Cefepime is a popular antibiotic due to high efficacy and extended-spectrum activity, though is associated with cefepime-induced neurotoxicity (CIN), particularly in patients with renal disease. We present a case of cefepime-induced non-convulsive status epilepticus (NCSE) in end-stage renal disease (ESRD) that did not improve with peritoneal dialysis (PD), but resolved with continuous renal replacement therapy (CRRT).

CIN may present with encephalopathy, myoclonus, or NCSE. A proposed etiology of CIN is cefepime-induced antagonism of gamma-aminobutyric acid.  Cefepime exhibits linear pharmacokinetics, with high drug concentration accumulation in renal disease. There is minimal evidence on the efficacy of treating CIN with PD. Limited data report cefepime elimination by hemodialysis up to 40-68% over 3 hours versus peritoneal dialysis up to 26% over 72 hours.

Case report and literature review.

53-year-old woman with ESRD on PD (Cr 11.7, Cr Cl 2 ml/min) admitted for community-acquired pneumonia and acute on chronic renal failure with subsequent hyperkalemic cardiopulmonary arrest lasting 5 minutes. She was initially placed on CRRT and started on full-dose cefepime. She  was extubated the day following admission and transitioned back to intermittent PD. On hospital day 3, she developed encephalopathy and multifocal myoclonus. Continuous electroencephalogram showed rhythmic, 3 Hz, generalized periodic discharges consistent with NCSE. Cefepime was discontinued; lorazepam, levetiracetam, and valproic acid were administered; and continuous PD was initiated for 36 hours without clinical or EEG response. She transitioned to CRRT with dramatic clinical and electrographic improvement within 24 hours.

Evidence on the use of PD in patients with CIN is limited, though our case and the minimal available data suggest that PD may be less effective in treating CIN than hemodialysis. Patients receiving PD who develop encephalopathy, myoclonus, and/or NCSE in association with cefepime should be considered for early transition to hemodialysis.