Delayed-Onset Cefepime Neurotoxicity in a Patient With Epilepsy and ESRD

Cefepime is associated with central nervous system toxicity, particularly in patients with renal impairment. Cefepime-induced neurotoxicity (CIN) can manifest as seizures, encephalopathy, and other neurologic disturbances, often mimicking other conditions in complex patients. In this case report, we report a 42-year-old woman with end-stage renal disease on hemodialysis, systemic lupus erythematosus, and epilepsy who presented with recurrent seizures after four months of indefinite cefepime therapy for chronic Pseudomonas aeruginosa catheter-related bacteremia. Despite therapeutic clobazam levels and stable metabolic parameters, she experienced multiple seizure episodes during a dialysis session. Further investigation revealed characteristic electroencephalography (EEG) for cefepime neurotoxicity as well as elevated serum cefepime level. Following immediate cefepime discontinuation and transition to ceftazidime with optimization of antiepileptic therapy, the patient remained seizure-free for the remainder of hospitalization. This case highlights the diagnostic challenge of cefepime neurotoxicity in patients with multiple comorbidities, particularly those with baseline seizure disorders and renal dysfunction. Clinicians should maintain a high suspicion for CIN in patients with renal impairment presenting with new or worsening seizures, utilize EEG findings and therapeutic drug monitoring when available, and promptly discontinue cefepime when toxicity is suspected.