New Onset Non-Convulsive Status Epilepticus Despite Cefepime Renal Dose Adjustment

Abstract

Cefepime, a widely used fourth-generation cephalosporin for coverage of both gram-positive and gram-negative bacteria, has been reported to have associated neurological adverse effects. These effects have been seen mostly in patients mostly with impaired renal function, and currently, dosing is based on creatinine clearance to reduce its toxic effect profile. Despite renal dose adjustment, we present a case of a 40-year-old woman who was managed for Escherichia coli bacteremia, acute kidney injury, and hemorrhagic shock. About 96 hours after cefepime therapy was commenced, she was noted to be twitching with passive movement of her upper limb and myoclonus of the facial muscles. Her workup including computed tomography (CT) scan of the head and magnetic resonance imaging (MRI) brain were negative. Electroencephalograph (EEG) showed 2 Hertz sharply contoured triphasic form rhythmic waves suggestive of nonconvulsive status epilepticus (NCSE). She received antiseizure medications and later had hemodialysis for effective clearance of cefepime. She had significant improvement in her neurological status following hemodialysis and a repeat EEG showed no further seizure activity. Clinicians should be aware of the risk of NCSE in patients on cefepime despite renal dose adjustment. Once identified, immediate discontinuation of the offending drug, treatment with benzodiazepines, and clearance of the medication with hemodialysis is recommended.

Cefepime-induced neurotoxicity in non-critically ill medical patients: a retrospective cohort study

“…Patients with acute kidney injury and chronic kidney disease were at higher risk [29]. Several studies correlating neurotoxicity with cefepime were mainly in the patients with certain degree of impaired kidney function [30][31][32][33][34][35][36][37], however neurotoxicity was also reported in patients of normal kidney function [38,39].…”

Cefepime Induced Neurotoxicity Following A Regimen Dose-Adjusted for Renal Function: Case Report and Review of the Literature

“…The onset of neurotoxic effects generally appears at a median of 4 days after the initiation of cefepime, but can occur as early as 1 day following cefepime use. 5,25 The most common presentation is altered mental status with reduced consciousness, but patients may progress to myoclonus or seizures if appropriate interventions are not made. After drug discontinuation, improvement or resolution of symptoms occurs at a median of 2 days.…”

Delayed Diagnosis of an Invisible Seizure: Cefepime-Induced Non-convulsive Status Epilepticus

“…For this reason, it is commonly used in many clinical settings. However, its use has been associated with neurologic side effects, including acute encephalopathy, myoclonus, and NCSE [4][5][6][7]. To avoid this adverse effect, the Food and Drugs Authority (FDA) advised healthcare practitioners, in a communique released in 2012, to renally dose cefepime [8].…”