A 78-year-old male patient with a history of chronic allergy to thiazides, ex-smoker and drinker, chronic bronchitis with home oxygen, chronic atrial fibrillation, peripheral arteriopathy and venous insufficiency
The usual treatment was furosemide, pentoxyphylline, acenocoumarol, oral iron and paracetamol.
He was admitted to our hospital for antibiotic treatment and cures of mixed ulcers of torpid evolution.
Physical examination at admission: blood pressure 100/61 mmHg, mixed ulcers with exudate in both lower extremities, rest of the examination without interest.
Blood analysis at admission was: creatinine 1.5 mg/dl (previous 1.4-1.6 mg/dl) (Cockcroft-Gault), normal hemoglobin, 8.92 mg/dl, hematocrit 28 ml/dl,
Culture of the ulcer exudate was positive for Pseudomona aeruginosa and non-B cefepime-sensitive Streptococcus beta.
Antibiotic treatment with cefepime was established 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 treatment with cefepime (when the antibiotic was suspended), it was found that there was a deterioration of previous renal function, with serum creatinine of 2.8 mg/dl. One day after cephaepime was suspended.
The anamnesis was impossible to perform due to the patient's excitability and uneasiness.
Serum therapy was established with isotonic saline.
Renal ultrasound showed decreased kidney size (8 cm).
An electroencephalogram (EEG) was performed, which was pathological, with the presence of bilateral electrical status (constant bilateral discharges of slow, acute and triphasic waves).
Cerebral computerized axial tomography was also performed with the only finding of a cortico-subcortical anomaly.
3 suspected cefepime-induced neurotoxicity phenytoin was prescribed at a loading dose of 1000 mg IV and then 100 mg/8 hours IV, and an emergency catheter was placed in the left vein via an emergency hemodialysis catheter.
Pre-dialysis cefepime plasma levels were quantified (24 hours after antibiotic discontinuation), which were 587 μg/ml.
After the first dialysis session, the patient was found to be more conscious and conscious.
Given the clinical improvement after the first dialysis session and considering the high mortality rate related to cefepime-related neurotoxicity, another three more hemodialysis sessions were performed, with undetectable levels of cefepime in the fourth pre-dime session.
The new EEG after 4 dialysis sessions showed a spectacular improvement compared to the previous recording.
After three days without dialysis, serum creatinine increased by 2.7 mg/dl.
One week after hospital discharge, the outpatient clinic showed recovery of renal function (creatinine 1.6 mg/dl), which persists at these levels two months after discharge.
