Factors predisposing to seizures in seriously ill infected patients receiving antibiotics: experience with imipenem/cilastatin

Real-world pharmacovigilance investigation of imipenem/cilastatin: signal detection using the FDA Adverse Event Reporting System (FAERS) database

Background

Although imipenem/cilastatin (IMI/CIL) has demonstrated favorable therapeutic efficacy against various infections, the incidence of potential adverse events (AEs) has escalated in parallel with its increased utilization and has been documented in clinical trials. However, a comprehensive understanding of real-world implications remains lacking.

Methods

By conducting a comprehensive search in the FDA Adverse Event Reporting System (FAERS) database, AE reports associated with IMI/CIL as the primary suspect (PS) were selected for analysis, spanning from the first quarter of 2004 to the fourth quarter of 2023. Utilizing disproportionality analysis techniques, potential signals of AE s were identified through reported odds ratio (ROR), proportional report ratio (PRR), Bayesian confidence propagation neural network (BCPNN), and empirical Bayesian geometric mean (EBGM). The obtained results were systematically classified using Medical Dictionary for Regulatory Activities (MedDRA).

Result

From the first quarter of 2004 to the fourth quarter of 2023, a total of 2,574 reports documenting AEs associated with IMI/CIL were obtained, with more than half (n = 1,517, 58.94%) involving individuals aged over 60 years old. Descriptive analysis was conducted based on age groups and time to onset, revealing that the majority of AEs occurred within 3 days. Adverse drug reactions caused by IMI/CIL were classified into 24 system organ classes (SOCs) at the preferred term (PT) level. Furthermore, previously unreported and clinically significant AEs such as cerebral atrophy, and delirium were also identified at the PT level.

Conclusion

This study offers a more comprehensive insight into the monitoring, supervision, and management of adverse drug reactions associated with IMI/CIL. Clinicians should pay further attention to the implications of numerous AEs and their corresponding signal intensities, as well as unrecorded signals of severe AEs. This holds significant value in enhancing the clinical safety profile of IMI/CIL.

Higher cefazolin concentrations in synovial fluid with intraosseous regional prophylaxis in knee arthroplasty: a randomized controlled trial

BACKGROUND

Prophylactic antibiotics reduce the risk of periprosthetic joint infection. However, conventional systemic administration may not provide adequate tissue concentrations against more resistant organisms such as coagulase-negative staphylococci. Intraosseous regional administration is known to achieve significantly higher antibiotic tissue concentrations than systemic administration, but it is unclear how synovial fluid concentrations are affected. We aimed to compare synovial fluid cefazolin concentrations achieved by regional intraosseous versus systemic intravenous administration, and also to compare synovial fluid cefazolin concentrations with those in subcutaneous fat.

METHODS

A total of 60 patients undergoing primary knee arthroplasty were randomized into 2 groups: group IO received 2 g interosseous cefazolin in 100 mL saline through a tibial cannula after tourniquet inflation and before skin incision; group IV received 2 g cefazolin in 100 mL saline via the median basilic or median cephalic vein 30 min before tourniquet inflation. Subcutaneous fat and synovial fluid samples were collected immediately after skin incision, and cefazolin concentrations were measured by high-performance liquid chromatography.

RESULTS

The cefazolin concentration in synovial fluid was 391.3 ± 70.1 μg/ml in group IO and 17.6 ± 3.5 μg/ml in group IV. The cefazolin concentration in subcutaneous fat was 247.9 ± 64.9 μg/g in group IO and 11.4 ± 1.9 μg/g in group IV.

CONCLUSION

Intraosseous regional administration results in several times higher tissue concentrations than systemic administration, especially in the synovial fluid.

Drugs with a negative impact on cognitive functions (part 3): antibacterial agents in patients with chronic kidney disease

The relationship between chronic kidney disease (CKD) and cognitive function has received increased attention in recent years. Antibacterial agents (ABs) represent a critical component of therapy regimens in patients with CKD due to increased susceptibility to infections. Following our reviewing work on the neurocognitive impact of long-term medications in patients with CKD, we propose to focus on AB-induced direct and indirect consequences on cognitive function. Patients with CKD are predisposed to adverse drug reactions (ADRs) due to altered drug pharmacokinetics, glomerular filtration decline, and the potential disruption of the blood-brain barrier. ABs have been identified as a major cause of ADRs in vulnerable patient populations. This review examines the direct neurotoxic effects of AB classes (e.g. beta-lactams, fluoroquinolones, aminoglycosides, and metronidazole) on the central nervous system (CNS) in patients with CKD. We will mainly focus on the acute effects on the CNS associated with AB since they are the most extensively studied effects in CKD patients. Moreover, the review describes the modulation of the gut microbiota by ABs, potentially influencing CNS symptoms. The intricate brain-gut-kidney axis emerges as a pivotal focus, revealing the interplay between microbiota alterations induced by ABs and CNS manifestations in patients with CKD. The prevalence of antibiotic-associated encephalopathy in patients with CKD undergoing intravenous AB therapy supports the use of therapeutic drug monitoring for ABs to reduce the number and seriousness of ADRs in this patient population. In conclusion, elucidating AB-induced cognitive effects in patients with CKD demands a comprehensive understanding and tailored therapeutic strategies that account for altered pharmacokinetics and the brain-gut-kidney axis.

Improved seizure liability detection by combining rat hippocampal brain slice electrophysiology with in vivo behavior observation following intracerebroventricular drug administration

An adverse effect of drug candidates, seizure is a serious issue in drug development. Improving evaluation systems for seizure liability is crucial for selecting good candidates. Firstly, in vitro electrophysiological measurement by a multielectrode array system in rat hippocampal brain slices was employed to confirm an increase in electrically evoked population spike (PS) area, the occurrence of multiple population spikes (MPSs), and thereby the seizure liability of five positive control chemicals: picrotoxin, 4-aminopyridine, pentylenetetrazole, penicillin G, and chlorpromazine. Aspirin, a negative control, did not affect PS area or generate MPSs. Furthermore, baclofen, an anticonvulsant drug, decreased PS area and inhibited the increase in PS area or occurrence of MPSs induced by picrotoxin. A comparative study of seizure liability among carbapenem antibiotics revealed that tienam > carbenin > omegacin and finibax. Despite leading to a strong decrease in PS area, physostigmine, cisplatin, and paroxetine still produced MPSs. Therefore, the increase in PS area or the occurrence of the MPS are considered significant evaluation parameters for seizure liability. In contrast, the in vitro electrophysiological measurement could not detect the seizure liability of diphenhydramine or fluvoxamine. A follow-up study of in vivo mouse behavioral change induced by intracerebroventricular administration of these drugs clearly detected convulsions. The in vitro electrophysiological study using hippocampal brain slices combined with in vivo behavior observation study of drug candidates administered by intracerebroventricular injection can implement to assess the seizure liability of even small amounts, especially in the early stages of drug development.

The Trend of Cefepime-Induced Neurotoxicity: A Systematic Review

There has been increased use of cefepime due to concerns about the nephrotoxic effects of the combined use of vancomycin and Zosyn. However, cefepime is associated with neurotoxicity. We conducted a systematic review using online data to explore the trend of cefepime-induced neurotoxicity over the last 10 years. Forty-six articles met our inclusion criteria, including 73 cases of cefepime-induced neurotoxicity. We noticed a steady increase in the reports of cefepime-induced neurotoxicity, from one case in 2013 to 11 cases in 2022. Individuals aged 65 and older accounted for most cefepime-induced neurotoxicity cases (52%). The top three indications for cefepime administration included bone and joint infections (25%), urinary tract infections (22.7%), and pneumonia (22.7%). Most patients with renal impairment have never had a renal adjustment of their cefepime dosage (either 2 g 12 hours a day or 2 g eight hours a day). Most cases of cefepime-induced neurotoxicity occurred between days two and five (n=29, 71%), while most resolution occurred between days one and five (n=29, 85%). While cefepime continues to be a popularly used and effective antibiotic against gram-negative bacteria like Pseudomonas aeruginosa, its dosage needs to be adjusted in patients with renal impairment to avoid neurotoxicity.

Antimicrobial safety considerations in critically ill patients: part II: focused on anti-microbial toxicities

INTRODUCTION

Antibiotic prescription is a challenging issue in critical care settings. Different pharmacokinetic and pharmacodynamic properties, polypharmacy, drug interactions, and high incidence of multidrug-resistant microorganisms in this population can influence the selection, safety, and efficacy of prescribed antibiotics.

AREAS COVERED

In the current article we searched PubMed, Scopus and Google Scholar for neurotoxicities, hematologic toxicity and fluid stewardship in intensive care units.

EXPERT OPINION

Critically ill patients who receive antimicrobial agents should be monitored for neurological, hematologic toxicities especially seizure, thrombocytopenia, and clostridioides infections. Other toxicities including QTc prolongation, electrolyte disturbances, liver enzyme elevation, and infusion-related reactions were being considered. Other changes, including fluid overload, hypoalbuminemia, augmented renal clearance, increased cardiac outputs in septic shock, and acute kidney injury, may influence treatment efficiency and patient outcome.

Probable Encephalopathy and Spasticity in a Multiple Sclerosis Patient Following Carbapenem Administration: A Case Report and Brief Literature Review

Purpose: The purpose of this case report is to describe spasticity and encephalopathy that developed in a multiple sclerosis patient following carbapenem administration. Summary: A 55-year-old female with multiple sclerosis developed spasticity and encephalopathy within 24 hours of meropenem and ertapenem administration. This was the second time that she had developed encephalopathy following carbapenem administration. The patient gradually recovered over four days following discontinuation of carbapenem therapy. Conclusion: Carbapenem neurotoxicity, a well-documented adverse effect, has been linked to several risk factors, including central nervous system lesions. Despite this, there is little evidence describing the risk of neurotoxicity in patients with multiple sclerosis. It is important to understand the potential adverse effects of carbapenems in specific patient populations to help guide appropriate treatment of infections.

Dosing strategies of imipenem in neonates based on pharmacometric modelling and simulation

OBJECTIVES

Imipenem is a broad-spectrum antibacterial agent used in critically ill neonates after failure of first-line treatments. Few studies have described imipenem disposition in this population. The objectives of our study were: (i) to characterize imipenem population pharmacokinetics (PK) in a cohort of neonates; and (ii) to conduct model-based simulations to evaluate the performance of six different dosing regimens aiming at optimizing PK target attainment.

METHODS

A total of 173 plasma samples from 82 neonates were collected over 15 years at the Lausanne University Hospital, Switzerland. The majority of study subjects were preterm neonates with a median gestational age (GA) of 27 weeks (range: 24-41), a postnatal age (PNA) of 21 days (2-153) and a body weight (BW) of 1.16 kg (0.5-4.1). PK data were analysed using non-linear mixed-effect modelling (NONMEM).

RESULTS

A one-compartment model best characterized imipenem disposition. Population PK parameters estimates of CL and volume of distribution were 0.21 L/h and 0.73 L, with an interpatient variability (CV%) of 20.1% on CL in a representative neonate (GA 27 weeks, PNA 21 days, BW 1.16 kg, serum creatinine, SCr 46.6 μmol/L). GA and PNA exhibited the greatest impact on PK parameters, followed by SCr. These covariates explained 36% and 15% of interindividual variability in CL, respectively.Simulated regimens using a dose of 20-25 mg/kg every 6-12 h according to postnatal age led to the highest PTA (T>MIC over 100% of time).

CONCLUSIONS

Dosing adjustment according to BW, GA and PNA optimizes imipenem exposure in neonates.

Beta-Lactams Toxicity in the Intensive Care Unit: An Underestimated Collateral Damage?

Beta-lactams are the most commonly prescribed antimicrobials in intensive care unit (ICU) settings and remain one of the safest antimicrobials prescribed. However, the misdiagnosis of beta-lactam-related adverse events may alter ICU patient management and impact clinical outcomes. To describe the clinical manifestations, risk factors and beta-lactam-induced neurological and renal adverse effects in the ICU setting, we performed a comprehensive literature review via an electronic search on PubMed up to April 2021 to provide updated clinical data. Beta-lactam neurotoxicity occurs in 10-15% of ICU patients and may be responsible for a large panel of clinical manifestations, ranging from confusion, encephalopathy and hallucinations to myoclonus, convulsions and non-convulsive status epilepticus. Renal impairment, underlying brain abnormalities and advanced age have been recognized as the main risk factors for neurotoxicity. In ICU patients, trough concentrations above 22 mg/L for cefepime, 64 mg/L for meropenem, 125 mg/L for flucloxacillin and 360 mg/L for piperacillin (used without tazobactam) are associated with neurotoxicity in 50% of patients. Even though renal complications (especially severe complications, such as acute interstitial nephritis, renal damage associated with drug induced hemolytic anemia and renal obstruction by crystallization) remain rare, there is compelling evidence of increased nephrotoxicity using well-known nephrotoxic drugs such as vancomycin combined with beta-lactams. Treatment mainly relies on the discontinuation of the offending drug but in the near future, antimicrobial optimal dosing regimens should be defined, not only based on pharmacokinetics/pharmacodynamic (PK/PD) targets associated with clinical and microbiological efficacy, but also on PK/toxicodynamic targets. The use of dosing software may help to achieve these goals.

Unmasking antibiotic-associated neurological disorders: The underminer in Intensive Care Unit

Psychosis is a common and intractable disorder of hospitalization, especially in patients hospitalized in Intensive Care Unit (ICU). Along with the widely use of multiple antibiotics in community-acquired infection and hospital-acquired infection, the occurrence of antibiotic-associated neurological disorders has become more frequently. However, antibiotic neurotoxicity is often overlooked or misinterpreted. In this review, we summarized the neurological disorders caused by antibacterial agent usage and firstly systematically formulated the pathogenesis of antibiotic-associated neurotoxic reactions. Precautions of the complications are critical in preventing serious clinical outcome as the inducement is curable. Regular neurological physical examination, electroencephalogram (EEG) examination, lumbar puncture and therapeutic drug monitoring closely are essential for early diagnosis and differential diagnosis.

Carbapenem use in critically ill patients

PURPOSE OF REVIEW

To review available data on carbapenem use in ICU. Carbapenem is a broad spectrum well tolerated antibiotic family that keep an excellent activity to extended spectrum β-lactamases and AmpC hyperproducer and in susceptible Pseudomonas aeruginosa and Acinetobacter baumannii. It becomes a drug of choice for empirical therapy of suspected sepsis in known or presumably known ESBLE carriers.

RECENT FINDINGS

Carbapenems remained the drug of choice for severe ESBLE infections. In severe critically ill patients, high off-label dose is necessary especially in patients with sepsis and glomerular hyperfiltration. Nevertheless, large spectrum of carbapenems leads to initial overuse. The increase in the overall consumption in the past years with lack of systematic re-evaluation observed is responsible of and carbapenem-selection pressure that contribute to the increase of carbapenem-resistant enterobacteriaceae, A. Baumannii and P. Aeruginosa in ICUs.

SUMMARY

Carbapenems remained a cornerstone of antibiotic therapy of severe infections. Emerging carbapenem resistance is related to the increase of carbapenem consumption. High doses are recommended for early therapy followed by systematic reevaluation on a daily basis with shift to narrow spectrum antimicrobials if possible and early stopping rules.

Antibiotic-induced epileptic seizures: mechanisms of action and clinical considerations

In recent years, there has been growing interest in the development of epileptic seizures as an adverse effect of antibiotic therapy. The most commonly accepted mechanisms underlying the development of antibiotic-induced seizures include direct- and indirect gamma-aminobutyric acid (GABA) antagonism, inhibition of GABA synthesis, and glutaminergic N-methyl-D-Aspartate (NMDA) receptor agonistic activity. Inhibitory pathway inhibition leads to increased neuronal excitability and lowered seizure threshold. Blockage of myoneural presynaptic acetylcholine release, mitochondrial dysfunction, interference of neural protein synthesis, and oxidative stress caused by the generation of neurotoxic radicals also contributes to the development of neurotoxicity. Patients with pre-existing risk factors such as renal or hepatic insufficiency, central nervous system pathology, neurological diseases, history of epilepsy or seizures, critical illness, and increased age are more susceptible to seizure development as a consequence of antibiotic therapy. Administration of antibiotics, together with antiseizure drugs, may also lead to enhanced seizure risk due to drug interactions, which predisposes to alterations in drug metabolism and therapeutic efficacy.

Ertapenem Neurotoxicity in Hemodialysis Patients-Safe and Effective Dosing Is Still Needed: A Retrospective Study and Literature Review

BACKGROUND

The approved dosing of ertapenem in patients with chronic kidney disease stage 5 utilizing dialysis (CKD-5D) is 0.5 g intravenous daily. Several reports associated this dosing strategy with neurotoxicity.

OBJECTIVE

The purpose of this study is to identify the incidence of neurotoxicity in this population and the risk factors associated with this toxicity. The secondary objective was to review the literature and discuss a safer/cost-effective dosing strategy based on available data.

METHODS

A retrospective study was conducted screening all patients who received ertapenem and hemodialysis at our quaternary hospital between May 2015 and March 2019. Patients' demographics, comorbidities, concomitant drugs (known to induce neurotoxicity), and seizure history were collected.

RESULTS

A total of 99 eligible patients were identified; 10 of them (10%) developed neurotoxicity. The patients who developed neurotoxicity were all male; mean age was 74 ± 9 years as compared with 68.9 ± 13 years in the sample. Bivariate relationships between all predictors and the seizures (dichotomously coded) were estimated to investigate the risk factors. The following were the significant predictors of seizures: male sex (17%; P = 0.014), dementia (27%; P = 0.012), and concomitant use of β-lactams, aminoglycosides, or fluoroquinolones (19.6%; P = 0.042).

CONCLUSION AND RELEVANCE

The currently approved ertapenem dose imposes a risk of developing neurotoxicity in patients with CKD-5D. Utilizing the published data in this population, alternative post-dialysis dosing strategies administered through dialysis access such as 1 g loading dose, followed by either 0.5 g (for the 48 hours interdialytic time) or 1 g (for the 72 hours interdialytic time) might warrant further investigation for efficacy and safety.

Twice- and Thrice-daily Cephalexin Dosing for Staphylococcus aureus Infections in Children

BACKGROUND

Cephalexin is used for the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) infections in children. Although 4 times daily dosing is recommended, less frequent dosing regimens are often prescribed to improve treatment acceptability and adherence. We developed a population pharmacokinetic model of cephalexin in children to determine a twice-daily (BID) and thrice-daily (TID) cephalexin dosing regimen for MSSA infections.

METHODS

A population pharmacokinetic model was developed using a nonlinear mixed effects modeling approach. The dataset used was from a prospective open-label pharmacokinetic study of orally administered cephalexin in 12 children 1-16 years of age with bone and joint infections. Simulations were performed to determine a BID and TID dosing regimen so that ≥90% of children in this age group would achieve the pharmacodynamic target for MSSA (ie, time that the free drug concentration exceeds the minimum inhibitory concentration of the bacteria for at least 40% of the dosing interval).

RESULTS

The final model was 1 compartment with a transit compartment model to account for delay in oral absorption. For BID dosing, doses of 22-45 and 80 mg/kg were required for MSSA with minimum inhibitory concentrations of 1-2 and 4 mg/L, respectively. For TID dosing, the respective required doses were 15-25 and 45 mg/kg.

CONCLUSIONS

Our study proposes a BID and TID cephalexin dosing regimen that can be prospectively evaluated. Through reducing the dose frequency of this widely prescribed antibiotic, we can reduce the medication burden for children and improve treatment compliance for MSSA infections.

Focal seizures with a migrating aspect in infants treated with beta-lactam antibiotics - Report of two cases

Seizures caused by beta-lactam antibiotics are relatively rare. However, they represent a clinically significant phenomenon and have been widely reported in all age groups. Here we describe two infants presenting subtle multifocal seizures with a migrating aspect on EEG during beta-lactam antibiotic treatment with agents from the carbapenem group (meropenem) and the cephalosporin group (ceftazidime).

Higher rates of carbapenem-related seizures in older hospitalised adults

Clinical experience suggests higher occurrence of carbapenem-associated seizures in the elderly than what is reported in the available literature (range between 0.2% and 0.7%). An audit of 1345 patients with age 60 years or older, who received imipenem, ertapenem or meropenem during their acute hospitalisation found 32 (2.4%) subjects developed seizures. Subjects with more than one central nervous system disorders were 11.6 times more likely to develop seizures (odds ratio 11.61, P < 0.001) and subjects with prior history of seizures is associated with four times greater risks (odds ratio 4.02, P = 0.005). Physicians should exercise caution when prescribing carbapenems in elderly, especially those with known epilepsy and a high number of intracranial pathologies.

Jerky Movement with Ceftazidime: A Case of Ceftazidime-Induced Neurotoxicity with a Review of the Literature

Neurotoxicity manifested as confusion and seizures has been recognized as a side effect of multiple cephalosporins including ceftazidime. Renal impairment and inappropriate dosing are the most common contributors to the development of neurological abnormalities in patients receiving these antibiotics. The presence of baseline neurological abnormalities likely contributes to the frequency of these adverse events. Here, we present a case of a 78-year-old man that developed altered mental status and myoclonic movement after initiation of ceftazidime in the setting of mild renal dysfunction. Resolution of clinical picture was evident after 48 hours of discontinuation of the antibiotic without additional interventions.

Reversible Choreoathetosis in a Patient with End-stage Renal Disease from Administration of Ceftriaxone

A wide spectrum of neurological manifestations may be induced in patients with impaired renal function when receiving beta-lactam antibiotics due to the altered pharmacokinetics. Beta-lactam antibiotics is commonly chosen for treatment in patients with end-stage renal disease due to its good penetration into the cerebrospinal fluid and long half-life.

Here, we present a case of a 73-year-old Malay lady with end-stage renal disease who was admitted for treatment of gastroenteritis. She presented with acute onset of diarrhoea and vomiting for two days. She was febrile during admission and was prescribed intravenous ceftriaxone 2 grams daily for coverage of bacterial gastroenteritis. Among the investigations done, white cell count were raised together with the C-reactive protein. Stool and blood cultures were also sent for further investigations. Over a three-day period, her general condition improved and she was discharged home. The onset of clinical manifestation of choreoathetosis was noticed by her caregiver on the same day of discharge. She was brought back to the emergency department and was readmitted for further workup of the new presenting complain of abnormal movement and disorientation. Haemodialysis was arranged and immediately commenced during her admission. The renal nurses reported that her neurological symptoms were noticeably improved after completion of the initial dialysis without any treatment.

Ceftriaxone including other beta lactam antibiotics penetrates the blood-brain barrier and induces glutamate in excess in the striatum and cerebral cortex, resulting in neurological hyper excitability disorders despite appropriate renal adjusted dosage for end-stage renal disease patients on haemodialysis.

Management of ventilator-associated pneumonia (VAP) caused by resistant gram-negative bacteria: which is the best strategy to treat?

Introduction: Treatment of ventilator-associated pneumonia (VAP) is a major challenge. The increase in multi-drug resistant bacteria has not been accompanied by the validation of new drugs, or by any new antimicrobial strategies to exploit the available agents. VAP due to Gram-negative bacteria has increased mortality, both due to the resistant pathogens themselves and due to inappropriate treatment. Local epidemiology, patients' characteristics and clinical responses provide the most important information for therapeutic decision-making. Moreover, data on VAP therapy due to resistant bacteria are lacking, and the choice of treatment is often based on clinical practice and individual experience. Areas covered: This review summarizes the strategies available for treating the three most prevalent resistant Gram-negative organisms causing VAP: Pseudomonas aeruginosa, Acinetobacter baumannii and Enterobacteriaceae. The review covers the results of a Pubmed search, clinical practice guidelines and reviews, and the authors' experience. Expert opinion: The existing evidence focuses on bloodstream infections or other sites rather than pneumonia and there are no recommendations for the treatment of VAP by multi-drug resistant Gram-negative bacteria, especially for combination regimens. The approval of new drugs is needed to provide effective and safe alternatives for treating carbapenemase-producing strains. Precision medicine and personalized approach are also fundamental in future research.

Pharmacokinetics of Doripenem in Healthy Koreans and Monte Carlo Simulations to Explore Optimal Dosage Regimens in Patients With Normal and Enhanced Renal Function

Supplemental Digital Content is Available in the Text.

Background:

Dose adjustment is often required in patients with normal or enhanced renal function. The aim of this study is to investigate the pharmacokinetic (PK) properties of doripenem and explore optimal dosing regimens in patients with normal or enhanced renal function according to various minimum inhibitory concentrations (MICs).

Methods:

The authors conducted a clinical trial and analyzed PK samples in 11 healthy Korean subjects applying noncompartmental analysis and a population approach. The population PK parameter estimates were used in Monte Carlo simulations to explore optimal dosing regimens for a probability of target attainment of 90% at 40% fT_MIC (free drug concentrations above MIC).

Results:

The time course of doripenem concentrations was well described by a 2-compartment model. The population typical values of clearance and steady-state volume were 22.9 L/h and 19.1 L, respectively, and were consistent with our noncompartmental analysis results. When the MIC was greater than 1 mcg/mL, at least increasing the dose or prolonging the infusion time was essential in patients with normal or enhanced renal function.

Conclusions:

These results suggest that dosage adjustment such as increasing the dose or lengthening the infusion time should be considered in patients with normal or enhanced renal function.

Neurological Adverse Effects Attributable to β-Lactam Antibiotics: A Literature Review

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.

Ceftriaxone-induced Neurotoxicity in a Patient after Pancreas-Kidney Transplantation

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.

Population Pharmacokinetic Analysis of Doripenem after Intravenous Infusion in Korean Patients with Acute Infections

We investigated the population pharmacokinetics (PK) of doripenem in Korean patients with acute infections and determined an appropriate dosing regimen using a Monte Carlo simulation for predicting pharmacodynamics (PD). Patients (n = 37) with a creatinine clearance (CL_CR) of 20 to 50 ml/min or >50 ml/min who received a 250-mg or 500-mg dose of doripenem over the course of 1 h every 8 h, respectively, were included in this study. Blood samples were taken predosing and 0 h, 0.5 h, and 4 to 6 h after the fourth infusion. A nonlinear mixed-effect modeling tool was used for the PK analysis and pharmacodynamic simulation; doripenem PK were well described by a one-compartment model. The population mean values of the body weight (WT)-normalized clearance (CL/WT) and the body weight-normalized volume of distribution (V/WT) were 0.109 liter/h/kg of body weight (relative standard error, 9.197%) and 0.280 liter/kg (relative standard error, 9.56%), respectively. Doripenem CL was significantly influenced by CL_CR The proposed equation to estimate doripenem CL in Korean patients was CL/WT = 0.109 × WT × (CL_CR/57)^0.688, where CL/WT is in liters per hour per kilogram. CL in Korean patients was expected to be lower than that in Caucasian patients, regardless of renal function. The Monte Carlo simulation showed that 90% attainment of target PK/PD magnitudes could be achieved with the usual dosing regimens when the MIC was ≤1 mg/liter. However, prolonged infusions (4 h) should be considered, especially when patients have augmented renal function and for patients infected with pathogens with a high MIC. Our results provide an individualized doripenem dosing regimen for patients with various renal functions and for patients infected with bacteria with decreased susceptibility.

Cefepime-induced encephalopathy in end-stage renal disease patients

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.

Ertapenem-Induced Encephalopathy in a Patient With Normal Renal Function

Drug-induced neurotoxicity is a rare adverse reaction associated with ertapenem. Encephalopathy is a type of neurotoxicity that is defined as a diffuse disease of the brain that alters brain function or structure. We report a patient with normal renal function who developed ertapenem-induced encephalopathy manifesting as altered mental status, hallucinations, and dystonic symptoms. The patient’s symptoms improved dramatically following ertapenem discontinuation, consistent with case reports describing ertapenem neurotoxicity in renal dysfunction. Since clinical evidence strongly suggested ertapenem causality, we utilized the Naranjo Scale to estimate the probability of an adverse drug reaction to ertapenem. Our patient received a Naranjo Scale score of 7, suggesting a probable adverse drug reaction, with a reasonable temporal sequence to support our conclusion.

Drug Dosing in Critically Ill Patients with Renal Failure: A Pharmacokinetic Approach

Accurate pharmacotherapy management in the intensive care unit (ICU) patient is crucial to minimize adverse drug events. Pharmacokinetic principles including absorption, distribution, metabolism, and excretion (ADME) all play an important role in determining the fate of medications used in the critical care setting. Renal failure in this setting further alters pharmacokinetic parameters, resulting in drug dosing changes. This article highlights and applies principles of drug dosing in normal patients and in the pharmacokinetically challenging environment of critically ill patients with renal failure. Specific drug dosing tables serve as a guide for the clinician to renally adjust medication doses in the critically ill patient with renal failure.

Lesson of the month 2: An easily missed cause of confusion

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.

Use of doripenem and risk of seizure and renal impairment in US hospitalized patients: a retrospective cohort study

OBJECTIVES

A large retrospective database study was conducted to assess the incidence rate of treatment-emergent renal impairment/failure, seizure, and hemolytic anemia in doripenem and imipenem intravenous (IV)-exposed patients treated for complicated urinary tract infection (cUTI) and complicated intra-abdominal infection (cIAI) in US hospitals.

METHODS

Using the Premier Perspective™ Database (PPD), which maintains hospital discharge records for over 309 million patients, the incidence rate of treatment-emergent renal impairment/failure, seizure, and hemolytic anemia in the doripenem-treated compared with imipenem IV-treated population was examined.

RESULTS

The unadjusted doripenem rate ratio (RR) for renal impairment/failure relative to imipenem IV was 1.13 [95% confidence interval (CI) 1.07-1.21; p < 0.0001]. The unadjusted doripenem rate ratio for seizure relative to imipenem IV was 0.74 (95% CI 0.52-1.05; p = 0.07). In the comparative safety analysis, adjusted incidence rates of renal impairment/failure between doripenem-exposed patients and a propensity score-matched comparator cohort of imipenem IV-exposed patients showed no statistically significant difference in cUTI [RR = 1.02; 95% CI 0.93-1.12; p = 0.71] or cIAI (RR = 1.17; 95% CI 1.00-1.36; p = 0.05). Likewise, there was no statistically significant difference in adjusted incidence rates for seizures in doripenem-treated versus matched imipenem-treated patients for cUTI (RR = 0.69; 95% CI 0.41-1.14; p = 0.15) or cIAI (RR = 0.45; 95% CI 0.15-1.41; p = 0.17). No hemolytic anemia events were observed in this study.

CONCLUSIONS

In this large retrospective cohort study of US hospitalized patients, no statistically significant differences in the adjusted relative rates of renal impairment/failure and seizure were observed between doripenem and a propensity score-matched comparator cohort of imipenem IV patients in the treatment of cUTI and cIAI.

Seizures as adverse events of antibiotic drugs: A systematic review

OBJECTIVE

Antibiotic drugs are commonly associated with seizures. Tailoring antibiotics to the individual risk for seizures is challenged as avoidance of certain antibiotic classes may no longer be possible due to the emergence of resistant bacteria. We performed a systematic review regarding the current evidence for seizures associated with all antibiotic classes, their underlying mechanisms, and predisposing factors.

METHODS

The medical search engine PubMed was systematically screened to identify articles in English published between 1960 and 2013. All study designs were considered and evidence was assessed.

RESULTS

We included 143 articles involving 25,712 patients and 25 different antibiotics. Evidence for antibiotic-related symptomatic seizures is low to very low, mainly deriving from studies regarding β-lactams, especially unsubstituted penicillins and fourth-generation cephalosporins, as well as carbapenems, mainly imipenem, all administered in high doses or in patients with renal dysfunction, brain lesions, or known epilepsy. Evidence regarding symptomatic seizures from fluoroquinolones only relies on case reports and case series with most reports for ciprofloxacin in patients with renal dysfunction, mental disorders, prior seizures, or coadministered theophylline.

CONCLUSIONS

Evidence for an association between antibiotic drugs and symptomatic seizures is low to very low (evidence Class III-IV). Despite this, numerous reports point to an increased risk for symptomatic seizures especially of unsubstituted penicillins, fourth-generation cephalosporins, imipenem, and ciprofloxacin in combination with renal dysfunction, brain lesions, and epilepsy. During administration of such antibiotics in patients with particular predispositions, close monitoring of serum levels is advocated. As most seizures associated with cephalosporins are nonconvulsive, continuous EEG should be considered in patients with altered levels of consciousness.

Etiological prevalence of epilepsy and epileptic seizures in hospitalized elderly in a Brazilian tertiary center - Salvador - Brazil

Epilepsy in the elderly has high incidence and prevalence and is often underecognized.

OBJECTIVE

To describe etiological prevalence of epilepsy and epileptic seizures in elderly inpatients.

METHODS

Retrospective analysis was performed on elderly patients who had epilepsy or epileptic seizures during hospitalization, from January 2009 to December 2010. One hundred and twenty patients were enrolled. They were divided into two age subgroups (median 75 years) with the purpose to compare etiologies.

RESULTS

The most common etiology was ischemic stroke (36.7%), followed by neoplasias (13.3%), hemorrhagic stroke (11.7%), dementias (11.4%) and metabolic disturbances (5.5%). The analysis of etiological association showed that ischemic stroke was predominant in the younger subgroup (45% vs 30%), and dementias in the older one (18.9% vs 3.8%), but with no statistical significance (p = 0.23).

CONCLUSION

This study suggests that epilepsy and epileptic seizures in the elderly inpatients have etiological association with stroke, neoplasias and dementias.

Evaluation of the appropriateness of imipenem/cilastatin prescription and dosing in a tertiary care hospital

BACKGROUND

Imipenem/cilastatin is an antibacterial agent of the carbapenem class of β-lactams that is known to have an extremely wide spectrum of activity against Gram-positive, Gram-negative, aerobic, anaerobic, and even multidrug-resistant strains. The objective of this study was to evaluate the appropriate use of imipenem/cilastatin in a local tertiary care hospital. The study assessed the indication both empirically and after the culture results were available, the dose and dose adjustment in renal failure, as well as the incidence of seizure in hospitalized patients receiving imipenem/cilastatin.

METHODS

This observational study was conducted in a tertiary care hospital over a 3-month period. The treatment of 100 patients with imipenem/cilastatin was evaluated both empirically and after culture results were available. Analysis of the appropriateness of imipenem/cilastatin indication, dose, and monitoring of seizure frequency was based on the package insert, updated published guidelines, and clinical judgment.

RESULTS

Patients from internal medicine and intensive care units comprised approximately 50% of the population in the study. The patients received imipenem/cilastatin mainly for urinary tract infections (27%) or for sepsis of an unknown focus (22%). The use of imipenem/cilastatin empirically was appropriate in 97.2% (n=69/71) of the cases, and its use postculture in 86% of the cases. There were 29% of the patients who were not started on imipenem/cilastatin empirically. Four patients out of the 29 patients (13.8%) who were not started on imipenem/cilastatin empirically inappropriately received imipenem/cilastatin post-culture results. Thirty-three patients (33%) were not dosed appropriately, 30 of whom had renal impairment and creatinine clearance fluctuations. Only one patient developed a seizure while on imipenem/cilastatin.

CONCLUSION

The prescription of imipenem/cilastatin at our setting was mostly appropriate to what is recommended in the guidelines and the literature, although a few cases could have been managed better. Dosage adjustment, however, was not as appropriate, mainly in patients who did not have a stable creatinine clearance.

Cloxacillin-induced seizure in a hemodialysis patient

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.

Ceftriaxone-induced acute encephalopathy in a peritoneal dialysis patient

Encephalopathy is a rare side effect of third and fourth generation cephalosporins. Renal failure and preexisting neurological disease are notable risk factors. Recognition is important as discontinuing the offending agent usually resolves symptoms. We present a case of acute encephalopathy in a patient with end stage renal disease (ESRD) treated with peritoneal dialysis (PD) who received intravenous ceftriaxone for peritonitis. This case illustrates the potential severe neurologic effects of cephalosporins, which are recommended by international guidelines as first-line antimicrobial therapy for spontaneous bacterial peritonitis.

The risk of seizures among the carbapenems: a meta-analysis

OBJECTIVES

A consensus exists among clinicians that imipenem/cilastatin is the most epileptogenic carbapenem, despite inconsistencies in the literature.

METHODS

We conducted a meta-analysis of all randomized controlled trials comparing carbapenems with each other or with non-carbapenem antibiotics to assess the risk of seizures for imipenem, meropenem, ertapenem and doripenem.

RESULTS

In the risk difference (RD) analysis, there were increased patients with seizure (2 per 1000 persons, 95% CI 0.001, 0.004) among recipients of carbapenems versus non-carbapenem antibiotics. This difference was largely attributed to imipenem as its use was associated with an additional 4 patients per 1000 with seizure (95% CI 0.002, 0.007) compared with non-carbapenem antibiotics, whereas none of the other carbapenems was associated with increased seizure. Similarly, in the pooled OR analysis, carbapenems were associated with a significant increase in the risk of seizures relative to non-carbapenem comparator antibiotics (OR 1.87, 95% CI 1.35, 2.59). The ORs for risk of seizures from imipenem, meropenem, ertapenem and doripenem compared with other antibiotics were 3.50 (95% CI 2.23, 5.49), 1.04 (95% CI 0.61, 1.77), 1.32 (95% CI 0.22, 7.74) and 0.44 (95% CI 0.13, 1.53), respectively. In studies directly comparing imipenem and meropenem, there was no difference in epileptogenicity in either RD or pooled OR analyses.

CONCLUSIONS

The absolute risk of seizures with carbapenems was low, albeit higher than with non-carbapenem antibiotics. Although imipenem was more epileptogenic than non-carbapenem antibiotics, there was no statistically significant difference in the imipenem versus meropenem head-to-head comparison.

Carbapenems in the USA: focus on doripenem

The threat of antibacterial resistance continues to increase globally, and therapeutic options for the treatment of some serious infectious diseases are diminishing. The carbapenems are a potent class of broad-spectrum drugs, and their stability against hydrolysis by many important beta-lactamases make them an important weapon in the treatment of beta-lactamase-producing bacterial pathogens. This review focuses on four carbapenems of clinical importance in the USA: imipenem, meropenem, ertapenem and doripenem. After a historical review of carbapenem development, these four carbapenems are evaluated based on their mechanism of action, spectrum of activity, potency, pharmacodynamics, clinical pharmacokinetics, clinical profiles and toxicity issues.

Epileptogenic drugs: a systematic review

A wide range of substances, including drugs and illicit compounds, increase the risk of epileptic seizures. In this systematic review, the authors address the issue of the epileptogenic potential of marketed drugs, with the aims of providing criteria for the assessment of the cause-effect relationship between drug exposure and the risk of seizures; and to identify the compounds better fulfilling the requirements of an epileptogenic drug. Finding a correlation between drug exposure and occurrence of seizures does not necessarily establish a causal association. In light of the available evidence, even with these limitations, some conclusive remarks can be made on the epileptogenic potential of some active principles. Drugs with high epileptogenic potential include meperidine, sevoflurane, clozapine, phenothiazines and cyclosporine. Drugs with intermediate epileptogenic potential include propofol, maprotiline, tricyclic antidepressants and chlorambucil. Drugs with low epileptogenic potential include fluorquinolones, carbapenems, bupropion and iodinated contrast media. Drugs with minimal or inconclusive epileptogenic potential include interferon alpha.

APPROPRIATE AND TIMELY EMPIRICAL ANTIMICROBIAL TREATMENT OF ICU INFECTIONS - A ROLE FOR CARBAPENEMS

Treatment of serious nosocomial infections in the intensive care unit requires swift, effective, well-tolerated and appropriate therapy from the outset. The consequences of inappropriate treatment, i.e. the use of antibiotics that are ineffective against the causative pathogen(s) or delayed therapy, are numerous and impact negatively upon both the patient and the ever-dwindling healthcare resources in many hospitals. Although antibiotics have revolutionised the treatment of infections, their inappropriate and untimely use within the intensive care setting has led to the emergence and spread of antibiotic-resistant bacteria worldwide. Consequently, to ensure successful patient outcomes (reduce morbidity and mortality), it is important that any antibiotic treatment employed is right first time. Treatment of serious infections in the intensive care unit requires an empirical stratagem providing broad-spectrum coverage to a wide range of suspected or difficult-to-treat pathogens such as Pseudomonas aeruginosa. However, to prevent the errors of the past, this needs to be tailored as soon as the pathogen has been identified and resistance patterns are known. The carbapenems are potent parenteral antibiotics, with an ultra-broad spectrum of activity that encompasses multi-drug resistant and difficult-to-treat Gram-negative bacteria. Clinical trial data supports the clinical effectiveness of these agents in patients with difficult to treat pathogens.

Population pharmacokinetic-pharmacodynamic target attainment analysis of imipenem plasma and urine data in neonates and children

BACKGROUND

Population pharmacokinetic (PK)-pharmacodynamic target attainment analysis of imipenem was performed to elucidate the PK properties in neonates and children and to rationalize and optimize dosing regimens.

METHODS

Population PK models were separately developed in neonates and children by simultaneously fitting plasma and urine data from 60 neonates and 39 children. The newly developed models were then used to estimate the probability of attaining the pharmacodynamic target (40% of the time above the minimum inhibitory concentration) against clinical isolates of common bacteria in pediatric patients.

RESULTS

The data were best described by a 1-compartment model in neonates and a 2-compartment model in children, respectively. Renal clearance in children (0.187 L/h/kg) was double that of neonates (0.0783 L/h/kg), whereas the volume of distribution at steady-state was approximately 1.8-fold larger in neonates (0.466 L/kg) than in children (0.260 L/kg). Age was not a statistically significant covariate in the PK of both groups. Infusions (0.5 h) of 15 mg/kg every 8 h (45 mg/kg/day) and 25 mg/kg every 12 h (50 mg/kg/day) were shown to be sufficient against common bacterial isolates in both patient populations. However, 1.5-h infusions of 25 mg/kg every 8 h (75 mg/kg/day) in neonates and 25 mg/kg every 6 h (100 mg/kg/day) in children were required to be effective against Pseudomonas aeruginosa (minimum inhibitory concentration for 90% of the isolates=16 μg/mL).

CONCLUSIONS

These results explain the changes in imipenem PK properties during the human growth process and provide guidance for tailoring dosing regimens in each pediatric age group.

Cefepime- Induced Non-Convulsive Status Epilepticus (NCSE)

Cefepime is a fourth-generation B-lactam cephalosporin, commonly used in immunosuppressed patients. Neurotoxicity, which present as nonconvulsive status epilepticus (NCSE), has been reported previously especially in adult patients with impaired renal function. We present a case of cefepime induced NCSE after recovering from acute renal failure. A 71-year-old woman was hospitalized for right lower lobe lobectomy after diagnosis of lung cancer. Although she had successful lobectomy, she underwent several post operative complication including operation site bleeding, acute renal failure, acute respiratory distress syndrome, and atypical pneumonia. Her renal failure was prerenal type after massive operation site bleeding, and continuous renal replacement therapy (CRRT) were started for renal replacement treatment. After 5 days of renal replacement therapy, her serum creatinine level was much improved from 2.7 mg/dL to 1.33 mg/dL. Cefepime renal dose were started, when atypical pneumonia became resistant to imipenem and vancomycin. After 5th day of cefepime use, the patient became stupor and developed one episode of brief generalized myoclonic seizure. Her electroencephalograph (EEG) revealed 2–3 Hz generalized sharp and with impression of NCSE, she was started on anti-epileptic treatment. Clinical symptoms improved 3 days after discontinuation of cefepime. She was than diagnosed with cefepime induced non convulsive status epilepticus. Anti-epileptic treatments were than discontinued uneventfully. Awareness of the potential neurotoxic clinical manifestations of various antibiotics and high degree of vigilance in critically ill patients is essential in identifying a potentially serious though reversible complication of antibiotic therapy.

Ceftiaxone-induced neurotoxicity: case report, pharmacokinetic considerations, and literature review

Ceftriaxone is widely used in patients for the treatment of serious gram-negative infections. Ceftriaxone can induce some potential side effects, including neurotoxicity, however, nonconvulsive status epilepticus has rarely been reported. We report a case of acute reversible neurotoxicity associated with ceftriaxone. A 65-yr-old woman with chronic kidney disease developed altered consciousness during ceftriaxone treatment for urinary tract infection. The electroencephalogram demonstrated continuous bursts of generalized, high-voltage, 1 to 2 Hz sharp wave activity. Neurologic symptoms disappeared following withdrawal of ceftriaxone. The possibility of ceftriaxone-induced neurotoxicity should be considered in patients developing neurological impairment during ceftriaxone use, and the discontinuation of the drug could lead to complete neurological improvement.

Ceftriaxone-induced acute reversible encephalopathy in a patient with enteric fever

Ceftriaxone is a commonly used, third-generation cephalosporin. Encephalopathy is a rare side effect of third- and fourth-generation cephalosporins. Renal failure and previous disease of the central nervous system predispose to this neurotoxicity. We describe a case of acute transient encephalopathy in a patient treated with ceftriaxone for enteric fever infection. Early detection of this complication is relevant given that stopping the drug usually reverts the neurological syndrome.