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Neurotoxicity is a rare side effect of Cefepime o Encephalopathy includes altered mental status, confusion, hallucinations, cognitive disturbances, myoclonus, seizures, nonconvulsive status epilepticus Cefepime 0.05% chance of seizures (MIMS) especially in renal insufficiency Mechanism of action: o Broad spectrum, 4th generation cephalosporin (contains beta lactam ring) o Hepatic metabolism but renal excretion Dose for normal renal function = 3g BD Dose adjustment if eGFR <50ml/min Half life in eGFR <10ml/min 5x longer o Inhibit GABA-A receptor blockade This is concentration-dependent in CSF o Risk factors Renal insufficiency But also described in pts w/normal renal function!!! (and cirrhosis) (ageing disease processes e.g. HTN) Disruption of BBB e.g. CVA ?Decreased seizure threshold not confirmed

Take-home messages - awareness of neurotoxic side effects of cefepime o also applies to other 3rd/4th gen cephalosporins, beta lactams, quinolones - non-convulsive status can be a challenged to recognise in those w/o b/g of epilepsy severly ill w/many potential causes for decreased consciousness safety precaution dose adjustment &/or monitoring of cefepime levels in o renal impairment o elderly o multiple medical co-morbidities

Seizures abnormal electrical activity in the brain presenting as motor, sensory or autonomic dysfunction

Epilepsy - recurrent, unprovoked seizures due to some chronic underlying process Classification epilepsy - Partial seizures o Simple seizures consciousness not impaired, motor, sensory or autonomic Motor Jacksonian march motor jerks start from the hand then progress up the arm) Todds paralysis paralysis following seizures Sensory Paraesthesia Autonomic Flushing, sweating few mins then resolves o Partial complex consciousness impaired Usually begin with an aura, some stereotypic e.g. epigastric sensations going to the head, depersonalisation automatism e.g. chewing, lip smacking, picking movements of the hands o Partial complex with secondary generalisation Starts off as a focal seizure, then progression of abnormal electrical activity to both hemispheres tonic-clonic seizures - Primary generalised o Absence (petit mal) sudden, brief lapses in consciousness without loss of postural control blank spell; no post-ictal confusion o Tonic clonic (grand mal) 2 phases, starts off with stiffening of muscles/tonic contraction of laryngeal muscles (ictal cry), respiration impaired, clonic (jerks) HR/BP increased, pupil dilatation due to sympathetic activity Post-ictal phase characterised by unresponsiveness, stridorous breathing, salivation, bladder/bowel incontinence; ~1-2h confusion/headache/fatigue o Atonic sudden loss of postural muscle tone lasting 1-2s, consciousness briefly impaired o Myoclonic brief muscle contractions in one part of the body Metabolic disorder, degenerative brain diseases and anoxic brain injury - Unclassified Neonatal seizures Infantile spasm Causes - Metabolic (.: need to check bloods, electrolytes, quick BSL)

o Hypoglycaemia o Hypo/hypernatraemia o Hypo/hypercalcaemia o Hypomagnesaemia o Renal/hepatic encephalopathy CVA especially embolic stroke (hypoperfusion of neurons irritability, fire off abnormally) SOL

Status epilepticus - medical emergency in which there is either more than 30 minutes of continuous seizure
activity; or there are two or more sequential seizures without recovery of full consciousness between two seizures

Continuous seizures with impaired consciousness in the inter-ictal period Duration of seizure activity 15-30 mins

Stop the seizure Look for reversible causes -