Remember princess Aurora in the classic “Sleeping Beauty” who was cursed by a witch to ‘sleep forever’ if she pricked her finger on a spindle ? Cefepime bestows a similar curse on some patients and you can be the clinician-prince who breaks it!
Cefepime is a commonly used antibiotic in hospitals – often started empirically in severe sepsis or septic shock in ICU given it’s broad anti-bacterial spectrum including Pseudomonas. Lately Cefepime is increasingly recognized as being neurotoxic & can cause encephalopathy with obtundation, hallucinations, myoclonus, seizures. etc.
A common scenario is patients in ICU who do not wake up or remain very drowsy or non-verbal even after critical illness with ABF (Acute Brain Failure) has resolved & are off all sedating meds resulting in expensive & normal brain imaging & EEGs. They start to wake up only after their Cefepime curse – oops i mean course 😉 – is completed ! I thought it was just a coincidence until case reports starting poppping up – like this, this and this . A retrospective case-control study showed Cefepime associated with neurotoxicity was more common when renal failure is present ( likely causes excessive blood levels considering majority of Cefepime is excreted unchanged via urine) Proposed mechanisms for this toxicity include GABA receptor antagonism and Carnitine deficiency via inducing renal depletion.
Don’t get me wrong – Cefepime is a good witch to have on your side to kill bad bacteria, but learn to remember that your patient may incur the wrath & curse from the prick of this witch! Consider stopping or switching Cefepime when you can’t explain your patient’s altered mentation.
💡 Tips reduce the risk of Cefepime neurotoxicity :
– Avoid a blanket use of Cefepime as a empiric antibiotic, reserve it for : previous known pseudomonas infection, febrile neutropenia, severe hospital-acquired or nosocomial pneumonia, etc.
– If you do not grow Pseudomonas in cultures in 2-3 days give switching to other antibiotics like Rocephin / Ceftazidime a thought.
– Be especially picky risk if high for Cefepime-induced Encephalopathy such as Renal dysfunction, Dementia, pre-existing brain injury,etc.
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