent H. cinaedi-induced bacteremia; however, evidence would suggest that selective digestive decontamination with kanamycin could potentially be a strategy to prevent recurrence of infectious bacteremia. 23 H. cinaedi is difficult to identify at the species level.…”

“…9 New cases of Helicobacter cinaedi-related bacteremia have been reported in immunocompromised patients, patients with rheumatoid arthritis and malignant lymphoma, 10 a prosthetic joint infection in an HIV-infected man, 11 X-linked agammaglobulinemia, 12 and acute gastroenteritis. 22 Anti-cancer chemotherapy and systemic steroids have been shown to be independent risk factors for recurrent H. cinaedi-induced bacteremia; however, evidence would suggest that selective digestive decontamination with kanamycin could potentially be a strategy to prevent recurrence of infectious bacteremia. 22 In the latter case, high plasma and cerebrospinal fluid ceftriaxone concentrations induced an encephalopathy in the hemodialysis patient.…”