Abstracts

Rationale: Cefepime is a fourth generation cephalosporin antibiotic used for gram negative sepsis. Its neurotoxicity was first reported in 2000 in two patients who developed nonconvulsive status epilepticus (NCSE) which subsided after cefepime discontinuation. Several more reports and publications followed and despite these, the neurotoxicity of cefepime and other antibiotics remains frequently unrecognized and underappreciated. An initial survey distributed to 30 providers at our institution, revealed that only 30% were aware of the EEG abnormalities associated with cefepime use. The purpose of this study was to assess in a single institution providers' practices and awareness of cefepime neurotoxicity when ordering continuous video-EEG monitoring (cVEEG) to evaluate patients with mental status change. Methods: This is a retrospective study of critically ill patients undergoing cVEEG for mental status change from January through February 2016. A total of 140 patients were identified. Charts of patients receiving cefepime during cVEEG monitoring were reviewed. Patients who sustained anoxic insults were excluded from the analysis. Individual electronic medical records were reviewed for demographics, past medical and surgical history, pertinent medications, cranial imaging, cVEEG monitoring results, as well as patients' outcomes. cVEEG findings were classified into: those who had seizures/status epilepticus, epileptiform discharges, generalized theta-delta slowing, and those with normal studies. Results: A total of 140 patients were identified. Among these patients, 21% (n=29) received cefepime during monitoring; hence, included in the analysis. Median age was 51 years and 16 patients were women. Conventional brain imaging of Computed-Tomography(CT) or Magnetic Resonance Imaging (MRI) were available for 97% (n=28) of patients, and 1 patient had ultrasonic encephalogram. History of epilepsy was identified in 24% (n=7) of study patients. Epileptiform discharges was the most common finding noted in 31% (n=9) of patients with no prior history of epilepsy; 56% (n=5) of which had unremarkable brain imaging. Of those, there were 3 patients (33%) presented in status epilepticus or had seizures. One patient with end stage renal disease developed periodic epileptiform discharges and 18% (n=5) patients who had epileptiform discharges on cVEEG, had unremarkable brain imaging and no prior history of epilepsy. Conclusions: Even though cefepime-associated neurotoxicity is well documented in the literature, it is still commonly used in critically-ill patients. Caution is required before use of cefepime in populations at higher risk; such as those with known history of epilepsy, intracranial injury and/or renal insufficiency. Further interventions such as staff education and an electronic alert system when ordering cefepime could improve patient care. Funding: none