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Zarauskas A, Rodrigues B, Alvarez V. Ceftriaxone-induced encephalopathy in a patient with a normal renal function. BMJ Case Rep 2024; 17:e256934. [PMID: 38216159 PMCID: PMC10806959 DOI: 10.1136/bcr-2023-256934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2024] Open
Abstract
Ceftriaxone-induced encephalopathy is an exceptionally rare adverse effect of this commonly used cephalosporin and is generally observed in patients undergoing haemodialysis or suffering from severe renal failure. We present a case of a fit woman in her mid-80s with a normal renal function who developed severe fluctuating neurological symptoms (aphasia, loss of contact, chorea-like tongue movements) while being treated with ceftriaxone for a urinary tract infection with bacteraemia. The symptoms began on day 4 of treatment and an adverse drug reaction was suspected on day 7, after exhaustive investigations failed to reveal another cause. A complete recovery was observed 3 days after discontinuing ceftriaxone. Our case highlights the need to consider the diagnosis of ceftriaxone encephalopathy, even if the traditional risk factors are lacking. In this article, we also provide a brief overview of the pathophysiology as well as a literature review concerning the subject.
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Affiliation(s)
- Audrius Zarauskas
- Internal Medicine, Hopital de Sion Centre Hospitalier du Valais Romand, Sion, Switzerland
| | - Bruno Rodrigues
- Internal Medicine, Hopital de Sion Centre Hospitalier du Valais Romand, Sion, Switzerland
| | - Vincent Alvarez
- Neurology, Hôpital de Sion Centre Hospitalier du Valais Romand, Sion, Switzerland
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Ajibola O, Aremu TO, Dada SO, Ajibola O, Adeyinka KO, Ajibola A, Oluwole OE. The Trend of Cefepime-Induced Neurotoxicity: A Systematic Review. Cureus 2023; 15:e40980. [PMID: 37503476 PMCID: PMC10370502 DOI: 10.7759/cureus.40980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
There has been increased use of cefepime due to concerns about the nephrotoxic effects of the combined use of vancomycin and Zosyn. However, cefepime is associated with neurotoxicity. We conducted a systematic review using online data to explore the trend of cefepime-induced neurotoxicity over the last 10 years. Forty-six articles met our inclusion criteria, including 73 cases of cefepime-induced neurotoxicity. We noticed a steady increase in the reports of cefepime-induced neurotoxicity, from one case in 2013 to 11 cases in 2022. Individuals aged 65 and older accounted for most cefepime-induced neurotoxicity cases (52%). The top three indications for cefepime administration included bone and joint infections (25%), urinary tract infections (22.7%), and pneumonia (22.7%). Most patients with renal impairment have never had a renal adjustment of their cefepime dosage (either 2 g 12 hours a day or 2 g eight hours a day). Most cases of cefepime-induced neurotoxicity occurred between days two and five (n=29, 71%), while most resolution occurred between days one and five (n=29, 85%). While cefepime continues to be a popularly used and effective antibiotic against gram-negative bacteria like Pseudomonas aeruginosa, its dosage needs to be adjusted in patients with renal impairment to avoid neurotoxicity.
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Affiliation(s)
- Oluwafemi Ajibola
- Pulmonary and Critical Care Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Taiwo O Aremu
- Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, USA
- Pediatrics, University of Minnesota School of Medicine, Minneapolis, USA
- Pharmaceutical Care & Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, USA
| | - Stephen O Dada
- Medicine, Windsor University School of Medicine, Cayon, KNA
| | - Olawale Ajibola
- Medicine, American University of St. Vincent School of Medicine, Leeward Hwy, VCT
| | | | | | - Oluwatosin E Oluwole
- Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, USA
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Legg A, Carmichael S, Chai MG, Roberts JA, Cotta MO. Beta-Lactam Dose Optimisation in the Intensive Care Unit: Targets, Therapeutic Drug Monitoring and Toxicity. Antibiotics (Basel) 2023; 12:antibiotics12050870. [PMID: 37237773 DOI: 10.3390/antibiotics12050870] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/31/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023] Open
Abstract
Beta-lactams are an important family of antibiotics used to treat infections and are commonly used in critically ill patients. Optimal use of these drugs in the intensive care unit (ICU) is important because of the serious complications from sepsis. Target beta-lactam antibiotic exposures may be chosen using fundamental principles of beta-lactam activity derived from pre-clinical and clinical studies, although the debate regarding optimal beta-lactam exposure targets is ongoing. Attainment of target exposures in the ICU requires overcoming significant pharmacokinetic (PK) and pharmacodynamic (PD) challenges. For beta-lactam drugs, the use of therapeutic drug monitoring (TDM) to confirm if the desired exposure targets are achieved has shown promise, but further data are required to determine if improvement in infection-related outcomes can be achieved. Additionally, beta-lactam TDM may be useful where a relationship exists between supratherapeutic antibiotic exposure and drug adverse effects. An ideal beta-lactam TDM service should endeavor to efficiently sample and report results in identified at-risk patients in a timely manner. Consensus beta-lactam PK/PD targets associated with optimal patient outcomes are lacking and should be a focus for future research.
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Affiliation(s)
- Amy Legg
- Menzies School of Health Research, Tiwi, Darwin, NT 0810, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, QLD 4029, Australia
| | - Sinead Carmichael
- Royal Brisbane and Women's Hospital, Departments of Intensive Care Medicine and Pharmacy, Brisbane, QLD 4029, Australia
| | - Ming G Chai
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
| | - Jason A Roberts
- Herston Infectious Diseases Institute, Herston, Brisbane, QLD 4029, Australia
- Royal Brisbane and Women's Hospital, Departments of Intensive Care Medicine and Pharmacy, Brisbane, QLD 4029, Australia
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, 30029 Nîmes, France
| | - Menino O Cotta
- Faculty of Medicine, University of Queensland Centre for Clinical Research (UQCCR), Brisbane, QLD 4029, Australia
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Bussaka S, Suehiro T, Mitsuiki K, Morioka T, Shono T, Fujiki F, Nakano T. Non-convulsive status epilepticus possibly induced by a rapid correction of severe hyperkalemia: a case report and literature review. BMC Nephrol 2023; 24:93. [PMID: 37038101 PMCID: PMC10084670 DOI: 10.1186/s12882-023-03141-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 03/24/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease frequently develop neurological complications including confusion and altered consciousness. Non-convulsive status epilepticus, which is characterized by a change in behavior and/or mental process accompanied by epileptiform discharges on electroencephalogram in the absence of convulsive seizures, is one of the overlooked causes of altered consciousness. The incidence and precise pathophysiological mechanism of non-convulsive status epilepticus in patients with kidney disease, and especially in patients with electrolyte disturbances, remains unknown. We recently treated an older patient with chronic kidney disease and severe hyperkalemia in whom non-convulsive status epilepticus developed following a correction of severe hyperkalemia. CASE PRESENTATION An 82-year-old male was admitted to our hospital at midnight because of weakness of all four limbs (Day 1). He underwent urgent hemodialysis for severe hyperkalemia (9.84 mEq/L) and his serum potassium concentration decreased to 4.97 mEq/L. He regained full consciousness and his limb weakness improved on the morning of Day 2, but he became confused in the evening. Electroencephalogram revealed repeated low-voltage ictal discharges in the right occipital region and a diagnosis of non-convulsive status epilepticus was made. Following medication with fosphenytoin and phenytoin, the patient became fully alert and orientated on Day 8. CONCLUSION We speculate that a rapid correction of hyperkalemia was the possible cause of non-convulsive status epilepticus development. To our knowledge, this is the first report of non-convulsive status epilepticus from a potassium abnormality. We described a case of this condition in detail and summarized 78 previous case reports of non-convulsive status epilepticus with kidney disease or electrolyte disturbances.
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Affiliation(s)
- Saki Bussaka
- Department of Nephrology, Harasanshin Hospital, 1-8, Taihakumachi, Hakata-Ku, Fukuoka, Fukuoka, 812-0033, Japan
| | - Takaichi Suehiro
- Department of Nephrology, Harasanshin Hospital, 1-8, Taihakumachi, Hakata-Ku, Fukuoka, Fukuoka, 812-0033, Japan.
| | - Koji Mitsuiki
- Department of Nephrology, Harasanshin Hospital, 1-8, Taihakumachi, Hakata-Ku, Fukuoka, Fukuoka, 812-0033, Japan
| | - Takato Morioka
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Japan
| | - Fujio Fujiki
- Department of Neurology, Harasanshin Hospital, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Maan G, Keitoku K, Kimura N, Sawada H, Pham A, Yeo J, Hagiya H, Nishimura Y. Cefepime-induced neurotoxicity: systematic review. J Antimicrob Chemother 2022; 77:2908-2921. [PMID: 35971666 DOI: 10.1093/jac/dkac271] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/24/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cefepime-induced neurotoxicity (CIN) has been well acknowledged among clinicians, although there are no clear diagnostic criteria or specific laboratory testing to help with its diagnosis. We aimed to summarize the existing evidence regarding CIN and provide future agendas for research. METHODS Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and Embase for all peer-reviewed articles using keywords including 'cefepime', 'neurotoxicity', 'encephalopathy' and 'seizure', from their inception to 20 January 2022. RESULTS We included 92 articles, including 23 observational studies and 69 cases from case reports and case series, in the systematic review. Among 119 patients with CIN, 23.5% were in the ICU at the time of diagnosis and nearly 90% of the cases showed renal dysfunction.Cefepime overdoses were described in 41%. The median latency period of developing CIN from cefepime initiation was 4 days, and about 12% developed CIN during empirical treatment. CIN patients commonly manifested altered mental status (93%), myoclonus (37%) and non-convulsive seizure epilepticus (28%). A serum cefepime trough level of >20 mg/L would put patients at risk for CIN. CIN-related symptoms were ameliorated in 97.5% by dose reduction or discontinuation of cefepime, with median time to improvement of 3 days. No CIN-associated deaths were reported. CONCLUSIONS This systematic review summarizes the current evidence and characteristics of CIN. In the current situation where there are no CIN diagnostic criteria and the drug monitoring platform is not routinely available, candidates for cefepime should be carefully selected. Also, based on these findings, it needs to be appropriately dosed to avoid the development of CIN.
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Affiliation(s)
- Gozun Maan
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Koichi Keitoku
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Nobuhiko Kimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Haruki Sawada
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Andrew Pham
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Jihun Yeo
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
| | - Hideharu Hagiya
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Yoshito Nishimura
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI 96813, USA
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama 700-8558, Japan
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Haddad NA, Schreier DJ, Fugate JE, Gajic O, Hocker SE, Ice CJ, Leung SB, Mara KC, Rabinstein AA, Rule AD, Barreto EF. Incidence and Predictive Factors Associated with Beta-Lactam Neurotoxicity in the Critically Ill: A Retrospective Cohort Study. Neurocrit Care 2022; 37:73-80. [PMID: 35137352 PMCID: PMC9288522 DOI: 10.1007/s12028-022-01442-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/04/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Beta-lactam neurotoxicity is a relatively uncommon yet clinically significant adverse effect in critically ill patients. This study sought to define the incidence of neurotoxicity, derive a prediction model for beta-lactam neurotoxicity, and then validate the model in an independent cohort of critically ill adults. METHODS This retrospective cohort study evaluated critically ill patients treated with ≥ 48 h of cefepime, piperacillin/tazobactam, or meropenem. Two separate cohorts were created: a derivation cohort and a validation cohort. Patients were screened for beta-lactam neurotoxicity by using search terms and diagnosis codes, followed by clinical adjudication using a standardized adverse event scoring tool. Multivariable regression models and least absolute shrinkage and selection operator were used to identify surrogates for neurotoxicity and develop a multivariable prediction model. RESULTS The overall incidence of beta-lactam neurotoxicity was 2.6% (n/N = 34/1323) in the derivation cohort and 2.1% in the validation cohort (n/N = 16/767). The final multivariable neurotoxicity assessment tool included weight, Charlson comorbidity score, age, and estimated creatinine clearance as predictors of neurotoxicity. Incidence of neurotoxicity reached 4% in those with a body mass index more than 30 kg/m2. Use of the candidate variables in the neurotoxicity assessment tool suggested that a score more than 35 would identify a patient at high risk for neurotoxicity with 75% sensitivity and 54% specificity. CONCLUSIONS In this single center cohort of critically ill patients, beta-lactam neurotoxicity was demonstrated less frequently than previously reported. We identified obesity as a novel risk factor for the development of neurotoxicity. The prediction model needs to be further refined before it can be used in clinical practice as a tool to avoid drug-related harm.
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Affiliation(s)
- Natalie A Haddad
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Diana J Schreier
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | | | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara E Hocker
- Division of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Calvin J Ice
- Department of Pharmacy, Spectrum Health, Grand Rapids, MI, USA
| | - Sarah B Leung
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA
| | - Kristin C Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | - Andrew D Rule
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
- Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, 200 1st St SW, Rochester, MN, 55902, USA.
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Shahbazi F, Shojaei L, Farvadi F, Kadivarian S. Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities. Expert Rev Clin Pharmacol 2022; 15:563-573. [PMID: 35734938 DOI: 10.1080/17512433.2022.2093716] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics. AREAS COVERED In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units. EXPERT OPINION Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.
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Affiliation(s)
- Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Fakhrossadat Farvadi
- Center for nanotechnology in drug delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sara Kadivarian
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Fernández-Torre JL, Kaplan PW. Atypical or Typical Triphasic Waves-Is There a Difference? A Review. J Clin Neurophysiol 2021; 38:384-398. [PMID: 34155183 DOI: 10.1097/wnp.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY The entity of triphasic waves (TWs) and TW encephalopathy has derived from the subjective art of EEG interpretation. Indeed, there are few if any guidelines regarding many different aspects of TWs. The authors seek to shed light on the nature and the diagnostic characteristics of various types of TWs, differentiating "typical" from "atypical" forms. The authors conclude that morphologies in the form of bursts of well-formed, smoothly contoured, negative-positive-negative, bilateral, symmetrical and synchronous, regular, reactive, periodic or rhythmic, 1.5 to 2.0 Hz, fronto-central, triphasic complexes with fronto-occipital lag meet the criteria for typical TWs and are highly suggestive of toxic-metabolic encephalopathies. These are most frequently hepatic, uremic, or sepsis-associated encephalopathies with multi-organ failure. In such cases, atypical TWs (frontopolar or parieto-occipital maximum, negative-positive or negative-positive-negative, asymmetric and asynchronous, unreactive, irregular, multifocal, continuous with spatiotemporal evolution, sharper and without fronto-occipital/occipito-frontal lag, or triphasic delta waves) are rarely seen. Atypical TWs are encountered in Angelman syndrome, toxic encephalopathies, hyperthyroidism/hypothyroidism, Hashimoto encephalopathy, nonconvulsive status epilepticus, dementia, sepsis-associated encephalopathy, cerebrovascular disorders, and certain boundary syndromes. Investigations describing TWs with uncommon etiologies revealed few with typical TWs, suggesting that the term "TWs" has been overused in the past. Triphasic waves arise from the interaction of multiple factors including toxic, metabolic, infectious, and structural disorders that affect circuits between thalamus and cortex. The patient's metabolic status, presence of potentially neurotoxic drugs, cerebral atrophy, white matter disease, dementia, or seizures help differentiate typical from typical TWs. Future studies will determine whether this dichotomy is heuristically and clinically helpful.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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Kaplan PW, Gélisse P, Sutter R. An EEG Voyage in Search of Triphasic Waves-The Sirens and Corsairs on the Encephalopathy/EEG Horizon: A Survey of Triphasic Waves. J Clin Neurophysiol 2021; 38:348-358. [PMID: 34155177 DOI: 10.1097/wnp.0000000000000725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
SUMMARY Generalized periodic discharges with triphasic wave (TW) morphology, long referred to as TWs, are typical of many toxic, metabolic, infectious, and cerebral structural problems, often in concert. Identifying TWs has been challenging for the electroencephalographer and clinician, as has been their cause, significance, prognosis, and treatment. This review highlights the many different patterns of TWs with commentary on their various causes and etiologies, characteristics, different morbidities, differentiation from nonconvulsive status epilepticus, and their prognosis. The articles in this Journal of Clinical Neurophysiology special issue on TWs will review the many challenges the clinician face when TWs are sighted.
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Affiliation(s)
- Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
| | - Philippe Gélisse
- Department of Neurology, Epilepsy Unit Montpellier, Montpellier, France
| | - Raoul Sutter
- Intensive Care Units and Department of Neurology, University Hospital Basel, Basel, Switzerland; and
- University of Basel, Basel, Switzerland
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10
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Fernández-Torre JL, Kaplan PW. Triphasic Waves: Historical Overview of an Unresolved Mystery. J Clin Neurophysiol 2021; 38:399-409. [PMID: 34155180 DOI: 10.1097/wnp.0000000000000809] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SUMMARY Triphasic waves are a fascinating and mysterious EEG feature. We now have to accept that, at times, epileptiform discharges may have a blunted "triphasic morphology," and that there may be great difficulty in distinguishing between these often similar forms. The aim of this review was to describe the evolution in our understanding of triphasic waves that has occurred regarding the pathophysiology of triphasic waves, their most frequent causes, and the diagnostic difficulties involved in interpretation and differentiation from nonconvulsive status epilepticus.
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Affiliation(s)
- José L Fernández-Torre
- Clinical Neurophysiology Department, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
- Biomedical Research Institute (IDIVAL), Santander, Cantabria, Spain; and
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, U.S.A
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Liu M, Sang Y, Zhang J, Li J, Yu W, Zhang F, Wang X. Development of a Broad-Specific Competitive ELISA for First-Generation Cephalosporin Antibiotics in Animal-Derived Foods Samples. BULLETIN OF ENVIRONMENTAL CONTAMINATION AND TOXICOLOGY 2021; 107:215-220. [PMID: 32472212 DOI: 10.1007/s00128-020-02885-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 05/19/2020] [Indexed: 06/11/2023]
Abstract
The abuse of antibiotics, such as the cephalosporins in livestock and aquaculture productions, usually causes the widespread antibiotic resistance due to their growth-promoting effects. In this study, cephalexin was chosen as the hapten molecule to prepare a broad-spectrum rabbit polyclonal antibody for cephalosporin antibiotics. The obtained antibody exhibited broad cross-reactivity ranging from 0.05% to 100% with 10 cephalosporins. Based on this antibody, we developed a broad-specific indirect competitive ELISA (ic-ELISA) for cefalexin, cefradine, cefadroxil and cefazolin with the half maximal inhibitory concentration (IC50) ranging from 0.72 to 2.99 ng/mL in working buffer. For animal-derived food samples with spiked cephalosporins, the ic-ELISA exhibited an excellent recovery ranging from 72.3% to 95.6%. To verify the accuracy of this proposed ic-ELISA, its detection performance was evaluated utilizing the high-performance liquid chromatography with satisfactory results. This study confirmed that: firstly, the prepared antibody can be used as a class-specific recognition element to develop immunoassays for cephalosporin antibiotics; and secondly, the developed ic-ELISA provided a new tool for broad-spectrum detection of first-generation cephalosporins in animal-derived foods.
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Affiliation(s)
- Minxuan Liu
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Yaxin Sang
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Jing Zhang
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Jian Li
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Wenlong Yu
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Fuyuan Zhang
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China
| | - Xianghong Wang
- College of Food Science and Technology, Hebei Agricultural University, Baoding, 071001, China.
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Lacroix C, Bera-Jonville AP, Montastruc F, Velly L, Micallef J, Guilhaumou R. Serious Neurological Adverse Events of Ceftriaxone. Antibiotics (Basel) 2021; 10:540. [PMID: 34066591 PMCID: PMC8148437 DOI: 10.3390/antibiotics10050540] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/28/2021] [Accepted: 05/04/2021] [Indexed: 11/21/2022] Open
Abstract
We described ceftriaxone-induced CNS adverse events through the largest case series of Adverse Drug Reactions (ADRs) reports, from 1995 to 2017, using the French Pharmacovigilance Database. In total, 152 cases of serious CNS ADRs were analyzed; 112 patients were hospitalized or had a prolonged hospitalization (73.7%), 12 dead (7.9%) and 16 exhibited life-threatening ADRs (10.5%). The median age was 74.5 years, mainly women (55.3%), with a median creatinine clearance of 35 mL/min. Patients mainly exhibited convulsions, status epilepticus, myoclonia (n = 75, 49.3%), encephalopathy (n = 45, 29.6%), confused state (n = 34, 22.4%) and hallucinations (n = 16, 10.5%). The median time of onset was 4 days, and the median duration was 4.5 days. The mean daily dose was 1.7 g mainly through an intravenous route (n = 106, 69.7%), and three patients received doses above maximal dose of Summary of Product Characteristics. Ceftriaxone plasma concentrations were recorded for 19 patients (12.5%), and 8 were above the toxicity threshold. Electroencephalograms (EEG) performed for 32.9% of the patients (n = 50) were abnormal for 74% (n = 37). We described the world's biggest case series of ceftriaxone-induced serious CNS ADRs. Explorations (plasma concentrations, EEG) are contributive to confirm the ceftriaxone toxicity-induced. Clinicians may be cautious with the use of ceftriaxone, especially in the older age or renal impairment population.
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Affiliation(s)
- Clémence Lacroix
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique, APHM, INSERM, Institut Neurosciences Système, UMR 1106, Aix Marseille Université, 13005 Marseille, France; (C.L.); (J.M.)
| | - Annie-Pierre Bera-Jonville
- Centre Régional de Pharmacovigilance et d’Information sur le Médicament Centre-Val-de-Loire, Service de Pharmacosurveillance, Centre Hospitalier Régional Universitaire de Tours, 37000 Tours, France;
| | - François Montastruc
- Service de Pharmacologie Médicale et Clinique, Centre de Pharmacovigilance, Pharmacoépidémiologie et d’Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, 31000 Toulouse, France;
- Unité Clinique de Pharmacologie Psychiatrique, Faculté de Médecine, Centre Hospitalier Universitaire, 31000 Toulouse, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille Université, 13005 Marseille, France;
- CNRS, INT, Institut Neurosci Timone, UMR 7289, Aix Marseille Université, 13005 Marseille, France
| | - Joëlle Micallef
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique, APHM, INSERM, Institut Neurosciences Système, UMR 1106, Aix Marseille Université, 13005 Marseille, France; (C.L.); (J.M.)
| | - Romain Guilhaumou
- Laboratoire de Pharmacologie Clinique, Service de Pharmacologie Clinique, APHM, INSERM, Institut Neurosciences Système, UMR 1106, Aix Marseille Université, 13005 Marseille, France
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Li HT, Lee CH, Wu T, Cheng MY, Tseng WEJ, Chang CW, Hsieh HY, Chiang HI, Lin CY, Chang BL, Lin WR, Lim SN. Clinical, Electroencephalographic Features and Prognostic Factors of Cefepime-Induced Neurotoxicity: A Retrospective Study. Neurocrit Care 2020; 31:329-337. [PMID: 30756319 DOI: 10.1007/s12028-019-00682-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The incidence of cefepime-induced neurotoxicity (CIN) has been previously underestimated, and there have only been sporadic reports from critical neurological settings. The present study aimed to investigate the potential factors associated with disease development, electroencephalography (EEG) sub-classification, and outcome measures. METHODS The 10-year medical records of patients who underwent EEG between 2007 and 2016 at a tertiary medical center in Taiwan, and developed encephalopathy after cefepime therapy were retrospectively reviewed. Age- and sex-matched controls were included for further analysis. Demographic data, the occurrence of clinical seizures, non-convulsive status epilepticus (NCSE), use of antiepileptic drugs (AEDs), receiving maintenance or urgent hemodialysis, EEG findings, and functional outcomes were analyzed. The Chi-square test and a logistic regression model were applied to survey significant prognostic factors relating to mortality. RESULTS A total of 42 CIN patients were identified, including 25 patients from wards and 17 from intensive care units; their mean age was 75.8 ± 11.8 years. Twenty-one patients (50%) had chronic kidney disease, and 18 (43%) had acute kidney injury. Among these patients, 32 (76%) received appropriate cefepime dose adjustment. Three patients had a normal renal function at the time of CIN onset. The logistic regression model suggested that maintenance hemodialysis and longer duration of cefepime use were independently associated with the development of CIN, with odds ratios of 3.8 and 1.2, respectively. NCSE was frequently noted in the CIN patients (64%). Generalized periodic discharge with or without triphasic morphology was the most common EEG pattern (38%), followed by generalized rhythmic delta activity and generalized spike-and-waves. AEDs were administered to 86% of the patients. A total of 17 patients (40%) did not survive to hospital discharge. Adequate cefepime dose adjustment and early cefepime discontinuation led to a better prognosis. CONCLUSIONS CIN was associated with high mortality and morbidity rates. Neurotoxic symptoms could still occur when the cefepime dose was adjusted, or in patients with normal renal function. Patients with maintenance hemodialysis or a longer duration of cefepime therapy tended to develop CIN. Early recognition of abnormal EEG findings allowed for the withdrawal of the offending agent, resulting in clinical improvements and a better prognosis at discharge.
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Affiliation(s)
- Han-Tao Li
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Hong Lee
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Tony Wu
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Mei-Yun Cheng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Wei-En Johnny Tseng
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chun-Wei Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Hsiang-Yao Hsieh
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Hsing-I Chiang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Chih-Yin Lin
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Bao-Luen Chang
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan
| | - Wey-Ran Lin
- Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, Taoyuan, 333, Taiwan
| | - Siew-Na Lim
- Section of Epilepsy, Department of Neurology, Chang Gung Memorial Hospital at Linkou Medical Center and Chang Gung University College of Medicine, 5 Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan.
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Kawano Y, Jordan O, Hanawa T, Borchard G, Patrulea V. Are Antimicrobial Peptide Dendrimers an Escape from ESKAPE? Adv Wound Care (New Rochelle) 2020; 9:378-395. [PMID: 32320368 PMCID: PMC7307686 DOI: 10.1089/wound.2019.1113] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/18/2020] [Indexed: 12/16/2022] Open
Abstract
Significance: The crisis of antimicrobial resistance (AMR) increases dramatically despite all efforts to use available antibiotics or last resort antimicrobial agents. The spread of the AMR, declared as one of the most important health-related issues, warrants the development of new antimicrobial strategies. Recent Advances: Antimicrobial peptides (AMPs) and AMP dendrimers (AMPDs), as well as polymer dendrimers are relatively new and promising strategies with the potential to overcome drug resistance issues arising in ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) colonizing chronic wounds. Critical Issues: AMPs-AMPDs suffer from limited efficacy, short-lasting bioactivity, and concerns of toxicity. To circumvent these drawbacks, their covalent coupling to biopolymers and/or encapsulation into different drug carrier systems is investigated, with a special focus on topical applications. Future Directions: Scientists and the pharmaceutical industry should focus on this challenging subject to either improve the activity of existing antimicrobial agents or find new drug candidates. The focus should be put on the discovery of new drugs or the combination of existing drugs for a better synergy, taking into account all kinds of wounds and existing pathogens, and more specifically on the development of next-generation antimicrobial peptides, encompassing the delivery carrier toward improved pharmacokinetics and efficacy.
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Affiliation(s)
- Yayoi Kawano
- Laboratory of Preformulation Study, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Olivier Jordan
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Takehisa Hanawa
- Laboratory of Preformulation Study, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Chiba, Japan
| | - Gerrit Borchard
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Viorica Patrulea
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
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16
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Stability of Ceftazidime Pentahydrate Investigated by Thermal Analysis Techniques. J Pharm Sci 2019; 109:1324-1329. [PMID: 31785240 DOI: 10.1016/j.xphs.2019.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/05/2019] [Accepted: 11/19/2019] [Indexed: 11/20/2022]
Abstract
Cephalosporins are among the most frequently used broad-spectrum antimicrobial agents. Ceftazidime is a semisynthetic β-lactam antibiotic for parenteral administration widely used in the clinical practice, which has been categorized as a third-generation cephalosporin antibiotic. This drug crystallizes as a pentahydrate and, as all cephalosporins, it is unstable and subject to hydrolytic degradation. Taking this into account, this study investigates the stability under 2 different conditions (high temperature and exposition to vacuum) by using various techniques, as thermal analysis, Raman spectroscopy, and X-ray powder diffraction supported by multivariate curve resolution. It was proved that ceftazidime pentahydrate is unstable under the studied variables, exhibiting several transformation processes, which were discussed in terms of the crystalline structure.
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Triplett JD, Lawn ND, Chan J, Dunne JW. Cephalosporin-related neurotoxicity: Metabolic encephalopathy or non-convulsive status epilepticus? J Clin Neurosci 2019; 67:163-166. [PMID: 31201049 DOI: 10.1016/j.jocn.2019.05.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 02/16/2019] [Accepted: 05/21/2019] [Indexed: 10/26/2022]
Abstract
Metabolic encephalopathy and Non-Convulsive Status Epilepticus (NCSE) have been reported with cephalosporin use, particularly cefepime. We aimed to analyze the clinical and EEG findings in patients with cephalosporin-related neurotoxicity (CRN) at our hospital identified via the hospital EEG database, and to critically review CRN case reports in the literature. A Medline search was performed to identify CRN cases where a representative sample of EEG was provided. EEGs were analyzed using published criteria differentiating NCSE from triphasic waves (TW). Eleven patients at our hospital were identified with CRN (9 cefepime, 2 ceftriaxone): all had an encephalopathy with decreased consciousness and/or confusion. One patient had clinical seizures and 6 had multifocal myoclonus. All patients had abnormal EEGs, all with moderate to severe generalized slowing and 10 also with TW. Recovery was related to cephalosporin withdrawal rather than antiepileptic therapy. Analysis of 37 EEG samples of CRN patients reported in the literature as NCSE (30) or TW (7) revealed that most did not meet criteria for NCSE, with 33 showing TW, 1 showing generalised epileptiform discharges and 3 being uninterpretable. CRN usually produces a toxic encephalopathy rather than NCSE, and is commonly associated with triphasic waves on EEG. In most patients anti-epileptic and/or sedative drugs do not hasten clinical improvement.
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Affiliation(s)
- James D Triplett
- Royal Perth Hospital, Department of Neurology, Perth, Western Australia, Australia.
| | - Nicholas D Lawn
- Royal Perth Hospital, Department of Neurology, Perth, Western Australia, Australia; Western Australian Adult Epilepsy Service, Perth, Western Australia, Australia
| | - Josephine Chan
- Western Australian Adult Epilepsy Service, Perth, Western Australia, Australia
| | - John W Dunne
- Royal Perth Hospital, Department of Neurology, Perth, Western Australia, Australia; Western Australian Adult Epilepsy Service, Perth, Western Australia, Australia; University of Western Australia, Faculty of Medicine, Perth, Western Australia, Australia
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Lacroix C, Kheloufi F, Montastruc F, Bennis Y, Pizzoglio V, Micallef J. Serious central nervous system side effects of cephalosporins: A national analysis of serious reports registered in the French Pharmacovigilance Database. J Neurol Sci 2019; 398:196-201. [PMID: 30683462 DOI: 10.1016/j.jns.2019.01.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/19/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Among antibiotics, Central Nervous System (CNS) adverse drug reactions (ADRs) are often under-suspected and overlooked. Cephalosporins are an important cause of drug-induced CNS ADRs but the characteristics of such ADR have not been fully explored. We aimed to characterize the profile of cephalosporins serious CNS ADRs. METHOD We performed an analysis of serious reports recorded in the French Pharmacovigilance database from 1987 to 2017. RESULTS A total of 511 serious ADRs reports was analyzed. Patients had a mean age of 67.1 years and were mainly men (52.5%), with a mean creatinine clearance of 32.9 ml/min. The most involved molecules were cefepime (33.1%), ceftriaxone (29.7%), ceftazidime (19.6%), cefotaxime (9%) and cefazoline (2.9%), mostly administered intravenously (87.3%). A CNS history was observed in 25% of the reports (n = 128). Patients exhibited encephalopathy (30.3%), confusional state (19.4%), convulsion (15.1%), myoclonia (9.4%), status epilepticus (9.2%), coma (6.3%) and hallucination (4.3%). The mean time of onset was 7.7 days and the mean duration was 6 days. Cephalosporin plasma levels were recorded for 153 patients (29.9%) and 107 were above the standards including 62 (57.9%) related to renal impairment. Electroencephalograms were performed in 38.2% (n = 195) of the patients and 81% (n = 158) were abnormal. CONCLUSION This study characterizes an off-target CNS ADRs of several cephalosporins. Ceftriaxone represented a large part of our reports after cefepime and it would be relevant to warn healthcare professionals. Investigations (EEG, though plasma levels and renal function) can be precious tools for clinicians to make a prompt diagnosis and improve patients' outcomes.
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Affiliation(s)
- C Lacroix
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique et Pharmacovigilance, APHM, INSERM, Inst Neurosci Syst, Aix Marseille Univ, Marseille, France
| | - F Kheloufi
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique et Pharmacovigilance, APHM, INSERM, Inst Neurosci Syst, Aix Marseille Univ, Marseille, France
| | - F Montastruc
- Centre Midi-Pyrénées de Pharmacovigilance, Pharmacoépidémiologie et d'Informations sur le Médicament, Centre Hospitalier Universitaire, Faculté de Médecine, Service de Pharmacologie Médicale et Clinique, Toulouse, France; Unité clinique de Pharmacologie psychiatrique, Faculté de Médecine, Centre Hospitalier Universitaire, Toulouse, France
| | - Y Bennis
- Centre Régional de Pharmacovigilance, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - V Pizzoglio
- Centre Régional de Pharmacovigilance, Hospices Civils de Lyon, Lyon, France
| | - J Micallef
- Centre Régional de Pharmacovigilance, Service de Pharmacologie Clinique et Pharmacovigilance, APHM, INSERM, Inst Neurosci Syst, Aix Marseille Univ, Marseille, France.
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Tchapyjnikov D, Luedke MW. Cefepime-Induced Encephalopathy and Nonconvulsive Status Epilepticus: Dispelling an Artificial Dichotomy. Neurohospitalist 2018; 9:100-104. [PMID: 30915188 DOI: 10.1177/1941874418803225] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cefepime is a fourth-generation cephalosporin antibiotic known to have neurotoxic side effects. Recent reports have described patients on cefepime presenting with altered mentation and concurrent triphasic wave discharges on electroencephalogram (EEG). Some have described this clinical presentation as cefepime-induced encephalopathy, while others have termed it as cefepime-induced nonconvulsive status epilepticus (NCSE). We report on 4 patients who developed cefepime-associated altered mentation with triphasic discharges on EEG. A benzodiazepine trial was attempted in 3 of the patients, all of whom had improvement in the frequency of the triphasic discharges, but only 2 of whom demonstrated a concurrent partial and transient improvement in mental status. All 4 patients had normalization of mental status upon discontinuation of cefepime. We provide a literature review of prior cases and propose that these reports, including those labeled as NCSE, are best described as a cefepime-induced encephalopathy with triphasic discharges as opposed to an ictal phenomenon. We contend that aggressive treatment with anti-seizure medications is not warranted and that cefepime discontinuation is the definitive treatment. This case series and review of the literature clarifies a long-standing terminological ambiguity in a unique clinical picture that can be encountered by the neurohospitalist or other providers.
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Affiliation(s)
- Dmitry Tchapyjnikov
- Division of Pediatric Neurology, Duke University Medical Center, Durham, NC, USA
| | - Matthew W Luedke
- Department of Neurology, Duke University Medical Center, Durham, NC, USA
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Ceftriaxone-Induced Non-Convulsive Status Epilepticus in an Elderly Patient with Renal Insufficiency. INT J GERONTOL 2018. [DOI: 10.1016/j.ijge.2018.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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