Case Presentation: We present a 65-year-old, woman who had developed pseudomonas bacteremia after a complicated femoral artery thrombosis s/p transcatheter repair of the mitral valve. The patient was discharged home on a 6-week course of IV cefepime for concerns of possible mitral valve endocarditis. Within 2 weeks of discharge, the patient had been brought back to the hospital by her family, with concerns of altered mentation and decreased PO intake. In the emergency department, the patient had noted to have a creatinine: 5.77 (baseline of 0.76), Urea: 94. She was noted to have transient slurring of speech, with speech arrest and what appeared to be tonic-clonic movements on the right. CT angiography of the Head and Neck: No acute intracranial pathology. EEG: generalized slowing with unclear left-sided epileptiform discharges. Concern for complex partial seizures where had. Nephrology and Neurology were consulted. The patient was given 1g of levetiracetam by neurology and sent for emergent hemodialysis. After dialysis, no other epileptiform activity was noted, with the eventual improvement of her encephalopathy.
Discussion: Cefepime, a 4th generation cephalosporin often used for its ability to cover gram-positives, gram negatives, anaerobic bacteria and most importantly pseudomonas. Prior to initiation of cefepime, the medication is dosed based on the renal function to avoid a multitude of its toxicity profiles. There have been reported severe neurological reactions including encephalopathy, aphasia, myoclonus, seizures, and nonconvulsive status epilepticus, whereby these risks are increased in the presence of renal impairment. In the setting of outpatient IV cefepime infusions regular and frequent monitoring of renal function is completed to avoid its toxicities. In the rare event of toxicity, immediate treatment is discontinuation of the offending agent and initiation of emergent hemodialysis.
Conclusions: With the increasing prevalence of hospital-acquired infections and the abundant use of cefepime. It is essential for physicians to recognize cefepime’s neurotoxic potential, since early and appropriate intervention is imperative for survival.