Introduction: We report a case of cefepime intoxication with acute
severe neurologic symptoms, which was treated by temporary hemodialysis.
Patients (or Materials) and Methods: Cefepime 2 g BID for endovascular
prosthesis infection was prescribed to a frail, chronically ill
88-year-old woman with a serum creatinine of 199 μmol/L and an
estimated creatinine clearance of 13 mL/min (Cockroft formula). Two
days later, she was transferred to a neurocritical care unit because
of acute aphasia, myoclonic jerks, and delirium with a Glasgow
coma scale score of 12/15. The following day, in the absence of
other causes, cefepime intoxication was hypothesized, and cefepime
was withdrawn after a total of 7 doses = 14 g. Over the next 24
hours, two 3-hour hemodialysis (HD) sessions were performed under
cefepime concentration monitoring.
Results: Cefepime plasma levels were measured by liquid chromatography/
mass spectrometry. There is no validated reference range,
but a study (Chapuis T et al, Critical Care, 2010) found a 50% risk
of neurotoxicity with residual levels > 15 mg/L. In our patient, levels
were 83.3 mg/L 10 hours after last dose, 24.1 mg/L immediately after
the first HD session, 13.4 mg/L immediately before the second HD
session, and 2.5 mg/L immediately after the second HD session. The
patient made a full clinical recovery over the next 48 hours. The 70%
to 80% fall in plasmatic levels observed during each HD session is
in accordance with literature data (Schmaldienst S et al, Eur J Clin
Pharmacol, 2000, and Manyor LM et al, Pharmacotherapy, 2008).
According to kinetic simulation, cefepime dropped at a concentration
< 15 mg/L 15 hours earlier with HD than it would have without.
Conclusion: Neuropsychiatric adverse effects of beta-lactam antibiotics
can be easily overlooked by clinicians. One should be especially
cautious with their use in very old and frail patients in whom plasma
creatinine poorly estimates renal function and cognitive impairment
is highly prevalent. Temporary hemodialysis effectively clears
cefepime, but its role in hastening clinical recovery may be limited.