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Saudi J Kidney Dis Transpl 2011;22(5):1026-1027

2011 Saudi Center for Organ Transplantation

Saudi Journal
of Kidney Diseases
and Transplantation

Letter to the Editor

Neurotoxicity due to Cefepime in Patients on Maintenance Hemodialysis
To the Editor,
Cefepime is a fourth-generation cephalosporin
active against both gram positive and gram
negative infections. It is administered parenterally for treatment of severe infections.1 Cefepime is excreted mainly through the renal route.
Clearance of cefepime is prolonged in renal
failure; hence, leading to a higher incidence of
neurotoxicity. Neurotoxicity in the form of
global aphasia, chorea and myoclonus has been
described.
We report here two cases of neurotoxicity
due to cefepime in patients on maintenance
hemodialysis.
Case 1
A 65-year-old woman, a known diabetic and
hypertensive on maintenance hemodialysis,
presented with breathlessness and productive
cough. Chest X-ray revealed features suggestive of pulmonary edema. Computerized tomography (CT) scan of the chest did not reveal
any evidence of consolidation. Dyspnea did
not subside with two sessions of hemodialysis
and, as sputum production continued, empirically, she was started on cefepime. Two days
later, she developed global aphasia with no
focal neurological deficit followed two days
later by chorea type of movements and myoclonus. Magnetic resonance imaging (MRI) of
the brain was within normal limits. An electroencephalography and cerebrospinal fluid
analysis were not done. Meanwhile, as sputum
grew Moraxella, she was switched to Meronem

based on culture and sensitivity. Within 4872

hours, she showed improvement in the level of
sensorium and global aphasia disappeared.
Myoclonic movements also decreased. At the
time of discharge, she was conscious, coherent
and ambulatory.
Case 2
A 45-year-old diabetic and hypertensive man
with diabetic nephropathy and chronic kidney
disease stage 5 on maintenance hemodialysis,
presented with fever and lower respiratory
tract infection. He had bilateral cervical lymphadenopathy. He was evaluated for evidence
of extrapulmonary tuberculosis. Meanwhile, he
was initiated on cefepime for management of
lower respiratory tract infection. Two days later,
he developed right side myoclonic movements.
CT scan of the brain was within normal limits.
The MRI of the brain was normal but, as the
lymphnodal histopathology was suggestive of
tuberculosis, cefepime was discontinued. Within three days, the myoclonic movements disappeared completely.
Several cases of cefepime neurotoxicity have
been reported.2 The prevalence was estimated
as 3% in various publications. The incidence
of cefepime neurotoxicity is more in the presence of renal failure due to prolongation of
the half-life from 2.3 hours to 13.5 and even
22 hours.3 The half-life of cefepime during
dialysis can vary between 1.6 and 2.3 hours
de-pending on the use of high-flux or low-flux
dialyzer and hence it is difficult to predict the
pharmacokinetics of cefepime in renal insuffi-

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Letter to the Editor

ciency patients.
The latency between the initiation of the drug
and the neurological complaints varies between 4.75 2.55 days (range 110 days). The
neurological syndrome consists of decreased
sensorium, confusion, agitation, global aphasia,
myoclonus, chorea, athetosis, convulsions and
coma.2
In our patients, the neurological symptoms
started after two to three days of initiation of
cefepime. Myoclonus was present in both patients, and global aphasia was present in one.
The evaluation for metabolic encephalopathy
was negative. The neurological symptoms disappeared within two days of discontinuation of
cefepime.
The most striking neurological manifestations were myoclonus and global aphasia. The
chronology of events helped us in arriving at
the etiology thus establishing an indirect relationship. In conclusion, we believe that physicians should be cautious for the side-effects of
cefepime in kidney disease patients with early
detection and management.
Dr. Manjusha Yadla1,
Dr. Chennu Krishna Kishore1,
Dr. Parvithina Sriramnaveen1,
Dr. Yanala Sandeep Reddy1,
Dr. Vellanki Venkata Sainaresh1,
Dr. Vengamma Bhuma2,
Dr. Vishnubotla Sivakumar 1
Department of 1Nephrology,
Department of Neurology2,
Sri Venkateswara Institute of Medical Sciences,
Tirupati, Andhra Pradesh, India
E-mail: manjuyadla@gmail.com

1027

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