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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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Behal ML, Thomas JK, Thompson Bastin ML, Mefford BM. Cefepime Induced Neurotoxicity Following A Regimen Dose-Adjusted for Renal Function: Case Report and Review of the Literature. Hosp Pharm 2022; 57:385-391. [PMID: 35615483 PMCID: PMC9125125 DOI: 10.1177/00185787211046856] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Introduction: Cefepime induced neurotoxicity (CIN) is commonly associated with renal dysfunction, however CIN can occur in patients with normal renal function or renally dose-adjusted regimens. Few reports of this kind have obtained cefepime concentrations to assist in diagnosis. Patient Case: A 42-year old female with a complex past medical history was transferred to our facility with chief complaint of worsening shock and respiratory failure, and the patient was also noted to be hypernatremic, experiencing diabetic ketoacidosis (DKA), and acute kidney injury (AKI). Her DKA resolved and hypernatremia and AKI began to improve. As a result, cefepime was dose-adjusted for renal function estimated by the Cockcroft-Gault (CG) equation. Her hospital course was complicated by persistent altered mental status (AMS), preventing extubation. Cefepime was discontinued due to concern for CIN, and a concentration was obtained 13-hours after the last dose which was elevated at 49 µg/mL. Two days following cefepime discontinuation, the patient's mental status improved allowing for successful extubation. The patient remained stable and was discharged to an acute care floor and then ultimately back to home. Conclusion: CIN should be part of a wider differential diagnosis for patients experiencing encephalopathy, and inaccurate renal function estimation may be a risk factor for developing CIN. Furthermore, therapeutic drug monitoring (TDM) may serve as an important clinical tool in diagnosing and managing CIN.
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DeMaagd GA, DeMaagd DR, Philip A. Delirium and Its Pharmacological Causes in Older People, Part Three. Sr Care Pharm 2021; 36:619-631. [PMID: 34861903 DOI: 10.4140/tcp.n.2021.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Delirium is a syndrome that can arise from many causes or underlying conditions, and though it has been reported in younger patients, it is more prevalent in older people, though it can occur in other age groups as well. Identifying delirium is challenging in older people because of the coexistence of underlying dementia or depression, which may further complicate the presentation. Drug-induced delirium is one of the major causes of delirium, and evaluation of this potential cause or contribution is an important component of the evaluation process, since it can lead to poor patient outcomes. Part one of this three part series reviewed the epidemiology, pathophysiology, evaluation, diagnostic process, and causes of delirium in older people. Parts two and three continued to review the pharmacological classes of medications that cause or contribute to delirium in older people.
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Affiliation(s)
| | | | - Ashok Philip
- Union University College of Pharmacy, Jackson, Tennessee
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Ortega AJ, Ghafouri SR, Vu L, Edwards B, Nickel N. Cefepime-Induced Encephalopathy in a High-Risk Patient With Renal Insufficiency and Cirrhosis. Cureus 2021; 13:e18767. [PMID: 34796060 PMCID: PMC8590204 DOI: 10.7759/cureus.18767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Cefepime is a fourth-generation, cephalosporin antibiotic commonly used as a first-line empirical treatment in a wide range of bacterial infections. It is predominantly excreted renally; therefore, a reduction in kidney function allows for the accumulation of cefepime to potentially toxic levels. Here we present a case of cefepime-induced encephalopathy (CIE) in a 67 years old male patient with advanced-stage renal insufficiency and cirrhosis who was admitted to our hospital for altered mental status (AMS). The patient was initially treated for hepatic encephalopathy (HE) given an elevated ammonia level (105 µg/dL), which had significantly improved. He was also placed on intravenous (IV) cefepime for Pseudomonas bacteremia. Four days later, the patient became drowsy and confused. A detailed workup for secondary causes of AMS was performed however no significant acute abnormalities were detected. The ammonia level remained within the normal range. There was no acute intracranial pathology reported on a head computerized tomography (CT). Furthermore, an electroencephalograph (EEG) was obtained which showed generalized periodic discharge with a tri-phasic wave pattern suggesting non-convulsive status epilepticus (NCSE). CIE was suspected at that point and cefepime administration was stopped. Following cefepime discontinuation, there was a remarkable improvement in the patient’s mental status for several days after cefepime discontinuation that supported the diagnosis of CIE in our patient. Although the exact pathophysiology is unclear, CIE should be suspected in elderly patients, patients with renal dysfunction, and critical illness. Meanwhile, liver dysfunction can be an additional risk factor for CIE as it increases the permeability of the blood-brain barrier (BBB), altered neurotransmission, and neuro-inflammation.
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Affiliation(s)
- Andrew J Ortega
- Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine, El Paso, USA
| | - S Reshad Ghafouri
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Lynn Vu
- Internal Medicine, Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine, El Paso, USA
| | - Brian Edwards
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
| | - Nils Nickel
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, USA
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Zimmermann P, Camenzind D, Beer JH, Tarnutzer AA. Negative myoclonus as the leading symptom in acute cefepime neurotoxicity. BMJ Case Rep 2021; 14:14/4/e239744. [PMID: 33832932 PMCID: PMC8039221 DOI: 10.1136/bcr-2020-239744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 86-year-old woman was diagnosed with hospital-acquired pneumonia with Pseudomonas aeruginosa and treated with cefepime adjusted to her renal clearance. After 4 days, she developed acute-onset negative myoclonus without signs of altered mental status. After ruling out an acute intracranial haemorrhagic or ischaemic stroke as well as other metabolic and endocrine causes of negative myoclonus, the antibiotic was switched to piperacillin/tazobactam due to a suspicion of cefepime neurotoxicity. The patient improved within 24 hours and her symptoms fully resolved within 4 days. These observations suggest a link of the negative myoclonus to acute cefepime neurotoxicity, which may occur without or with minimal alteration of mental status, thus extending its spectrum of clinical presentation.
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Affiliation(s)
| | | | - Jürg Hans Beer
- Internal Medicine, Kantonsspital Baden, Baden, Switzerland
| | - Alexander Andrea Tarnutzer
- Neurology, Kantonsspital Baden, Baden, Switzerland .,University of Zurich Faculty of Medicine, Zürich, Switzerland
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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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Amakhin DV, Smolensky IV, Soboleva EB, Zaitsev AV. Paradoxical Anticonvulsant Effect of Cefepime in the Pentylenetetrazole Model of Seizures in Rats. Pharmaceuticals (Basel) 2020; 13:ph13050080. [PMID: 32357511 PMCID: PMC7281561 DOI: 10.3390/ph13050080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
Many β-lactam antibiotics, including cephalosporins, may cause neurotoxic and proconvulsant effects. The main molecular mechanism of such effects is considered to be γ-aminobutyric acid type a (GABAa) receptor blockade, leading to the suppression of GABAergic inhibition and subsequent overexcitation. We found that cefepime (CFP), a cephalosporin, has a pronounced antiepileptic effect in the pentylenetetrazole (PTZ)-induced seizure model by decreasing the duration and severity of the seizure and animal mortality. This effect was specific to the PTZ model. In line with findings of previous studies, CFP exhibited a proconvulsant effect in other models, including the maximal electroshock model and 4-aminopyridine model of epileptiform activity, in vitro. To determine the antiepileptic mechanism of CFP in the PTZ model, we used whole-cell patch-clamp recordings. We demonstrated that CFP or PTZ decreased the amplitude of GABAa receptor-mediated postsynaptic currents. PTZ also decreased the current decay time constant and temporal summation of synaptic responses. In contrast, CFP slightly increased the decay time constant and did not affect summation. When applied together, CFP prevented alterations to the summation of responses by PTZ, strongly reducing the effects of PTZ on repetitive inhibitory synaptic transmission. The latter may explain the antiepileptic effect of CFP in the PTZ model.
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9
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Khoo CS, Tee TY, Tan HJ, Ali RA. A Treatable Encephalopathy in a Peritoneal Dialysis Patient - Cefepime-Induced Encephalopathy. J Neurosci Rural Pract 2019; 10:324-326. [PMID: 31001027 PMCID: PMC6454930 DOI: 10.4103/jnrp.jnrp_315_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We report a patient with end-stage renal disease on peritoneal dialysis, who developed encephalopathy after receiving a few doses of cefepime. He recovered clinically and electroencephalographically after having discontinued the culprit agent and undergone hemodialysis. This case highlights the importance of promptly recognizing this reversible encephalopathy, which can lead to the avoidance of unnecessary workup, reduce the length of hospital stay, and thereby improve the patients’ outcome.
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Affiliation(s)
- Ching Soong Khoo
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Tze Yuan Tee
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Hui Jan Tan
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Raymond Azman Ali
- Neurology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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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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Grahl JJ, Stollings JL, Rakhit S, Person AK, Wang L, Thompson JL, Pandharipande PP, Ely EW, Patel MB. Antimicrobial exposure and the risk of delirium in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:337. [PMID: 30541600 PMCID: PMC6291937 DOI: 10.1186/s13054-018-2262-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 11/13/2018] [Indexed: 02/13/2023]
Abstract
Background Prior retrospective cross-sectional work has associated antimicrobials with a non-specific phrase: encephalopathy without seizures. The purpose of this study is to determine whether different classes of antimicrobials have differential associations with the daily risk of delirium after critical illness is adjusted for. Methods Our study was a nested cohort that enrolled non-neurological critically ill adults from a medical or surgical intensive care unit (ICU) with daily follow-up to 30 days. Our independent variable was exposure to previous-day antimicrobial class: beta-lactams (subclasses: penicillins, first- to third-generation cephalosporins, fourth-generation cephalosporins, and carbapenems), macrolides, fluoroquinolones, and other. We adjusted for baseline covariates (age, comorbidities, cognition scores, sepsis, and mechanical ventilation), previous-day covariates (delirium, doses of analgesics/sedatives, and antipsychotic use), and same-day covariates (illness severity). Our primary outcome of delirium was measured by using the Confusion Assessment Method for the ICU. A daily delirium logistic regression model was used with an ICU time-restricted sensitivity analysis including daily adjustment for sepsis and mechanical ventilation. Results Of 418 ICU patients, delirium occurred in 308 (74%) with a median of 3 days (interquartile range 2–6) among those affected and 318 (76%) were exposed to antimicrobials. When covariates and ICU type were adjusted for, only first- to third-generation cephalosporins were associated with delirium (logistic regression model odds ratio (OR) = 2.2, 95% confidence interval (CI) 1.28–3.79, P = 0.004; sensitivity analysis OR = 2.13, 95% CI 1.10–4.10, P = 0.024). Conclusions First-, second-, and third-generation cephalosporins doubled the odds of delirium after baseline co-morbidities, ICU type, the course of critical care, and other competing antimicrobial and psychotropic medication risks were adjusted for. We did not find an association between delirium and cefepime, penicillins, carbapenems, fluoroquinolones, or macrolides. Electronic supplementary material The online version of this article (10.1186/s13054-018-2262-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica J Grahl
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37212, USA
| | - Joanna L Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37212, USA. .,Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.
| | - Shayan Rakhit
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA
| | - Anna K Person
- Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue S, Nashville, TN, 37232-2650, USA
| | - Li Wang
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37232, USA
| | - Jennifer L Thompson
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Department of Biostatistics, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, TN, 37232, USA
| | - Pratik P Pandharipande
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Division of Anesthesiology Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, 1211 21st Avenue S, Nashville, TN, 37212, USA.,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA
| | - E Wesley Ely
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA.,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA.,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA.,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, 1310 24th Avenue S, Nashville, TN, 37212, USA.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue S, Nashville, TN, 37232-2650, USA
| | - Mayur B Patel
- Critical Illness, Brain dysfunction, Survivorship (CIBS) Center, 2525 West End Avenue, Nashville, TN, 37232, USA. .,Vanderbilt University School of Medicine, 2215 Garland Avenue, Nashville, TN, 37212, USA. .,Center for Health Services Research, Vanderbilt University Medical Center, 1215 21st Avenue S, Nashville, TN, 27232-8300, USA. .,Geriatric Research, Education and Clinical Center Service, Department of Veterans Affairs Medical Center, Tennessee Valley Health Care System, 1310 24th Avenue S, Nashville, TN, 37212, USA. .,Division of Trauma and Surgical Critical Care, Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Section of Surgical Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, 1211 Medical Center Drive, 404 Medical Arts Building, Nashville, TN, 37212, USA.
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12
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Schlidt K, Kadlec A, Bhandari S, Jha P. Cefepime-induced Neurotoxicity: Five Cases Reported in a Single Institution. Cureus 2018; 10:e3666. [PMID: 30740285 PMCID: PMC6355299 DOI: 10.7759/cureus.3666] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Cefepime is a fourth-generation cephalosporin widely used to treat gram-positive and gram-negative infections. Its half-life is approximately two hours in patients with normal renal function and may increase to 13.5 hours in patients with acutely or chronically impaired renal function. Although dosage adjustment is recommended for patients with renal insufficiency to prevent drug accumulation, toxicity has been reported in patients even with normal renal function. One underreported complication of cefepime toxicity is cefepime-induced encephalopathy (CIE). While the pathophysiology is unclear, treatment involves early discontinuation of this antibiotic to decrease morbidity and mortality. We report five cases of cefepime-induced encephalopathy occurring within one year at a single institution.
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Affiliation(s)
- Kevin Schlidt
- Student, Medical College of Wisconsin, Wauwatosa, USA
| | - Andrew Kadlec
- Student, Medical College of Wisconsin, Wauwatosa, USA
| | | | - Pinky Jha
- Medicine, Medical College of Wisconsin, Brookfield, USA
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13
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Han Y, Zheng Y, Zhang J, Hu C. Neurobehavioral Effects of Cephalosporins: Assessment of Locomotors Activity, Motor and Sensory Development in Zebrafish. Front Pharmacol 2018; 9:160. [PMID: 29551974 PMCID: PMC5840155 DOI: 10.3389/fphar.2018.00160] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/14/2018] [Indexed: 12/14/2022] Open
Abstract
Most third- and fourth-generation cephalosporins, such as cefotaxime, cefmenoxime, cefepime, and cefpirome, contain an aminothiazoyl ring at the C-7 position. Drug impurity, which may be produced either during synthesis or upon degradation, can induce adverse effects. Various reports have indicated that neurotoxicity is a side effect of cephalosporin. In this study, we developed methods for assessing the free-swimming activities and behaviors in zebrafish larvae in response to continuous darkness and stimulation of light-to-dark photoperiod transition by chemical treatments. We also performed transcriptome analysis to identify differentially expressed genes (DEGs). Gene ontology analysis revealed that various processes related to nervous system development were significantly enriched by DEGs. We integrated 16 DEGs with protein–protein interaction networks and identified that neuroactive ligand–receptor interaction [e.g., λ-aminobutyric acid and glutamate receptor, metabotropic 1a (GRM1A)] pathway was regulated by the compounds. Our findings suggested that neurobehavioral effects mainly depend on the mother nucleus structure 7-aminocephalosporanic acid and the substitution at the C-3 position. In addition, gad2, or111-4, or126-3, grm1a, opn8c, or111-5, or113-2, and or118-3 may potentially be utilized as novel biomarkers for this class of cephalosporins, which causes neurotoxicity. This study provides neurological behavior, transcriptome, and docking information that could be used in further investigations of the structures and developmental neurotoxicity relationship of chemicals.
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Affiliation(s)
- Ying Han
- Division of Antibiotics, National Institutes for Food and Drug Control, Beijing, China
| | - Yangmin Zheng
- Department of Pharmacology, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jingpu Zhang
- Department of Pharmacology, Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changqin Hu
- Division of Antibiotics, National Institutes for Food and Drug Control, Beijing, China
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14
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In vitro binding comparison of cephalosporins to human serum albumin by spectroscopy and molecular docking approaches: A novel structural pursuing. J Mol Liq 2017. [DOI: 10.1016/j.molliq.2017.10.045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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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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