Refractory convulsive status epilepticus secondary to cefepime-induced neurotoxicity in a patient with chronic kidney disease

Background: Cefepime-induced neurotoxicity is an important adverse drug reaction in patients with impaired or rapidly changing renal function. The initial manifestations are often nonspecific, which may delay recognition until seizures or coma develop. 
Case presentation: We report a 61-year-old man with stage 4 chronic kidney disease who was admitted with severe Pseudomonas aeruginosa pneumonia. Cefepime was prescribed at 2 g intravenously every 12 hours after a 2-g loading dose and was not reduced when his creatinine clearance declined from approximately 22 to 14 mL/min. On treatment day 4, disorientation and multifocal myoclonus progressed to recurrent generalized tonic-clonic seizures despite lorazepam and a full levetiracetam loading dose. Continuous electroencephalography demonstrated 2-2.5 Hz generalized periodic discharges and recurrent electrographic seizures. Structural neuroimaging and metabolic testing did not identify another sufficient cause. A cefepime concentration obtained 8 hours after the last dose was 52.4 mg/L. Cefepime was stopped, continuous propofol and midazolam were used for seizure control, and two hemodialysis sessions were completed. Electrographic seizures ceased within 18 hours; the patient was extubated at 60 hours and recovered without recurrent seizures during 90 days of follow-up. 
Conclusion: Renal dose adjustment at the start of therapy does not protect against later accumulation when kidney function deteriorates. Daily reassessment of renal clearance, prompt review of new neurologic symptoms, early electroencephalography, immediate withdrawal of cefepime, and hemodialysis in severe cases can shorten exposure and support full neurologic recovery.