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Medication-induced delirium — SCE Acute Medicine MCQ

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HardMedicine in the elderlyMedication-induced deliriumSCE Acute Medicine

A patient with eGFR 18 mL/min/1.73 m² receives unadjusted cefepime for four days. He develops fluctuating aphasia, confusion and stimulus-induced myoclonus; EEG shows generalised periodic discharges on the ictal–interictal continuum. Which intervention addresses the most likely cause?

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Reveal the answer and explanation

Correct answer: B — Stop cefepime, maintain alternative antimicrobial cover and consider haemodialysis

Explanation lettering: C = shown as A · D = shown as C · E = shown as D · A = shown as E

B is correct. Cefepime is renally cleared and can accumulate to produce encephalopathy, aphasia, myoclonus and non-convulsive status, often after several treatment days. Withdrawal is central; severe or refractory toxicity may improve faster with haemodialysis while infection remains covered by an alternative. Haloperidol and levodopa do not remove the cause, dose escalation worsens exposure, and flumazenil has no mechanistic role.

Reference: Systematic review: cefepime-induced neurotoxicity: https://pmc.ncbi.nlm.nih.gov/articles/PMC5686900/