From the Guidelines
When choosing antibiotics for patients with seizures or those on antiepileptic medications, the safest options include beta-lactam antibiotics with lower neurotoxicity thresholds, such as cefepine or ceftazidin, but with careful monitoring of plasma free concentrations to avoid exceeding eight times the MIC (1). To minimize the risk of neurotoxicity, it is essential to consider the patient's renal function and adjust the antibiotic dosage accordingly. Some key points to consider when selecting antibiotics for patients with seizures or those on antiepileptic medications include:
- Avoiding antibiotics with high neurotoxicity thresholds, such as fluoroquinolones and carbapenems
- Monitoring plasma free concentrations of beta-lactam antibiotics to avoid exceeding eight times the MIC (1)
- Being aware of potential interactions between antibiotics and antiepileptic drugs, such as enzyme inhibition or induction
- Informing healthcare providers about all medications being taken, including over-the-counter products, to prevent potential drug interactions
- Adjusting dosage based on kidney function, weight, and severity of infection Some specific antibiotic regimens that may be considered include:
- Cefepine 1-2 grams every 8-12 hours, with monitoring of trough concentrations to avoid exceeding 22 mg/L (1)
- Ceftazidin 1-2 grams every 8-12 hours, with monitoring of trough concentrations to avoid exceeding 64 mg/L (1) It is crucial to prioritize the patient's safety and adjust the antibiotic regimen as needed to minimize the risk of neurotoxicity and interactions with antiepileptic medications (1).
From the FDA Drug Label
Seizures and other adverse CNS experiences have been reported during treatment with meropenem for injection. These experiences have occurred most commonly in patients with CNS disorders (e.g., brain lesions or history of seizures) or with bacterial meningitis and/or compromised renal function The concomitant use of meropenem and valproic acid or divalproex sodium is generally not recommended. Consider administration of antibacterial drugs other than carbapenems to treat infections in patients whose seizures are well controlled on valproic acid or divalproex sodium.
The safest approach is to avoid using meropenem in patients with seizures and antiepileptics, especially those on valproic acid or divalproex sodium, due to the risk of breakthrough seizures and drug interactions. Instead, consider alternative antibiotics that do not have significant interactions with antiepileptic drugs 2.
From the Research
Safest Antibiotics for Patients with Seizures and Antiepileptics
- The safest antibiotics to use in patients with seizures and antiepileptics are those with a low proconvulsive potential 3.
- Antibiotics such as macrolides and antitubercular medications may be safer options as they have a lower risk of inducing seizures compared to penicillins, cephalosporins, fluorochinolons, and carbapenems 3, 4.
- It is essential to select an antibiotic that does not interact with the patient's antiepileptic medications to avoid decreasing or increasing the plasma concentration of the antiepileptic drug, which can lead to seizures or drug-associated neurotoxicity 3, 5.
Factors to Consider When Choosing an Antibiotic
- Patients with a history of seizures or epilepsy should be treated with caution when administering antibiotics, and the dose should be adequately adjusted, especially in individuals with renal failure 3, 4.
- The presence of conditions that damage the blood-brain barrier, such as cerebral trauma or encephalitis, can increase the risk of seizures during antibiotic therapy 3.
- Close monitoring of serum levels and continuous EEG should be considered in patients with altered levels of consciousness, especially when administering cephalosporins 3, 4.
Interactions between Antibiotics and Antiepileptics
- Certain antibiotics, such as carbapenems, can interact with antiepileptic agents, causing a decrease or increase in the plasma concentration of the latter, which can lead to seizures or drug-associated neurotoxicity 3, 5.
- Antiepileptic drugs with cytochrome P450 enzyme-inducing properties, such as carbamazepine and phenytoin, can worsen comorbid coronary and cerebrovascular disease and facilitate the development of osteopenia and osteoporosis 6.
- Drugs like levetiracetam, gabapentin, or pregabalin can be recommended in patients with cancer, transplants, anticoagulant treatments, or HIV infection due to their favorable pharmacokinetic profile and lack of significant interactions 5.