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Althubyani AA, Canto S, Pham H, Holger DJ, Rey J. Antibiotic-induced neuropsychiatric toxicity: epidemiology, mechanisms and management strategies - a narrative literature review. Drugs Context 2024; 13:2024-3-3. [PMID: 39072301 PMCID: PMC11281100 DOI: 10.7573/dic.2024-3-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024] Open
Abstract
Antibiotics are amongst the most prescribed medications globally in both inpatient and outpatient settings. Antibiotic-induced neuropsychiatric toxicity is relatively uncommon; yet, when it occurs, it can lead to severe morbidity ranging from dizziness and confusion to seizure and psychosis. However, the actual incidence rate of these adverse events may be higher due to underdiagnosis or misdiagnosis as they are commonly confused with clinical manifestations of different neuropsychiatric conditions. The incidence and mechanism of antibiotic-induced neuropsychiatric toxicity vary between different antibiotic classes and clinical presentation (i.e. neurotoxicity versus psychiatric toxicity). However, the exact mechanism by which antibiotics can cause neuropsychiatric toxicity remains unclear. This article reviews the epidemiology of antibiotic-induced neuropsychiatric toxicity, explores potential mechanisms of this adverse event, investigates variations in frequency and clinical presentations between different antibiotic classes causing neuropsychiatric toxicity, and discusses management strategies.
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Affiliation(s)
- Ali A Althubyani
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Saudi Arabia
| | - Samantha Canto
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Services, South Florida State Hospital, Pembroke Pines, Florida, USA
| | - Huy Pham
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Dana J Holger
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jose Rey
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Services, South Florida State Hospital, Pembroke Pines, Florida, USA
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2
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Vanneste D, Gijsen M, Maertens J, Van Paesschen W, Debaveye Y, Wauters J, Spriet I. Ceftazidime-related neurotoxicity in a patient with renal impairment: a case report and literature review. Infection 2024; 52:1113-1123. [PMID: 38305827 DOI: 10.1007/s15010-023-02167-9] [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] [Received: 10/31/2023] [Accepted: 12/22/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE We present the case of a 67-year-old woman with severely reduced renal clearance suffering from ceftazidime-induced encephalopathy. Subsequently, we search the literature to review and describe the neurotoxicity of ceftazidime. METHODS A search string was developed to search PubMed for relevant cases from which relevant information was extracted. Using the collected data a ROC analysis was performed in R to determine a neurotoxicity threshold. RESULTS Our patient suffered from progressive loss of consciousness and myoclonic seizures, with improvements noted a few days after discontinuation of treatment. The dose was not appropriately reduced to take into account her reduced renal function. The highest ceftazidime concentration recorded was 234.9 mg/mL. Using the Naranjo score we found a probable relationship between our patient's encephalopathy and ceftazidime administration. In the literature we found a total of 32 similar cases, most of which also had some form of renal impairment. Using our collected data and ceftazidime concentrations provided in the literature, a ROC analysis provided a neurotoxicity threshold of 78 mg/L for ceftazidime neurotoxicity. CONCLUSION Ceftazidime-related neurotoxicity is a known issue, especially in patients with severe renal impairment. Yet no concrete toxicity threshold has been reported so far. We propose the first toxicity threshold for ceftazidime of 78 mg/L. Future prospective studies are needed to validate and optimize the neurotoxicity threshold as upper limit for ceftazidime therapeutic drug monitoring.
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Affiliation(s)
- Dorian Vanneste
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Louvain, Belgium.
| | - Matthias Gijsen
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Louvain, Belgium
- Pharmacy Department, UZ Leuven, 3000, Louvain, Belgium
| | - Johan Maertens
- Haematology Unit, UZ Leuven, 3000, Louvain, Belgium
- Laboratory for Clinical Microbiology, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Louvain, Belgium
| | - Wim Van Paesschen
- Neurology Department, UZ Leuven, 3000, Louvain, Belgium
- Laboratory for Epilepsy Research, Department of Neurosciences, KU Leuven, 3000, Louvain, Belgium
| | - Yves Debaveye
- Intensive Care Unit, UZ Leuven, 3000, Louvain, Belgium
- Laboratory for Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000, Louvain, Belgium
| | - Joost Wauters
- Medical Intensive Care Unit, UZ Leuven, 3000, Louvain, Belgium
- Laboratory for Clinical Infectious and Inflammatory Diseases, Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Louvain, Belgium
| | - Isabel Spriet
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Louvain, Belgium
- Pharmacy Department, UZ Leuven, 3000, Louvain, Belgium
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3
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Lacroix C, Pietri T, Montero V, Soeiro T, Rouby F, Blin O, Guilhaumou R, Micallef J. Antibiotic-induced neurological adverse drug reactions. Therapie 2024; 79:181-188. [PMID: 37957055 DOI: 10.1016/j.therap.2023.09.008] [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] [Received: 07/11/2023] [Accepted: 09/18/2023] [Indexed: 11/15/2023]
Abstract
Antibiotics are drugs widely used all around the world. Central nervous system adverse drug reactions (CNS ADRs) are mostly under-suspected with antibiotics. Nevertheless, these ADRs could lead to severe complications such as encephalopathy. To illustrate the clinical patterns of these off-target ADRs, we here present data from pharmacovigilance system, through different populations and points of view (worldwide, French population, vulnerable population and individual). These data could help clinicians to better know about CNS ADRs with antibiotics, to better identify risk factors and vulnerable patients and to highlight the importance to set up the right diagnostic explorations in the best timing to avoid complications. Clinicians should request a pharmacological opinion from pharmacologist (biologists and pharmacovigilance clinicians) in front of vulnerable population before or during antibiotics. Pharmacovigilance advice could help clinicians in the diagnosis and the management of an ADR. Therapeutic drug monitoring is particularly contributive to adjust doses of antibiotics administered in vulnerable patients. Pharmacovigilance advice and TDM are essential to perform personalized medicine, and contribute to the proper use of drugs.
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Affiliation(s)
- Clémence Lacroix
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France.
| | - Tessa Pietri
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Vincent Montero
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Thomas Soeiro
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Frank Rouby
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Olivier Blin
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Romain Guilhaumou
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
| | - Joëlle Micallef
- Aix Marseille Univ, APHM, INSERM, Inst Neurosci Syst, UMR 1106, University Hospital Federation DHUNE, service de pharmacologie clinique et pharmacosurveillance (CEIP-Addictovigilance PACA-Corse ; centre régional de pharmacovigilance Marseille Provence Corse ; Laboratoire de Pharmacologie Biologique ; Pharmacoépidémiologie), 13009 Marseille, France
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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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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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6
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Toda M, Yoshifuji A, Hosoya K, Taguchi K, Komatsu M, Kobayashi E, Fujii K, Kato A, Hasegawa N, Matsumoto K, Ryuzaki M. Ceftazidime encephalopathy developed without the elevation of cerebrospinal fluid concentration of ceftazidime: A case report of two cases. J Infect Chemother 2022; 28:1667-1671. [PMID: 36028210 DOI: 10.1016/j.jiac.2022.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/30/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Ceftazidime encephalopathy is reported to be caused by the repeated administration of ceftazidime in patients with renal impairment because of the high serum concentration of ceftazidime. Ceftazidime encephalopathy has been considered to be caused by the elevation of the cerebrospinal fluid (CSF) concentration. However, as no reports have measured CSF concentrations, the relationship with ceftazidime encephalopathy and CSF concentration has not been clarified. CASE PRESENTATION Case 1: An 80-year-old Japanese man under a combination therapy with peritoneal dialysis and hemodialysis, who had been treated for a cellulitis with ceftazidime, developed altered consciousness and was diagnosed as ceftazidime encephalopathy. His serum concentration of ceftazidime was elevated, but CSF concentration was only under 0.1 μg/mL. Case 2: An 88-year-old Japanese man with chronic kidney disease, who had been treated for a urinary tract infection with ceftazidime, developed altered consciousness and was diagnosed as ceftazidime encephalopathy. His serum concentration of ceftazidime was elevated, but CSF concentration was within the therapeutic range. However, his serum and CSF concentration of quinolinic acid was markedly increased. CONCLUSIONS Patients with renal failure are more likely to develop ceftazidime encephalopathy. We need to pay attention to the dosage of ceftazidime and to the appearance of neurological symptoms. Ceftazidime encephalopathy was considered to be caused by the high CSF concentration, but it could be caused by quinolinic acid as neurotoxic substance.
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Affiliation(s)
- Masataro Toda
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Ayumi Yoshifuji
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan.
| | - Koji Hosoya
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kazuaki Taguchi
- Division of Practical Pharmacy, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Motoaki Komatsu
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Emi Kobayashi
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kentaro Fujii
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Ai Kato
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Naoki Hasegawa
- Department of Infectious Disease, Keio University School of Medicine, Tokyo, Japan
| | - Kazuaki Matsumoto
- Division of Practical Pharmacy, Keio University Faculty of Pharmacy, Tokyo, Japan
| | - Munekazu Ryuzaki
- Division of Nephrology, Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan
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7
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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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Abstract
SUMMARY Generalized periodic patterns with triphasic wave morphology, long referred to as triphasic waves [TWs], had been associated with metabolic encephalopathies, although other neurologic and systemic causes have since been identified. In a recent classification of periodic patterns, TWs were formally grouped with the generalized periodic discharges, which are often associated with ictal activity. The interpretation of generalized periodic patterns with TWs as nonictal can have significant implications in the management of comatose patients in nonconvulsive status epilepticus. Electrographic characteristics that help distinguish nonictal periodic patterns with TWs from generalized periodic discharge ictal patterns include (1) TWs in long runs of periodic bilaterally synchronous and symmetric discharges, maximal in frontocentral or posterior head regions with and without a frontal-to-occipital lag or posterior-to-anterior lag, respectively; (2) recurrent spontaneous and/or low-dose benzodiazepine-induced attenuation and/or suppression of the periodic pattern and replacement with a diffuse slow wave activity throughout a prolonged EEG recording; and (3) stimulation-induced activation and/or increase in frequency and/or organization of TWs. We coined the term of status triphasicus to describe the electrographic periodic pattern of TWs with these three distinct characteristics. In this article, we discuss the advantages and limitations of keeping the status triphasicus pattern as a distinct electrographic entity different from periodic ictal generalized periodic discharge patterns. We discuss the circumstances in which a status triphasicus pattern can be associated with ictal activity and propose a simple pragmatic classification of status triphasicus that encompasses the different clinical scenarios it can be associated with.
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Affiliation(s)
- Manuel M Bicchi
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, U.S.A.; and
- Neurology Services, University of Miami Hospital and Clinics and Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Ayham Alkhachroum
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, U.S.A.; and
- Neurology Services, University of Miami Hospital and Clinics and Jackson Memorial Hospital, Miami, Florida, U.S.A
| | - Andres M Kanner
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Florida, U.S.A.; and
- Neurology Services, University of Miami Hospital and Clinics and Jackson Memorial Hospital, Miami, Florida, U.S.A
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9
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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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10
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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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11
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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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Possible Neurological Toxicity of Ceftazidime/Avibactam in Acute Kidney Injury. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2021. [DOI: 10.1097/ipc.0000000000000986] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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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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Suzuki S, Naito S, Uchida S. Author's Reply: Why Did the Patient Not Show Any Neurological Symptoms on the Day of the Higher Serum Concentration of Ceftriaxone? Intern Med 2019; 58:3617. [PMID: 31366808 PMCID: PMC6949443 DOI: 10.2169/internalmedicine.3454-19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Soichiro Suzuki
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Shotaro Naito
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Shinichi Uchida
- Department of Nephrology, Tokyo Medical and Dental University, Japan
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Waddy SP, Ward JB, Becerra AZ, Powers T, Fwu CW, Williams KL, Eggers PW, Abbott KC, Kimmel PL. Epilepsy and antiseizure medications increase all-cause mortality in dialysis patients in the United States. Kidney Int 2019; 96:1176-1184. [DOI: 10.1016/j.kint.2019.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/04/2019] [Accepted: 04/25/2019] [Indexed: 11/25/2022]
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Wong G, Briscoe S, McWhinney B, Ally M, Ungerer J, Lipman J, Roberts JA. Therapeutic drug monitoring of β-lactam antibiotics in the critically ill: direct measurement of unbound drug concentrations to achieve appropriate drug exposures. J Antimicrob Chemother 2019; 73:3087-3094. [PMID: 30137377 DOI: 10.1093/jac/dky314] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/10/2018] [Indexed: 01/30/2023] Open
Abstract
Objectives To describe the achievement of unbound β-lactam antibiotic concentration targets in a therapeutic drug monitoring (TDM) programme in critically ill patients, and the factors associated with failure to achieve a target concentration. Patients and methods Plasma samples and clinical data were obtained for analysis from a single centre prospectively. Unbound concentrations of ceftriaxone, cefazolin, meropenem, ampicillin, benzylpenicillin, flucloxacillin and piperacillin were directly measured using ultracentrifugation. Factors associated with the achievement of pharmacokinetic/pharmacodynamic (PK/PD) targets or negative clinical outcomes were evaluated with binomial logistic regression. Results TDM data from 330 patients, and 369 infection episodes, were included. The range of doses administered was 99.4% ± 45.1% relative to a standard daily dose. Dose increases were indicated in 33.1% and 63.4% of cases to achieve PK/PD targets of 100% fT>MIC and 100% fT>4×MIC, respectively. Dose reduction was indicated in 17.3% of cases for an upper PK/PD threshold of 100% fT>10×MIC. Higher protein bound β-lactams (ceftriaxone and benzylpenicillin) had better therapeutic target attainment (P < 0.01), but were prone to excessive dosing. Augmented renal clearance (calculated CLCR >130 mL/min) increased the odds of failure to achieve 100% fT>MIC and 100% fT>4×MIC (OR 2.47 and 3.05, respectively; P < 0.01). Conclusions Measuring unbound concentrations of β-lactams as part of a routine TDM programme is feasible and demonstrates that a large number of critically ill patients do not achieve predefined PK/PD targets. The clinical significance of this finding is unknown due to the lack of correlation between PK/PD findings and clinical outcomes.
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Affiliation(s)
- Gloria Wong
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Scott Briscoe
- Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Brett McWhinney
- Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Mumtaz Ally
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Jacobus Ungerer
- Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Jeffrey Lipman
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Queensland, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Queensland, Australia
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Skaistys A, Rätz Bravo AE, Leuppi-Taegtmeyer A, Zysset Y. [Fatal Outcome of Agranulocytosis after Re-Exposure to Metamizole and Cefepime-Induced Encephalopathy]. PRAXIS 2019; 108:693-697. [PMID: 31387493 DOI: 10.1024/1661-8157/a003275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Fatal Outcome of Agranulocytosis after Re-Exposure to Metamizole and Cefepime-Induced Encephalopathy Abstract. We present the case of an 83-year-old female patient who died as a result of likely drug-induced complications, namely agranulocytosis caused by metamizole and cefepime-induced encephalopathy. Agranulocytosis precipitated a cascade of events that eventually led to death. As prescription of metamizole has increased over the past decades, it is important to keep in mind its serious adverse drug reactions. Metamizole must be stopped immediately at the onset of symptoms such as fever, mucositis and sore throat, and re-exposure in patients who have previously developed leukopenia under metamizole must be avoided. This can be achieved by meticulous documentation in the medical records and the use of an emergency or allergy alert card which the patient carries at all times. When using cefepime, renal function should be closely monitored, especially in multimorbid geriatric patients, and the dose should be adjusted accordingly.
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Affiliation(s)
- Ana Skaistys
- 1 Universitäre Altersmedizin FELIX PLATTER, Basel
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Boschung-Pasquier L, Atkinson A, Kastner LK, Banholzer S, Haschke M, Buetti N, Furrer DI, Hauser C, Jent P, Que YA, Furrer H, Babouee Flury B. Cefepime neurotoxicity: thresholds and risk factors. A retrospective cohort study. Clin Microbiol Infect 2019; 26:333-339. [PMID: 31284030 DOI: 10.1016/j.cmi.2019.06.028] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/27/2019] [Accepted: 06/19/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Toxic serum cefepime trough concentrations are not well defined in the current literature. We aimed to define a more precise plasma trough concentration threshold for this antibiotic's neurological toxicity and to identify individuals at risk for developing neurotoxic side effects. METHODS Retrospective study including all individuals who underwent cefepime therapeutic drug monitoring (TDM) between 2013 and 2017. Individuals with cefepime concentrations other than trough were excluded. The primary outcome was to assess the incidence of neurotoxicity and its relationship with cefepime plasma trough concentrations. Secondary outcomes were the relationship of renal function, cefepime daily dose, age, and cerebral and general co-morbidities with the occurrence of neurotoxicity. We also compared the mortality rate during hospitalization in individuals with and without neurotoxicity, and the possible impact of neuroprotective co-medications on outcomes. RESULTS Cefepime concentrations were determined in 584 individuals. Among 319 individuals with available trough concentrations included, the overall incidence of neurotoxicity was 23.2% (74 of 319 individuals). Higher cefepime plasma trough concentrations were significantly associated with risk of neurotoxicity (no neurotoxicity 6.3 mg/L (interquartile range (IQR) 4.1-8.6) versus with neurotoxicity 21.6 mg/L (IQR 17.0-28.6), p <0.001). Individuals with presumed cefepime neurotoxicity had a significantly lower renal function (estimated glomerular filtration rate 82.0 mL/min/1.73 m2 (IQR 45.0-105.0) versus 35.0 mL/min/1.73 m2 (IQR 23.3-53.3], p <0.001), and significantly higher in-hospital mortality (19 (7.8%) versus 26 (35.1%) individuals, p <0.001). No neurotoxic side effects were seen below a trough concentration of 7.7 mg/L. Levels ≥38.1 mg/L always led to neurological side effects. CONCLUSION In individuals with risk factors for cefepime neurotoxicity, such as renal insufficiency, TDM should be systematically performed, aiming at trough concentrations <7.5 mg/L.
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Affiliation(s)
- L Boschung-Pasquier
- Faculty of Medicine, University of Bern, Bern, Switzerland; Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland; Department of Geriatrics and Rehabilitation, Hôpital Fribourgeois Tavel, Tavel, Switzerland
| | - A Atkinson
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - L K Kastner
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Banholzer
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - M Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - N Buetti
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland; UMR 1137 - IAME Team 5 - DeSCID: Decision SCiences in Infectious Diseases, Control and Care Inserm/University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - D I Furrer
- Insel Data Science Center and Insel Data Coordination Lab, Directorate of Teaching and Research, Bern University Hospital, University of Bern, Bern, Switzerland
| | - C Hauser
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - P Jent
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Y A Que
- Department of Intensive Care Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - H Furrer
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - B Babouee Flury
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland.
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Suzuki S, Naito S, Numasawa Y, Asada M, Shoji N, Zeniya M, Takahashi D, Sato H, Iimori S, Nomura N, Sohara E, Okado T, Ishiwata Y, Nagata M, Rai T, Yokota T, Uchida S. Encephalopathy Induced by High Plasma and Cerebrospinal Fluid Ceftriaxone Concentrations in a Hemodialysis Patient. Intern Med 2019; 58:1775-1779. [PMID: 30799339 PMCID: PMC6630125 DOI: 10.2169/internalmedicine.1785-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Encephalopathy is a rare side effect of cephalosporin treatment. We herein present a case of encephalopathy induced by ceftriaxone, a third-generation cephalosporin, in a patient with renal failure. An 86-year-old woman on maintenance hemodialysis received ceftriaxone for Helicobacter cinaedi bacteremia. Her mental status deteriorated during antibiotic treatment, and an electroencephalogram revealed triphasic waves predominantly in the frontal area. Her consciousness improved after the discontinuation of the antibiotic due to the suspicion of ceftriaxone-induced encephalopathy. This is the first reported case of encephalopathy associated with high plasma and cerebrospinal fluid ceftriaxone concentrations, and provides significant evidence for a causal relationship between the administration of ceftriaxone and the onset of encephalopathy.
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Affiliation(s)
- Soichiro Suzuki
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Shotaro Naito
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Yoshiyuki Numasawa
- Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Japan
| | - Mizuho Asada
- Department of Pharmacy, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Norikazu Shoji
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Moko Zeniya
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Daiei Takahashi
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Hidehiko Sato
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Soichiro Iimori
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Naohiro Nomura
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Eisei Sohara
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Tomokazu Okado
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Yasuyoshi Ishiwata
- Department of Pharmacy, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Masashi Nagata
- Department of Pharmacy, Medical Hospital, Tokyo Medical and Dental University, Japan
| | - Tatemitsu Rai
- Department of Nephrology, Tokyo Medical and Dental University, Japan
| | - Takanori Yokota
- Department of Neurology and Neurological Science, Tokyo Medical and Dental University, Japan
| | - Shinichi Uchida
- Department of Nephrology, Tokyo Medical and Dental University, Japan
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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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Zhang P, Lu K, Xia H. Multiple Factors Including Infections and Antibiotics Affecting New‐Onset Epilepsy in Hemodialysis Patients. Ther Apher Dial 2019; 23:404-408. [PMID: 30673174 DOI: 10.1111/1744-9987.12793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Peipei Zhang
- Department of Nephrologythe First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou China
| | - Keda Lu
- Department of Nephrologythe First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou China
| | - Hong Xia
- Department of Nephrologythe First Affiliated Hospital of Zhejiang Chinese Medical University Hangzhou China
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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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Tamune H, Hamamoto Y, Aso N, Yamamoto N. Cefepime-induced encephalopathy: Neural mass modeling of triphasic wave-like generalized periodic discharges with a high negative component (Tri-HNC). Psychiatry Clin Neurosci 2019; 73:34-42. [PMID: 30375126 PMCID: PMC7379539 DOI: 10.1111/pcn.12795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 01/08/2023]
Abstract
AIM Cefepime, a fourth-generation cephalosporin, acts as a GABAA receptor antagonist. Cefepime-induced encephalopathy (CIE) is frequently overlooked. We aimed to clarify the clinical features, characteristic electroencephalography (EEG), and mechanisms of CIE to aid in its early recognition. METHODS CIE cases documented by a single-center consultation-liaison team between April 2015 and March 2017 were retrospectively reviewed. For further investigation, neural mass modeling was performed in silico. RESULTS Three patients with CIE refused medication/examination and showed overt pain, palilalia, and much greater deterioration of eye and verbal response than the motor response, which was possibly related to GABAergic dysfunction. Triphasic wave-like generalized periodic discharges with a high negative component (Tri-HNC) were identified on the EEG of all three cases. The simulation reproduced the characteristic feature of 2-3 Hz Tri-HNC and recovery course on EEG, and a possible involvement of individual differences in pharmacological intervention. It also suggested that auto-inhibition (synaptic inputs from interneuron to interneuron) dysregulation contributed to generating Tri-HNC in CIE. CONCLUSION As CIE is iatrogenic and continues unless cefepime is stopped, early recognition is crucial. Physicians should be vigilant about altered mental status, pain, and verbal changes in patients taking cefepime. Tri-HNC on EEG can expedite the diagnosis of CIE, and the association between Tri-HNC and CIE suggests that an excitatory and inhibitory imbalance due to the dysfunction of GABAergic interneurons is the underlying mechanism. This modeling may offer a new method of investigating disorders related to GABAergic dysfunction.
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Affiliation(s)
- Hidetaka Tamune
- Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.,Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Cellular Neurobiology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yu Hamamoto
- Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.,Department of Neuropsychiatry, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naofumi Aso
- Department of Earth and Planetary Science, Graduate School of Science, The University of Tokyo, Tokyo, Japan.,School of Science, Tokyo Institute of Technology, Tokyo, Japan
| | - Naoki Yamamoto
- Department of Neuropsychiatry, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Deshayes S, Coquerel A, Verdon R. Neurological Adverse Effects Attributable to β-Lactam Antibiotics: A Literature Review. Drug Saf 2018; 40:1171-1198. [PMID: 28755095 DOI: 10.1007/s40264-017-0578-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
β-lactam antibiotics are commonly prescribed antibiotic drugs. To describe the clinical characteristics, risk markers and outcomes of β-lactam antibiotic-induced neurological adverse effects, we performed a general literature review to provide updated clinical data about the most used β-lactam antibiotics. For selected drugs in each class available in France (ticarcillin, piperacillin, temocillin, ceftazidime, cefepime, cefpirome, ceftaroline, ceftobiprole, ceftolozane, ertapenem and aztreonam), a systematic literature review was performed up to April 2016 via an electronic search on PubMed. Articles that reported original data, written in French, Spanish, Portuguese or English, with available individual data for patients with neurological symptoms (such as seizure, disturbed vigilance, confusional state, myoclonia, localising signs, and/or hallucinations) after the introduction of a β-lactam antibiotic were included. The neurological adverse effects of piperacillin and ertapenem are often described as seizures and hallucinations (>50 and 25% of cases, respectively). Antibiotic treatment is often adapted to renal function (>70%), and underlying brain abnormalities are seen in one in four to one in three cases. By contrast, the neurological adverse drug reactions of ceftazidime and cefepime often include abnormal movements but few hallucinations and seizures. These reactions are associated with renal insufficiency (>80%) and doses are rarely adapted to renal function. Otherwise, it appears that monobactams do not have serious neurological adverse drug reactions and that valproic acid and carbapenem combinations should be avoided. The onset of disturbed vigilance, myoclonus, and/or seizure in a patient taking β-lactam antibiotics, especially if associated with renal insufficiency or underlying brain abnormalities, should lead physicians to suspect adverse drug reactions and to consider changes in antibacterial therapy.
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Affiliation(s)
- Samuel Deshayes
- Department of Internal Medicine, CHU de Caen, 14000, Caen, France. .,Department of Infectious Diseases, CHU de Caen, Université de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France.
| | - Antoine Coquerel
- Department of Pharmacology, CHU de Caen, Regional Pharmacovigilance Center, 14000, Caen, France.,University of Caen-Normandy, INSERM Unit 1075, 14000, Caen, France
| | - Renaud Verdon
- Groupe de Recherche sur l'Adaptation Microbienne (GRAM 2.0), Normandie Université, UNICAEN, UNIROUEN, GRAM, 14000, Caen, France. .,Department of Infectious Diseases, CHU de Caen, Université de Caen-Normandie, Avenue de la Côte de Nacre, 14000, Caen, France.
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26
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27
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Ong CY, Qin Y. Myoclonus from Antibiotic Therapy (Ceftazidime-induced Neurotoxicity): A Case Report and Review. Cureus 2018; 10:e2250. [PMID: 29721398 PMCID: PMC5929940 DOI: 10.7759/cureus.2250] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 78-year-old Chinese man with a history of end-stage renal disease (ESRD) presented with fever of one-day duration. He was treated for catheter-related sepsis with intravenous piperacillin and tazobactam, which was later switched to vancomycin and ceftazidime secondary to persistent fever with negative cultures. On the fifth day of treatment with vancomycin and ceftazidime, he developed new-onset upper limb myoclonus which progressed to bilateral upper limb ataxia. A provisional diagnosis of myoclonus and ataxia secondary to neurotoxicity related to ceftazidime was made and the ceftazidime was ceased. His symptoms resolved over three days and he returned to his baseline neurological status by day 5 following cessation.
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Affiliation(s)
- Chong Yau Ong
- Family Medicine, Sengkang General Hospital, Sengkang Health, Singhealth, Singapore
| | - Yan Qin
- Department of Internal Medicine, Singapore General Hospital
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28
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Hagiya H, Miyawaki K, Yamamoto N, Yoshida H, Kitagawa A, Asaoka T, Eguchi H, Akeda Y, Tomono K. Ceftriaxone-induced Neurotoxicity in a Patient after Pancreas-Kidney Transplantation. Intern Med 2017; 56:3103-3107. [PMID: 28943562 PMCID: PMC5725869 DOI: 10.2169/internalmedicine.8774-16] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Ceftriaxone is a widely used third-generation cephalosporin showing advantageous pharmacokinetic properties and a broad antimicrobial spectrum. We herein report a case of ceftriaxone-induced neurotoxicity in a 56-year-old man on hemodialysis. Seven days after initiating high-dose ceftriaxone, the patient developed impaired consciousness along with facial myoclonus and sporadic phonation. The symptoms clearly disappeared shortly after withdrawal of the drug. Ceftriaxone is considered a safe antibiotic for patients with renal insufficiency, since it is excreted via both haptic and renal pathways. Physicians should note that antibiotic-associated encephalopathy may develop in patients administered ceftriaxone, especially in those complicated with renal dysfunction.
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Affiliation(s)
- Hideharu Hagiya
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Japan
| | - Koji Miyawaki
- Department of Pharmacy, Osaka University Hospital, Japan
| | - Norihisa Yamamoto
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Japan
| | - Hisao Yoshida
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Japan
| | - Akihiro Kitagawa
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Japan
| | - Tadafumi Asaoka
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Japan
| | - Yukihiro Akeda
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Japan
| | - Kazunori Tomono
- Department of Infection Control and Prevention, Osaka University Graduate School of Medicine, Japan
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Payne LE, Gagnon DJ, Riker RR, Seder DB, Glisic EK, Morris JG, Fraser GL. Cefepime-induced neurotoxicity: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:276. [PMID: 29137682 PMCID: PMC5686900 DOI: 10.1186/s13054-017-1856-1] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/05/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cefepime is a widely used antibiotic with neurotoxicity attributed to its ability to cross the blood-brain barrier and exhibit concentration-dependent ϒ-aminobutyric acid (GABA) antagonism. Neurotoxic symptoms include depressed consciousness, encephalopathy, aphasia, myoclonus, seizures, and coma. Data suggest that up to 15% of ICU patients treated with cefepime may experience these adverse effects. Risk factors include renal dysfunction, excessive dosing, preexisting brain injury, and elevated serum cefepime concentrations. We aimed to characterize the clinical course of cefepime neurotoxicity and response to interventions. METHODS A librarian-assisted search identified publications describing cefepime-associated neurotoxicity from January 1980 to February 2016 using the CINAHL and MEDLINE databases. Search terms included cefepime, neurotoxicity, encephalopathy, seizures, delirium, coma, non-convulsive status epilepticus, myoclonus, confusion, aphasia, agitation, and death. Two reviewers independently assessed identified articles for eligibility and used the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) for data reporting. RESULTS Of the 123 citations identified, 37 (representing 135 patient cases) were included. Patients had a median age of 69 years, commonly had renal dysfunction (80%) and required intensive care (81% of patients with a reported location). All patients exhibited altered mental status, with reduced consciousness (47%), myoclonus (42%), and confusion (42%) being the most common symptoms. All 98 patients (73% of cohort) with electroencephalography had abnormalities, including non-convulsive status epilepticus (25%), myoclonic status epilepticus (7%), triphasic waves (40%), and focal sharp waves (39%). As per Food and Drug Administration (FDA)-approved dosing guidance, 48% of patients were overdosed; however, 26% experienced neurotoxicity despite appropriate dosing. Median cefepime serum and cerebrospinal fluid (CSF) concentrations were 45 mg/L (n = 21) and 13 mg/L (n = 4), respectively. Symptom improvement occurred in 89% of patients, and 87% survived to hospital discharge. The median delay from starting the drug to symptom onset was 4 days, and resolution occurred a median of 2 days after the intervention, which included cefepime discontinuation, antiepileptic administration, or hemodialysis. CONCLUSIONS Cefepime-induced neurotoxicity is challenging to recognize in the critically ill due to widely varying symptoms that are common in ICU patients. This adverse reaction can occur despite appropriate dosing, usually resolves with drug interruption, but may require additional interventions such as antiepileptic drug administration or dialysis.
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Affiliation(s)
- Lauren E Payne
- University of New England College of Pharmacy, 716 Stevens Ave, Portland, ME, 04102, USA.
| | - David J Gagnon
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Richard R Riker
- Department of Critical Care, Maine Medical Center, 22 Bramhall St., Portland, ME, 04102, USA
| | - David B Seder
- Department of Critical Care, Maine Medical Center, 22 Bramhall St., Portland, ME, 04102, USA
| | - Elizabeth K Glisic
- Department of Pharmacy, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
| | - Jane G Morris
- Maine Medical Partners Neurology, 49 Spring St, Scarborough, ME, 04074, USA
| | - Gilles L Fraser
- Department of Pharmacy and Critical Care, Maine Medical Center, 22 Bramhall St, Portland, ME, 04102, USA
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Abstract
Patients with chronic kidney disease (CKD) are at risk for complications both inherent to the disease and as a consequence of its treatment. The dangers that CKD patients face change across the spectrum of the disease. Providers who are well-versed in these safety threats are best poised to safeguard patients as their CKD progresses.
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Affiliation(s)
- Lee-Ann Wagner
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Jeffrey C Fink
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD.
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31
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Inoue Y, Doi Y, Arisato T, Sugioka S, Koga K, Nishioka K, Sugawara A. Three Cases of Hemodialysis Patients Receiving High-Dose Ceftriaxone: Serum Concentrations and Its Neurotoxicity. Kidney Int Rep 2017; 2:984-987. [PMID: 29270508 PMCID: PMC5733829 DOI: 10.1016/j.ekir.2017.03.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Yui Inoue
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Tetsuya Arisato
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Sayaka Sugioka
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Kenichi Koga
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Keisuke Nishioka
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
| | - Akira Sugawara
- Department of Nephrology, Osaka Red Cross Hospital, Osaka, Japan
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32
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Prognosis of neurologic complications in critical illness. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190446 DOI: 10.1016/b978-0-444-63599-0.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.
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33
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Cefepime-induced encephalopathy in end-stage renal disease patients. J Neurol Sci 2017; 376:123-128. [PMID: 28431597 DOI: 10.1016/j.jns.2017.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/03/2017] [Accepted: 03/14/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Impaired renal function is a risk factor for cefepime (CFPM)-induced encephalopathy (CFPMIE) in patients treated with CFPM; dose-titration to renal function is recommended to prevent CFPMIE. However, available evidence on the incidence of CFPMIE or preventive efficacy of dose adjustment against CFPMIE in end-stage renal disease (ESRD) patients is limited. METHODS Single-centre, retrospective observational study. We reviewed consecutive in-hospital adult patients treated with adjusted-dose of CFPM in the period between September 2012 and September 2016, and assessed the CFPMIE in ESRD patients treated with adjusted-dose of CFPM. RESULTS Out of 422 eligible patients, 6 patients (1.4%) were diagnosed with CFPMIE. The incidence of CFPMIE in ESRD patients was 7.5% (5/67). Among ESRD patients, pre-existing central nervous system (CNS) morbidity was significantly associated with the risk of CFPMIE. CFPMIE occurred in ESRD patients regardless of daily dose, and even with 0.5g/day of CFPM. CONCLUSIONS Pre-existing CNS morbidity may be associated with an increased risk of CFPMIE in ESRD patients. No significant association was observed between CFPM dose and incidence of CFPMIE in ESRD patients, and future investigation on the safer dose-adjustment strategy in ESRD patients is required for achieving balance between successful infectious treatment and reducing CFPMIE.
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O'Rourke D, Chen PM, Gaspard N, Foreman B, McClain L, Karakis I, Mahulikar A, Westover MB. Response Rates to Anticonvulsant Trials in Patients with Triphasic-Wave EEG Patterns of Uncertain Significance. Neurocrit Care 2017; 24:233-9. [PMID: 26013921 DOI: 10.1007/s12028-015-0151-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Generalized triphasic waves (TPWs) occur in both metabolic encephalopathies and non-convulsive status epilepticus (NCSE). Empiric trials of benzodiazepines (BZDs) or non-sedating AED (NSAEDs) are commonly used to differentiate the two, but the utility of such trials is debated. The goal of this study was to assess response rates of such trials and investigate whether metabolic profile differences affect the likelihood of a response. METHODS Three institutions within the Critical Care EEG Monitoring Research Consortium retrospectively identified patients with unexplained encephalopathy and TPWs who had undergone a trial of BZD and/or NSAEDs to differentiate between ictal and non-ictal patterns. We assessed responder rates and compared metabolic profiles of responders and non-responders. Response was defined as resolution of the EEG pattern and either unequivocal improvement in encephalopathy or appearance of previously absent normal EEG patterns, and further categorized as immediate (within <2 h of trial initiation) or delayed (>2 h from trial initiation). RESULTS We identified 64 patients with TPWs who had an empiric trial of BZD and/or NSAED. Most patients (71.9%) were admitted with metabolic derangements and/or infection. Positive clinical responses occurred in 10/53 (18.9%) treated with BZDs. Responses to NSAEDs occurred in 19/45 (42.2%), being immediate in 6.7%, delayed but definite in 20.0%, and delayed but equivocal in 15.6%. Overall, 22/64 (34.4%) showed a definite response to either BZDs or NSAEDs, and 7/64 (10.9%) showed a possible response. Metabolic differences of responders versus non-responders were statistically insignificant, except that the 48-h low value of albumin in the BZD responder group was lower than in the non-responder group. CONCLUSIONS Similar metabolic profiles in patients with encephalopathy and TPWs between responders and non-responders to anticonvulsants suggest that predicting responders a priori is difficult. The high responder rate suggests that empiric trials of anticonvulsants indeed provide useful clinical information. The more than twofold higher response rate to NSAEDs suggests that this strategy may be preferable to BZDs. Further prospective investigation is warranted.
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Affiliation(s)
- Deirdre O'Rourke
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Patrick M Chen
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Nicolas Gaspard
- Hôpital Erasme - ULB, Cliniques universitaires de Bruxelles, Brussels, Belgium.,Neurology Department, Yale Comprehensive Epilepsy Center, New Haven, CT, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Lauren McClain
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Advait Mahulikar
- Department of Neurology, Wayne State University, Detroit, MI, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, WACC 735, Boston, MA, 02114, USA.
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Park HM, Noh Y, Yang JW, Shin DH, Lee YB. Cefepime-Induced Non-Convulsive Status Epilepticus in a Patient with Normal Renal Function. J Epilepsy Res 2016; 6:97-99. [PMID: 28101482 PMCID: PMC5206107 DOI: 10.14581/jer.16018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/06/2016] [Indexed: 11/17/2022] Open
Abstract
Cefepime-induced encephalopathy including nonconvulsive status epilepticus has been known to develop in the patients with renal impairment. However, we report a 74-year-old woman with normal renal function who developed stuporous mental status during cefepime administration. Electroencephalogram (EEG) revealed 2 Hz rhythmic sharp-and-waves continuously, which suggested nonconvulsive status epilepticus (NCSE). After cefepime discontinuation, clinical symptoms recovered gradually and EEG findings showed only background slowing without epileptiform discharges. Cefepime-induced NCSE could be developed even in the patients with normal renal function, when they are elderly. Therefore, clinicians should be aware of the possibility of cefepime-induced NCSE when prescribing cefepime even to the patients with normal renal function.
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Affiliation(s)
- Hyeon-Mi Park
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Young Noh
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Ji Won Yang
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Dong Hoon Shin
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
| | - Yeong-Bae Lee
- Department of Neurology, Gachon University Gil Medical Center, Incheon, Korea
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Toda Y, Yamazaki M, Ota T, Fujisawa Y, Kimura K. A case of Cefepime encephalopathy, being difficult to distinguish from non-convulsive status epilepticus during the treatment of bacterial meningitis. Rinsho Shinkeigaku 2016; 56:678-683. [PMID: 27680224 DOI: 10.5692/clinicalneurol.cn-000898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 64-year-old man with fever, appetite loss, and pain in the back of the neck visited our hospital. We diagnosed him as having bacterial meningitis because of pleocytosis of the cerebrospinal fluid, and started treatment with antibiotics. Multiple cerebral infarcts were found on brain MRI. We suspected that the origin of the bacterial meningitis was infective endocarditis, and administered Cefepime and Gentamicin according to the guidelines for treatment of infective endocarditis. Three days later, he became drowsy and had myoclonus and flapping of the extremities. An electroencephalograph showed generalized periodic discharge and a triphasic wave pattern. We thought that the cause of disturbance in consciousness was Cefepime-induced encephalopathy, and stopped administration of Cefepime. A few days later, he became clear, and the myoclonus and flapping disappeared. It was difficult to distinguish between non-convulsive status epilepticus and Cefepime-induced encephalopathy. However, since stopping Cefepime treatment had made the patient clear, we diagnosed his condition as Cefepime-induced encephalopathy, which often occurs in patients with renal or liver dysfunction, or in brain infarction or meningitis, which results in blood-brain barrier disruption. Thus, care should be taken when administering Cefepime to such patients.
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Affiliation(s)
- Yusuke Toda
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School
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37
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Abstract
We describe the case of an 85-year-old woman who developed acute confusion, acute kidney injury and temperature spikes while on extended courses of beta-lactams for osteomyelitis. The cause of her deterioration was felt to be due to sepsis when in fact it was as a result of toxicity from antibiotics. This was demonstrated by a rapid resolution in her condition following haemodialysis. We also performed a literature review to appraise the neuro and nephrotoxicity of various antibiotics and how best to manage toxicity when it occurs.
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38
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Abstract
This chapter reviews the neurologic complications of medications administered in the hospital setting, by class, introducing both common and less common side effects. Detail is devoted to the interaction between pain, analgesia, sedation, and their residual consequences. Antimicrobials are given in nearly every hospital setting, and we review their capacity to produce neurologic sequelae with special devotion to cefepime and the antiviral treatment of human immunodeficiency virus. The management of hemorrhagic stroke has become more complex with the introduction of novel oral anticoagulants, and we provide an update on what is known about reversal of the new oral anticoagulants. Both central and peripheral nervous system complications of immunosuppressants and chemotherapies are reviewed. Because diagnosis is generally based on clinical acumen, alone, neurotoxic syndromes resulting from psychotropic medications may be easily overlooked until severe dysautonomia develops. We include a practical approach to the diagnosis of serotonin syndrome and neuroleptic malignant syndrome.
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Affiliation(s)
- Elliot T Dawson
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sara E Hocker
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN, USA.
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Bora I, Demir AB, Uzun P. Nonconvulsive status epilepticus cases arising in connection with cephalosporins. EPILEPSY & BEHAVIOR CASE REPORTS 2016; 6:23-7. [PMID: 27408805 PMCID: PMC4925880 DOI: 10.1016/j.ebcr.2016.04.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 04/11/2016] [Accepted: 04/30/2016] [Indexed: 11/28/2022]
Abstract
Cephalosporins, particularly cefepime, exert neurotoxic side effects that can lead to status epilepticus. These neurotoxic side effects include myoclonus, dystonic movements, tremor, asterixis, seizure, status epilepticus, encephalopathy, and sometimes coma. Status epilepticus, particularly nonconvulsive status epilepticus (NCSE), is a well-known but unusual complication in patients with altered renal function who were receiving treatment with intravenous cephalosporins, especially cefepime. We reviewed the clinical and electroencephalographic (EEG) characteristics of 7 patients with renal failure who developed consciousness alterations with changes in EEG activity while being treated with cephalosporins. All patients developed renal failure: six patients had chronic renal failure, one patient had acute renal failure, and two patients were administered hemodialysis. Nonconvulsive status epilepticus was observed between 2 and 8 days (average of 5.6 days) after initiation of cephalosporins. Cephalosporins are epileptogenic drugs, especially when used in excessive doses or when renal function is impaired. Critically ill patients with chronic kidney disease are particularly susceptible to cefepime neurotoxicity. Clinical and electrophysiological results of patients guide the diagnosis of NCSE by healthcare providers.
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Affiliation(s)
- Ibrahim Bora
- Uludag University Medical School, Neurology Department, 16059 Görükle, Bursa, Turkey
| | - Aylin Bican Demir
- Uludag University Medical School, Neurology Department, 16059 Görükle, Bursa, Turkey
| | - Pinar Uzun
- Uludag University Medical School, Neurology Department, 16059 Görükle, Bursa, Turkey
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Coelho FMS, Bernstein M, Yokota PKO, Coelho RME, Wachemberg M, Sampaio LPDB, Caboclo LO. Cefepime-induced encephalopathy in patient without renal failure. EINSTEIN-SAO PAULO 2016; 8:358-60. [PMID: 26760155 DOI: 10.1590/s1679-45082010rc1121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This case report describes neurotoxicity in an older patient on cefepime 2 g twice a day. The 81-year-old male patient developed non-convulsive status epilepticus during cefepime treatment with 1 g twice a day. There was recovery 30 days after discontinuation of cefepime.
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Collins RD, Tverdek FP, Bruno JJ, Coyle EA. Probable Nonconvulsive Status Epilepticus With the Use of High-Dose Continuous Infusion Ceftazidime. J Pharm Pract 2015; 29:564-568. [PMID: 26475124 DOI: 10.1177/0897190015608503] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multidrug resistant (MDR) bacterial infections are a major concern of health care providers due to their increasing incidence and associated mortality. In some cases, few or no antibiotics have preserved activity. Beta-lactam administration via continuous infusion can optimize time over minimum inhibitory concentration (MIC). In some cases, use of high-dose continuous infusion (HDCI) may be necessary to achieve serum levels in excess of nonsusceptible MIC values. The use of HDCI beta-lactams is not without risk, specifically neurotoxic adverse effects, which appear dose related. We describe a 64-year-old male who experienced myoclonus and nonconvulsive status epilepticus while receiving HDCI ceftazidime for treatment of multidrug resistant Pseudomonas aeruginosa bacteremia. This report serves as a cautionary example of the potential toxicities associated with HDCI beta-lactams and supports the importance of risk-benefit analysis prior to and during treatment. Additionally, the use of serum drug level monitoring may be necessary to better prevent or predict toxicity.
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Affiliation(s)
- Reagan D Collins
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Frank P Tverdek
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey J Bruno
- Department of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Generalized periodic discharges and 'triphasic waves': A blinded evaluation of inter-rater agreement and clinical significance. Clin Neurophysiol 2015; 127:1073-1080. [PMID: 26294138 DOI: 10.1016/j.clinph.2015.07.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/29/2015] [Accepted: 07/14/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Generalized periodic discharges (GPDs) are associated with nonconvulsive seizures. Triphasic waves (TWs), a subtype of GPDs, have been described in relation to metabolic encephalopathy and not felt to be associated with seizures. We sought to establish the consistency of use of this descriptive term and its association with seizures. METHODS 11 experts in continuous EEG monitoring scored 20 cEEG samples containing GPDs using Standardized Critical Care EEG Terminology. In the absence of patient information, the inter-rater agreement (IRA) for EEG descriptors including TWs was assessed along with raters' clinical EEG interpretation and compared with actual patient information. RESULTS The IRA for 'generalized' and 'periodic' was near-perfect (kappa=0.81), but fair for 'triphasic' (kappa=0.33). Patients with TWs were as likely to develop seizures as those without (25% vs 26%, N.S.) and surprisingly, patients with TWs were less likely to have toxic-metabolic encephalopathy than those without TWs (55% vs 79%, p<0.01). CONCLUSIONS While IRA for the terms "generalized" and "periodic" is high, it is only fair for TWs. EEG interpreted as TWs presents similar risk for seizures as GPDs without triphasic appearance. GPDs are commonly associated with metabolic encephalopathy, but 'triphasic' appearance is not predictive. SIGNIFICANCE Conventional association of 'triphasic waves' with specific clinical conditions may lead to inaccurate EEG interpretation.
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Bearden S, Eisenschenk S, Uthman B. Diagnosis of Nonconvulsive Status Epilepticus (NCSE) in Adults with Altered Mental Status: Clinico - Electroencephalographic Considerations. ACTA ACUST UNITED AC 2015. [DOI: 10.1080/1086508x.2008.11079655] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Scott Bearden
- Clinical Neurophysiology Laboratory/Neurology Services North Florida/South Georgia Veterans Health System Gainesville, Florida
| | | | - Basim Uthman
- Department of Neurology University of Florida Gainesville, Florida
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El Nekidy W, Dziamarski N, Soong D, Donaldson C, Ibrahim M, Kadri A. Cloxacillin-induced seizure in a hemodialysis patient. Hemodial Int 2015; 19:E33-6. [PMID: 25582344 DOI: 10.1111/hdi.12262] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We are reporting a cloxacillin-induced seizure in a patient with stage 5 chronic kidney disease requiring hemodialysis. To our knowledge, there are no published case reports of seizures induced by parenteral cloxacillin in hemodialysis patients. A young hemodialysis female was admitted to the hospital with decreased level of consciousness. Blood cultures revealed methicillin-sensitive Staphylococcus aureus where cloxacillin 2 g intravenously every 4 hours was initiated. Head computed tomography (CT) was not significant. After 14 hours of cloxacillin therapy (4 doses), the patient demonstrated tonic/clonic seizure activity, where phenytoin and lorazepam were initiated. The anti-seizure medications partially reduced seizure activity. Once the cloxacillin was discontinued, the seizures stopped. Two weeks later, all anti-seizure medications were stopped with no further seizure activity. Cloxacillin elimination in hemodialysis patients is similar to patients with normal kidney function. Although cloxacillin does not significantly cross the blood-brain barrier, the correlation between the start of seizures and cloxacillin initiation was confirmed by the negative CT and blood chemistry laboratory results. Moreover, seizure activity was terminated upon discontinuation of cloxacillin. Although further investigation for the cause of such seizures is warranted, clinicians should use caution when giving high doses of cloxacillin in hemodialysis patients.
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Affiliation(s)
- Wasim El Nekidy
- Department of Nephrology, Windsor Regional Hospital, Windsor, Ontario, Canada.,Department of Pharmacy, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Nicole Dziamarski
- Department of Nephrology, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Derrick Soong
- Department of Nephrology, Windsor Regional Hospital, Windsor, Ontario, Canada.,Department of Pharmacy, Windsor Regional Hospital, Windsor, Ontario, Canada
| | | | - Muhieldean Ibrahim
- Department of Nephrology, Windsor Regional Hospital, Windsor, Ontario, Canada
| | - Albert Kadri
- Department of Nephrology, Windsor Regional Hospital, Windsor, Ontario, Canada
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Kwon J, Choi JY, Bae EK. Cefepime-induced Aphasic Status Epilepticus Mimicking Acute Stroke. J Epilepsy Res 2014; 4:85-7. [PMID: 25625095 PMCID: PMC4295060 DOI: 10.14581/jer.14018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 11/01/2014] [Indexed: 11/03/2022] Open
Abstract
Cefepime-induced neurotoxicity, including nonconvulsive status epilepticus, has been reported especially in patients with renal impairment. However, focal nonconvulsive status epilepticus is very rare and cefepime-induced aphasic status epilepticus proven by electroencephalography have never been reported to our knowledge. We present an interesting case of aphasic status epilepticus mimicking acute stroke in a patient treated by cefepime.
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Affiliation(s)
- Jiwon Kwon
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Jun Yong Choi
- Department of Neurology, Inha University Hospital, Incheon, Korea
| | - Eun-Kee Bae
- Department of Neurology, Inha University Hospital, Incheon, Korea
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Mattappalil A, Mergenhagen KA. Neurotoxicity with Antimicrobials in the Elderly: A Review. Clin Ther 2014; 36:1489-1511.e4. [DOI: 10.1016/j.clinthera.2014.09.020] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/24/2014] [Accepted: 09/17/2014] [Indexed: 02/07/2023]
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Lewis SJ, Mueller BA. Antibiotic Dosing in Patients With Acute Kidney Injury: "Enough But Not Too Much". J Intensive Care Med 2014; 31:164-76. [PMID: 25326429 DOI: 10.1177/0885066614555490] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 08/25/2014] [Indexed: 12/21/2022]
Abstract
Increasing evidence suggests that antibiotic dosing in critically ill patients with acute kidney injury (AKI) often does not achieve pharmacodynamic goals, and the continued high mortality rate due to infectious causes appears to confirm these findings. Although there are compelling reasons why clinicians should use more aggressive antibiotic dosing, particularly in patients receiving aggressive renal replacement therapies, concerns for toxicity associated with higher doses are real. The presence of multisystem organ failure and polypharmacy predispose these patients to drug toxicity. This article examines the pharmacokinetic and pharmacodynamic consequences of critical illness, AKI, and renal replacement therapy and describes potential solutions to help clinicians give "enough but not too much" in these very complicated patients.
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Affiliation(s)
- Susan J Lewis
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Bruce A Mueller
- Department of Clinical, Social, and Administrative Sciences, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Mani LY, Kissling S, Viceic D, Vogt B, Burnier M, Buclin T, Renard D. Intermittent hemodialysis treatment in cefepime-induced neurotoxicity: case report, pharmacokinetic modeling, and review of the literature. Hemodial Int 2014; 19:333-43. [PMID: 25052578 DOI: 10.1111/hdi.12198] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Cefepime is a broad-spectrum cephalosporin indicated for in-hospital treatment of severe infections. Acute neurotoxicity, an increasingly recognized adverse effect of this drug in an overdose, predominantly affects patients with reduced renal function. Although dialytic approaches have been advocated to treat this condition, their role in this indication remains unclear. We report the case of an 88-year-old female patient with impaired renal function who developed life-threatening neurologic symptoms during cefepime therapy. She was treated with two intermittent 3-hour high-flux, high-efficiency hemodialysis sessions. Serial pre-, post-, and peridialytic (pre- and postfilter) serum cefepime concentrations were measured. Pharmacokinetic modeling showed that this dialytic strategy allowed for serum cefepime concentrations to return to the estimated nontoxic range 15 hours earlier than would have been the case without an intervention. The patient made a full clinical recovery over the next 48 hours. We conclude that at least 1 session of intermittent hemodialysis may shorten the time to return to the nontoxic range in severe clinically patent intoxication. It should be considered early in its clinical course pending chemical confirmation, even in frail elderly patients. Careful dosage adjustment and a high index of suspicion are essential in this population.
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Affiliation(s)
- Laila-Yasmin Mani
- Department of Nephrology, Hypertension and Clinical Pharmacology, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
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Ugai T, Morisaki K, Tsuda K, Sugihara H, Nishida Y, Yamakura M, Takeuchi M, Matsue K. Cefepime-induced encephalopathy in patients with haematological malignancies: clinical features and risk factors. ACTA ACUST UNITED AC 2014; 46:272-9. [PMID: 24506579 DOI: 10.3109/00365548.2013.878032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cefepime is an antibiotic that is widely used in patients with haematological malignancies (HM). Although its use has been reported to be associated with encephalopathy, only case reports or small case series have been reported so far. PATIENTS AND METHODS We conducted a retrospective cohort study of 243 patients with HM treated with cefepime at our hospital between August 2011 and May 2013. We also investigated the clinical features of patients with cefepime-induced encephalopathy (CIE). RESULTS Among 243 HM patients treated with cefepime, 10 were diagnosed with CIE, indicating a cumulative incidence of approximately 4.1%. The median creatinine level on commencement of treatment was 2.13 mg/dl (range 0.60-19.85) and the median initial dose of cefepime was 4.0 g/day (range 1.0-6.0). The median time between commencement of treatment and symptoms was 4.0 days (range 2-5). The most common clinical manifestations were decreased level of consciousness and myoclonus. Symptoms resolved fully in all patients. Univariate analyses showed that impaired renal function (creatinine clearance (CLCr) < 30 ml/min, acute renal failure, and chronic dialysis) was significantly associated with the development of CIE (univariate p < 0.0001, p = 0.020, and p = 0.0025, respectively). Receiver operating characteristic (ROC) analysis demonstrated that the threshold levels of creatinine, CLCr, and estimated glomerular filtration rate for CIE were 1.22 mg/dl, 22.96 ml/min, and 43.9 ml/min/1.73 m(2), respectively. CONCLUSIONS This study indicated that the development of CIE is associated with severely impaired renal function in patients with HM.
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Affiliation(s)
- Tomotaka Ugai
- From the 1 Division of Haematology/Oncology, Department of Medicine, Kameda Medical Centre , Chiba
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