A 78-year-old man with a personal history of allergy to sulphonamides and thiazides, ex-smoker and ex-drinker, chronic bronchitis with home oxygen, chronic atrial fibrillation, peripheral arteriopathy and chronic venous insufficiency. His usual treatment was furosemide, pentoxifylline, acenocoumarol, omeprazole, oral iron and paracetamol. She was admitted to our hospital for antibiotic treatment and treatment of mixed ulcers with a torpid evolution.
Physical examination on admission: blood pressure 100/61 mmHg, mixed ulcers with exudate on both lower limbs; the rest of the examination was of no interest.
Blood tests on admission: creatinine 1.5 mg/dl (previous 1.4-1.6 mg/dl) (Cockcroft-Gault 28 ml/min), uric acid 9.4 mg/dl, albumin 3.2 g/dl, haematocrit 27.8 %, haemoglobin 8.9 g/dl, other blood tests normal. Culture of the exudate from the ulcers was positive for Pseudomona aeruginosa and Streptococcus beta non-A non-B sensitive to cefepime.
Antibiotic treatment was started with cefepime at a dose of 2 grams every 8 hours i.v. for 10 days. On the fourth day of antibiotic treatment renal function remained stable with serum creatinine of 1.4 mg/day. On the tenth day of cefepime treatment (when the antibiotic was discontinued), previous renal function deterioration was noted, with serum creatinine of 2.8 mg/dl. One day after discontinuation of cefepime, this deterioration of renal function persisted and the patient also presented confusional syndrome and restlessness, for which reason the Nephrology and Neurology Departments were consulted.
The anamnesis was impossible to perform due to the patient's excitability and restlessness. Serum therapy with isotonic saline solution was started. Renal ultrasound showed reduced kidney size (8 cm).
An electroencephalogram (EEG) was performed, which was pathological, with the presence of bilateral electrical status (constant bilateral slow, sharp and triphasic wave discharges). A cerebral axial computed tomography scan was also performed, with the only finding being cortico-subcortical atrophy.
Given the suspicion of neurotoxicity caused by cefepime, phenytoin was prescribed with a loading dose of 1000 mg i.v. and then 100 mg/8 hours i.v., and urgent haemodialysis was performed through a catheter in the left femoral vein for 3 hours. Pre-dialysis plasma levels of cefepime (24 hours after antibiotic discontinuation) were measured and were 50,087 µg/ml. After the first dialysis session the patient was calmer and more alert.
Given the clinical improvement after the first dialysis session and considering the high mortality rate related to cefepime-related neurotoxicity, three more haemodialysis sessions were performed, with undetectable pre-dialysis cefepime levels in the fourth session.
The new EEG, after 4 dialysis sessions, showed a dramatic improvement over the previous recording. After three days without dialysis, serum creatinine remained at 2.7 mg/dl.
One week after discharge from hospital, the recovery of renal function (creatinine 1.6 mg/dl) was observed at the outpatient clinic, which persisted at these levels two months after discharge.

