B48-03 Multifactorial Encephalopathy in Sepsis: Cefepime Toxicity as the Hidden Culprit

Introduction Cefepime-induced neurotoxicity (CIN) is a well-documented but often underrecognized complication, particularly in elderly patients with renal impairment. It typically presents as altered mental status (AMS), with hallmark EEG findings such as triphasic waves and, in some cases, patterns along the ictal-interictal continuum (IIC) suggestive of nonconvulsive status epilepticus. Despite its prevalence, there are no standardized treatment guidelines. Management strategies vary, ranging from cefepime withdrawal alone to combinations with antiepileptic therapy or hemodialysis. We present a case of suspected CIN in a septic elderly patient with AKI, whose encephalopathy persisted despite standard interventions and ultimately improved following dialysis. Case Presentation An 82-year-old female with a history of hypertension, hyperlipidemia, OSA, GERD, osteoporosis, and stage II endometrial carcinoma was hospitalized abroad for pneumonia and Group B Streptococcus bacteremia complicated by septic arthritis. She underwent multiple joint washouts and was treated with meropenem and vancomycin, later switched to daptomycin. Upon transfer to the U.S., she received additional washouts and was discharged on IV cefepime and vancomycin. While receiving home infusions, routine labs revealed severe AKI, hypokalemia, and a supratherapeutic vancomycin level. She was advised to present to the ED, where she was febrile, tachypneic, and encephalopathic. Labs showed neutropenia, anemia, and elevated troponin. She was admitted for sepsis and AKI, then transferred to the ICU for worsening AMS and respiratory distress. EEG revealed triphasic waves and IIC patterns. Lumbar puncture was performed due to concern for CNS infection. She was started on Keppra and broad-spectrum antibiotics. Despite cefepime discontinuation and antiepileptic therapy, her encephalopathy persisted. Two sessions of hemodialysis were performed, after which her mental status improved significantly. She underwent multiple I&D procedures for septic arthritis and was eventually extubated and transferred to the medical floor. Conclusion This case underscores the diagnostic and therapeutic complexity of cefepime-induced neurotoxicity. While EEG findings and clinical suspicion prompted early intervention, standard measures were insufficient. Hemodialysis ultimately led to neurologic recovery, highlighting its role when other strategies fail. Given the lack of standardized management, this case contributes to the evolving understanding of CIN and emphasizes the need for heightened clinical vigilance and individualized treatment approaches. This abstract is funded by: none