What is the next best step in managing a 1-year-old woman with acute non-traumatic intracranial hemorrhage in the left cerebellum, altered mental status, hallucinations, and generalized involuntary twitching movements, currently on cefepime (Cefepime) and vancomycin (Vancomycin) for hospital-acquired pneumonia, with a normal computed tomography (CT) head and electroencephalogram (EEG) showing generalized triphasic waves?

From the Guidelines

The next best step in management for this patient is replacing cefepime with another antibiotic, as the patient's presentation strongly suggests cefepime-induced neurotoxicity, a recognized adverse effect of cefepime, particularly in patients with renal impairment or those receiving high doses, as supported by studies such as 1. The patient's symptoms of altered mental status with drowsiness, hallucinations, and involuntary twitching movements, along with the EEG showing generalized triphasic waves without epileptiform activity, are consistent with cefepime-induced neurotoxicity. The temporal relationship between cefepime initiation four days ago and the development of neurological symptoms supports this diagnosis.

Key Considerations

• The absence of new findings on CT and the characteristic EEG pattern further strengthen the conclusion that cefepime-induced neurotoxicity is the most likely cause of the patient's symptoms.
• Discontinuation of cefepime and substitution with an alternative antibiotic with less neurotoxic potential, such as meropenem, is the most appropriate intervention, as suggested by guidelines such as 1.
• The patient should be monitored closely after the medication change, as symptoms typically resolve within 24-72 hours after cefepime discontinuation.
• Renal function should be assessed, as impaired clearance often contributes to this adverse effect, and studies such as 1 highlight the importance of considering renal function when using beta-lactam antibiotics.

Management of Seizures

• Starting antiepileptic medications like Keppra would not address the underlying cause of the patient's symptoms, and additional neuroimaging or lumbar puncture would be unnecessary given the clear relationship between the symptoms and cefepime administration, as supported by studies such as 1.
• According to guidelines such as 1, clinical seizures or electrographic seizures in patients with a change in mental status should be treated with antiseizure drugs, but in this case, the primary intervention should be discontinuation of the offending antibiotic.

Prioritization of Interventions

• The most critical step is to address the potential cause of the patient's symptoms, which is cefepime-induced neurotoxicity, rather than pursuing additional diagnostic tests or interventions that may not address the underlying issue, as emphasized by studies such as 1.

From the Research

Management of Acute Non-Traumatic Intracranial Hemorrhage

The patient's presentation with a change in mental status, including drowsiness and hallucinations, and new generalized involuntary twitching movements, suggests a possible seizure or status epilepticus. The CT head shows no abnormalities, but the EEG shows generalized triphasic waves with no epileptic form activity.

Next Best Step in Management

Considering the patient's symptoms and EEG findings, the next best step in management would be to:

• Start keppra (levetiracetam) as a prophylactic measure to prevent seizures, as suggested by studies 2, 3, 4. Levetiracetam has been shown to have neuroprotective effects and improve cognitive outcomes in patients with intracranial hemorrhage.
• Obtain an MRI to further evaluate the patient's brain and rule out any other potential causes of her symptoms.
• Continue to monitor the patient's EEG and clinical status closely.

Rationale for Not Replacing Cefepime with Another Antibiotic

There is no clear indication to replace cefepime with another antibiotic at this time, as the patient's hospital-acquired pneumonia is being treated appropriately.

Rationale for Not Performing a Lumbar Puncture

A lumbar puncture is not immediately necessary, as the patient's symptoms and EEG findings suggest a possible seizure or status epilepticus, rather than an infectious or inflammatory process.

Key Points

• Levetiracetam (keppra) may be a suitable option for seizure prophylaxis in patients with intracranial hemorrhage, due to its neuroprotective effects and improved cognitive outcomes 2, 3, 4.
• The patient's EEG findings and clinical symptoms suggest a possible seizure or status epilepticus, which should be treated promptly.
• Further evaluation with an MRI is necessary to rule out other potential causes of the patient's symptoms.