Motivation: My favorite fourth generation cephalosporin is cefepime. Only a definite history of anaphylaxis to penicillins holds me back from prescribing cefepime. More recently, I have met a few patients with confusion allegedly caused by cefepime. Amazingly, stopping the cefepime improved the encephalopathy.
So, what is wrong with my favorite cephalosporin? The literature on cefepime neurotoxicity is evolving and is still at the case report level. Reviewed here is a case report and literature summary.
Paper: McNally, A., Pithie, A., and Jardine, D. "Cefepime: a rare cause of encephalopathy." Internal Medicine Journal (2012); 42 (6): 732-3.
Method: Case report and review of published literature.
Result:
Case report: A 70 year old woman after eleven days of cefepime for Pseudomonas osteomyelitis developed myoclonus and stupor. Concurrently, patient also suffered from hepatic cirrhosis and acute on chronic renal failure. For presumed drug toxicity, cefepime and all psychotropic drugs in patient's regimen (including morphine, gabapentin, oxazepam) were stopped. Over three days, encephalopathy and myoclonus resolved. Patient was re-challenged with cefepime at renal-adjusted dose. Encephalopathy and myoclonus recurred in the next two days despite now resolved renal failure and normal ammonia. Cefepime was stopped, and patient's encephalopathy cleared.
Literature Review: Eetrospective review of 42 cases showed that encephalopathy consisted of temporospatial disorientation (96%), myoclonus (33%), and seizures (13%). The clearest association of cefepime toxicity exists with renal impairment though cefepime toxicity has also been described in patients with normal renal function. The reported latency of symptoms from cefepime initiation is 1-10 days. After stopping cefepime, symptoms regress over 2-7 days.
Discussion:
While the case for cefepime toxicity in this case report is weakened by concurrent hepatic and renal failure, the history of encephalopathy linked temporally with cefepime initiation along with improved mental clarity with cefepime cessation makes a good causal argument for cefepime causing encephalopathy. There do not appear to be symptoms characteristic of cefepime neurotoxicity though seizures and myoclonus are frequent occurrences. Without a larger case series, it is hard to attribute causality to cefepime. On the other hand, if a patient with renal failure on cefepime develops confusion, I would recommend cefepime cessation (despite my personal attachment to the drug).
So, what is wrong with my favorite cephalosporin? The literature on cefepime neurotoxicity is evolving and is still at the case report level. Reviewed here is a case report and literature summary.
Paper: McNally, A., Pithie, A., and Jardine, D. "Cefepime: a rare cause of encephalopathy." Internal Medicine Journal (2012); 42 (6): 732-3.
Method: Case report and review of published literature.
Result:
Case report: A 70 year old woman after eleven days of cefepime for Pseudomonas osteomyelitis developed myoclonus and stupor. Concurrently, patient also suffered from hepatic cirrhosis and acute on chronic renal failure. For presumed drug toxicity, cefepime and all psychotropic drugs in patient's regimen (including morphine, gabapentin, oxazepam) were stopped. Over three days, encephalopathy and myoclonus resolved. Patient was re-challenged with cefepime at renal-adjusted dose. Encephalopathy and myoclonus recurred in the next two days despite now resolved renal failure and normal ammonia. Cefepime was stopped, and patient's encephalopathy cleared.
Literature Review: Eetrospective review of 42 cases showed that encephalopathy consisted of temporospatial disorientation (96%), myoclonus (33%), and seizures (13%). The clearest association of cefepime toxicity exists with renal impairment though cefepime toxicity has also been described in patients with normal renal function. The reported latency of symptoms from cefepime initiation is 1-10 days. After stopping cefepime, symptoms regress over 2-7 days.
Discussion:
While the case for cefepime toxicity in this case report is weakened by concurrent hepatic and renal failure, the history of encephalopathy linked temporally with cefepime initiation along with improved mental clarity with cefepime cessation makes a good causal argument for cefepime causing encephalopathy. There do not appear to be symptoms characteristic of cefepime neurotoxicity though seizures and myoclonus are frequent occurrences. Without a larger case series, it is hard to attribute causality to cefepime. On the other hand, if a patient with renal failure on cefepime develops confusion, I would recommend cefepime cessation (despite my personal attachment to the drug).
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ReplyDeleteAs an EEG'er I have personally seen 4 cases of EEG abnormality (triphasic complexes) associated with cefepime. 2 of these patients had myoclonus.
ReplyDelete