Elvia Rivera-Figueroa, MD, MPH,
Pediatric Critical Care Fellow
UMMC
Jackson, MS
Disclosure information not submitted.
Whitney Mays, PharmD
Clinical Pharmacist
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Sara Jones, PharmD
Clinical Pharmacist
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Carrie Henderson, MD
Associate Professor, School of Medicine, Department of Pediatrics, University of Mississippi Medical
University of Mississippi Medical Center, United States
Disclosure information not submitted.
Title: Inadvertent Intrathecal Cefepime Administration: A Neurological Emergency
Case Report Body:
Introduction: Cefepime neurotoxicity often presents as confusion, hallucinations, convulsions, encephalopathy, and seizures due to the ability of the drug to cross the blood-brain barrier causing inhibition of GABA(A) receptors. Cefepime neurotoxicity can be neurologically devastating with toxic cerebrospinal fluid (CSF) levels greater than 20,000 ng/mL. Most case reports identified are a result of acute kidney injury leading to increased drug levels; however, we present a case of inadvertent direct administration of cefepime into the intrathecal space.
Description: A 10 year old male with a history of a traumatic brain injury involving a decompressive craniotomy presents with persistent CSF otorrhea. His hospital course began with a 10-day cefepime course and lumbar drain placement followed by a trans-mastoid repair with ossiculoplasty and right tympanostomy tube for drainage monitoring. On post-operative day 1, patient began complaining of itching that progressed to muscle rigidity and then tonic-clonic seizures with a fever of 104.6F. It was discovered that cefepime 1,400 mg was directly infused into his lumbar drain approximately two hours prior. Patient was immediately intubated, given multiple benzodiazepine doses, dexamethasone, propofol, pentobarbital, and intermittent paralytic doses. He had a computerized tomography scan done and was started on continuous electroencephalogram. Additional antiepileptic medications administered consisted of levetiracetam, valproate, and fosphenytoin. Continuous veno-venous hemodiafiltration (CVVHDF) was initiated and the lumbar drain was set to drain 10 ml/hr. On day of insult (D0I-0), initial CSF cefepime level was 760,597 ng/mL followed by 311,743 ng/mL on DOI-1. The first serum cefepime level drawn on DOI-1 was 6,282 ng/ml and was undetectable by DOI-3. CSF cefepime levels continued to trend down while on CVVHDF and were undetectable on DOI-7. Patient was later discharged to inpatient rehabilitation on baclofen, levetiracetam, parampanel, phenobarbital wean, and pregabalin.
Discussion: Emergent intubation and seizure control with antiepileptics, particularly benzodiazepines and barbituates, and initiation of CVVHDF to decrease CSF cefepime levels were vital in the treatment of this first documented direct intrathecal cefepime toxicity.