Each year, June 27th is observed as National HIV Testing Day (NHTD). This year’s NHTD theme is “Take the Test & Take the Next Step.” The act of getting tested is the first step in either treatment or prevention that leads to individuals being empowered to live long and healthy lives.
HIV testing is the pathway to engaging in care to keep yourself healthy, regardless of the test result. People who receive a negative test result can take advantage of HIV prevention tools such as pre-exposure prophylaxis (PrEP), condoms, and other sexual health services such as vaccines and testing for sexually transmitted infections. People who receive a positive test result can rapidly start HIV treatment (antiretroviral therapy, or ART) to stay healthy.
The Nebraska Medicine/UNMC Specialty Care Clinic specializes in the prevention and treatment of HIV. Our clinic is staffed with doctors, nurse practitioners, pharmacists, nurses, social workers, and more! We are all here to provide the highest level of care in a judgement-free atmosphere. There is a wide range of prevention and treatment options available and we would be happy to review your best options with you. If you or someone you know could potentially benefit from HIV testing, we invite you to our clinic, located at 804 South 52nd Street Omaha, NE 68106. We can also be reached at 402-559-2666. We look forward to serving you!
Content adapted from HIV.gov, visit the link for more information about National HIV Testing Day.
The following reflection was provided by graduating UNMC ID fellow, Dr. Mackenzie Keintz.
Dr. Keintz will be transitioning to an infectious diseases faculty position here at UNMC ID! Congrats Mackenzie!
“My mentor, Dr. Jasmine Marcelin, likes to joke that I decided to go into infectious disease in-utero. While this is somewhat of an exaggeration, I did start this journey to become an infectious disease physician before I ever stepped foot into medical education. The journey was long, over a decade since I made the decision but now as I stand on the precipice of being an independent ID doctor, I feel significant gratitude for the road that has led me here.
I started at UNMC in 2018 as an internal medicine resident. I quickly found a home in the division of infectious disease. The mentorship that followed affirmed my decision to pursue ID and eventually persuaded me to stay here at UNMC for my fellowship training.
Although I could spend hours telling you about the wonderful training I received during fellowship about all manners of infectious disease, the thing that has meant the most to me has been the relationships I have built with both faculty and my co-fellows. It has been a wonderful experience learning from some of the best clinical and research clinicians and pharmacists in the field. My practice style has been influenced by each one of you throughout the years, and the combination has made me a better physician. The mentorship I have received has prepared me to excel in the field and I cannot thank you all enough.
As I transition to the faculty, I aspire to embody the compassion of Dr. Marcelin, the stewardship of Dr. Van Schooneveld, the leadership skills of Dr. Rupp, the thoroughness of Dr. Schnaubelt, the educational aptitude of Dr. Cortes, the kindness of Dr. Walker and many other skills imparted by the faculty I have had the privilege to work alongside. The lessons I have learned from each of you are endless, and I am immensely grateful for the profound influence you’ve had on me. I am so excited to join this exceptional division for another year and I hope I can make even a fraction of the impact you have all given me to the next class of fellows, residents, and students. Thank you all!”
– Dr. Mackenzie Keintz, ID physician and graduating UNMC ID fellow, 2023
The UNMC ID Division is launching Achieving Equitable Health Outcomes in Nebraska, a program to support Nebraska-based organizations in improving health equity in alignment with the Joint Commission’s new priority. See the flyer below and check out this linked website for more information.
Interested in learning more? The first meeting is TODAY, June 21st, at 12pm.
Research Digest is a periodic installment that recognizes the world-class clinical research performed right here at UNMC ID.This week, we feature three articles exploring infectious complications associated with ventilator use. As always, be sure to check out the linked full articles for more details.
The first article, co-authored by Dr. Kelly Cawcutt and Dr. Trevor Van Schooneveld (pictured right), provides commentary on the usefulness of risk factors and outcome research on ventilator-associated events (VAE), which include pneumonia as well as a diverse set of additional disorders such as pulmonary edema and mucus plugging among many others. They review multiple previous studies which have attempted to characterize the impact of adverse ventilator-associated events and further distinguish them from specifically ventilatory-associated pneumonia (VAP). The authors conclude that risk factors and outcome research which identify ways to prevent VAE may not be applicable to improvement in the smaller subcategory of VAP. Read the full details here.
In the second article, also co-authored by Dr. Cawcutt (pictured left), ID experts offer guidance on strategies to prevent VAP and VAE as well as non-ventilator hospital-acquired pneumonia. These recommendations are stratified by patient population, offering specific guidance for neonates, pediatric patients, and adults. Cumulating in an extensive update guided by expert testimony and reviewed and approved by a panel of ID specialists, this article provides the medical community with essential tips to avoid common yet life-threatening adverse events. Read the full recommendations at this link.
The last article, authored by Dr. Jonathan Ryer (pictured left) and Dr. Andre Kalil (pictured right), explores the association between COVID-19 and VAP. This patient population has been noted to experience VAP at a much higher rate than patients infected with other viruses. Adding to this, there is also an increased risk of shock and bloodstream infections in COVID-19 patients. This article comments on the questions that still exist surrounding this trend and what may be behind it. While a clear cause remains elusive, as the authors note, “[there is]…one thing we can say with certainty: patients hospitalized with COVID-19 are undoubtedly requiring longer hospital/ICU stay and prolonged mechanical ventilation duration, are more frequently proned, and are receiving more immunosuppressive drugs than any other respiratory viral infection ever before.” These factors provide clues to the potential cause of the increased risk of VAP. Read the whole commentary here.
The 2023 Nebraska HIV Prevention & Care Update was a great success on 5/18/23 at UNO Barbara Weitz Center for Community Engagement. Hosted by the Nebraska Dept of Health and Human Services and KS/NE AIDS Education and Training Center, the program featured presenters and panelists representing the health department, Nebraska Medicine/UNMC Specialty Care Center, community-based organizations, and consumers of HIV care. Over 100 participants joined in person and virtually from across the region.
Here is a quick summary of what was discussed:
New developments in HIV care in 2023
Patient perspectives on aging with HIV
Barriers to HIV prevention and PrEP for cisgender Black women
HIV prevention and care needs for incarcerated and system-impacted people
Updates in oral health access and correlations of health for people with HIV
Best practices regarding PrEP uptake in disproportionally impacted communities of color in Nebraska
HIV prevention and PrEP disparities for people who are Transgender
Socioeconomic barriers to engaging patients in HIV care
Lessons learned with long-acting antiretroviral therapy
For more information about this year’s conference, or if you are interested in getting involved in future Nebraska HIV Update conferences, please contact Nichole Regan at nregan@nebraskamed.com.
Earlier this month, the Specialty Care Clinic’s telehealth intervention plan was recognized and published as a ‘Best Practice’ on TargetHIV.org. This achievement follows from extensive research into existing patients utilizing the telehealth platform and confirmed that HIV care delivered via phone or video chat can be just as effective as care provided in a clinic for patients who prefer it. Read on for the details about Target HIV, best practices, and how the COVID-19 pandemic changed how effective HIV care could be offered at Nebraska Medicine.
What is TargetHIV?
From their webpage, “The TargetHIV website is the one-stop shop for technical assistance and training resources for HRSA’s Ryan White HIV/AIDS Program (RWHAP), the federal program that funds local and state agencies to deliver HIV care for people with HIV who are uninsured or underinsured.“
Essentially, TargetHIV is a nationally recognized resource for clinics looking to improve care of patients living with HIV.
What are Best Practices?
In short, ‘Best Practices’ are exactly that: documented successes in HIV care which are published on the TargetHIV webpage so others can learn from and implement similar interventions. This section gathers and shares what works in RWHAP-funded settings to improve outcomes for people with HIV and to support replication by others.
Why did the Specialty Care Clinic start to trial telehealth care?
During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV, with many clinics transitioning rapidly to alternative methods such as telehealth. In March 2020, SCC recognized the need to adjust its clinic operations to promote patient and staff safety during the pandemic. This adjustment, limiting in-person interactions, conflicted with the clinic’s usual approach to promoting retention in care and viral suppression, which relied on patients making frequent visits to the clinic not only for clinical care but also for ongoing medication adherence and case management support. Prior to March 2020, SCC did not offer telehealth services.
How did it go?
Great! Analysis of the first six months of telehealth offerings (around the beginning of the COVID-19 pandemic) revealed that 35% of visits utilized telehealth technology. In all patients, viral suppression rates were high, but telehealth patients actually maintained a higher rate of viral suppression than patients who visited the clinic in-person during the same time period. This indicates that telehealth HIV care can be highly effective for those patients who choose it.
What else can I find on the Specialty Care Clinic Telehealth Best Practices webpage?
The SCC published all the information that another clinic might find useful when implementing telehealth for their patients, including planning and implementation tips for setting up telehealth, lessons learned during this trial phase, and additional resources for those looking to get started. Check it out here for more information
The following content was provided by Valentina Orduna, a medical case manager at the Specialty Care Clinic. She joined the HIV/Infectious Diseases team in May 2017 after already working for Nebraska Medicine for 16 years. At Nebraska Medicine, she started as a Pharmacy Technician for 10 years, three years as a Pharmacy Financial Counselor, and three years at the Peggy Cowdery Clinic as a New Patient Coordinator. Valentina is bilingual in Spanish and English. She is devoted and passionate about assisting in the medical field and helping the community.
Earlier this month, UNMC ID’s Specialty Care Clinic participated in the annual Cinco De Mayo festivities, using this opportunity to spread awareness and education about HIV. Read on for Valentina’s report from this great community outreach event.
“Earlier this month we celebrated Cinco De Mayo in South Omaha. Brief information about Cinco De Mayo: this event is NOT Mexican Independence Day. Cinco de Mayo celebrates the date of the Mexican army’s May 5th, 1862 victory over France at the Battle of Puebla during the Franco-Mexican War. Although this event is not celebrated much in Mexico (except in Puebla), in the United States, Cinco de Mayo is a big celebration.
In Omaha, the event runs for three days and attracts about 200,000 people to South Omaha. Each year the Specialty Care Center (SCC) tries to participate in either the health fair or the parade. This year we participated in the parade to bring HIV awareness and education to the community. From my experience working with mainly Hispanic patients, there is still a lot of stigma about HIV and how it is transmitted. We wanted to bring basic information about how HIV is transmitted and how it is not transmitted. I’m thankful for the support of everyone at the SCC who helped me make the participation in this event a success and I’m looking forward to future participation in different events in the Hispanic community. “
– Valentina Orduna, bilingual medical case manager, Specialty Care Clinic – Nebraska Medicine
The third annual Infectious Diseases (ID) Pharmacists Day is today, Monday, May 22, 2023. This day recognizes the importance of ID pharmacists and the contributions they make to patient care. Here at UNMC ID, we are lucky to have a team of highly talented and dedicated ID pharmacists working to help patients and fight infectious diseases every day. In celebration of this day, read on below for a quick introduction to some of our fantastic ID pharmacists.
Bryan Alexander, PharmD, BCIDP, BCPS, AAHIVP
Clinical Pharmacist and Pharmacy Program Coordinator for Outpatient Parenteral Antimicrobial Therapy
Brief Biography: After having been raised in the suburbs outside Cleveland, my training and professional life have taken me to stops living in Chicago, Baltimore, Saint Louis, central Virginia, and now Omaha. My family is now happily settled here – my wife is a university professor and we have two elementary-age children.
I love being an ID Pharmacist because the profession is so wide-ranging in scope and impact, and pharmacotherapy remains central to the range of countermeasures that we employ. Also, infectious disease attracts the most collaborative, brilliant, and compassionate people, such that the teams I get to work with and the problems we work on are constantly edifying.
I love being an ID Pharmacist because ID is so complex and interesting; there is always a new problem to solve or a drug regimen to optimize to try to ensure the best care for patients. I work with the absolute best people who make my job so much fun.
Brief Biography: Grew up in rural Nebraska and attended the University of Nebraska-Lincoln (Go Huskers!) for undergrad prior to obtaining my PharmD from the University of Nebraska Medical Center. I then completed my PGY1 pharmacy residency and PGY2 ID pharmacy residency at Nebraska Medicine prior to accepting my current position.
Molly Miller, PharmD, BCIDP
Clinical Pharmacist Practitioner practicing in Infectious Diseases, Antimicrobial Stewardship, and Outpatient Parenteral Antimicrobial Therapy
Brief Biography: I am from a small town in Northern Nevada originally and went to undergrad and pharmacy school in Utah, where I graduated in 2020. I then came to NMC for residency, and stayed on for my career!
I love being an ID Pharmacist because… Too many reasons to just pick one. For starters, I love the impactful work that I get to do day in and day out. Making a positive impact on patients’ lives and public health is very rewarding and fulfilling. This area of medicine also appeals to my natural curiosity and need for life-long learning as the field is rapidly evolving with new drugs, pathogens, emerging infections, and evolving resistance patterns.
I love being an ID Pharmacist because it keeps me on my toes! There is always something new to learn and new ways to solve problems. The ID group at Nebraska Medicine is extraordinarily collaborative and knowledgeable and I am lucky to be able to work with them on a daily basis.
Brief Biography: I was born and raised in Omaha, received my PharmD from the University of Nebraska Medical Center in 2012, and started at Nebraska Medicine Bellevue. I became the Antimicrobial Stewardship Pharmacist at Nebraska Medicine Bellevue in 2017.
Daniel Schroeder, PharmD, BCPS
Clinical Pharmacist Practitioner and Antimicrobial Stewardship Pharmacist at Nebraska Medicine Bellevue and Nebraska Antimicrobial Stewardship Assessment and Promotion Program
Jenna Pruesker, PharmD, BCPS
Nebraska Antimicrobial Stewardship Assessment and Promotion Program Pharmacy Coordinator at Nebraska Medicine and Nebraska DHHS Pharmacist
Brief Biography: Doctor of Pharmacy; University of Nebraska Medical Center, College of Pharmacy 2013, PGY1. Residency: CHI Health Saint Elizabeth, Lincoln, Nebraska.
Before joining Nebraska Medicine in 2022, I spent 9 years at Faith Regional Health Services in Norfolk, Nebraska as the Antimicrobial Stewardship Program Director.
I love being an ID Pharmacist because it involves so much critical thinking and problem-solving. My work is primarily outreach to rural, resource-limited settings, so helping facilities solve antibiotic-related problems challenges me to think outside the box every day.
I love being an ID Pharmacist because the field is constantly evolving which provides plenty of challenging clinical situations to work through and endless research opportunities.
Brief Biography: I graduated from the University of Nebraska College of Pharmacy in 2007 and joined the HIV/Infectious Diseases group in 2015 and the Department of Pharmacy Practice in 2019. As a pharmacy clinician at the Specialty Care Center, I provide care for people living with HIV including antiretroviral therapy initiation and revision as well as various other management services together with primary care services.
Josh Havens, PharmD, BCPS
Specialty Care Center, HIV Program
Shawna Sunagawa, PharmD
PGY2 ID Resident
Brief Biography: I am originally from Hawaii but completed my undergrad and pharmacy degree at Creighton University, #RollJays! I matched for PGY1 residency at Nebraska Medicine and was fortunate enough to stay on for a PGY2 ID!
I love being an ID Pharmacist because of the interprofessional nature of the field! Not only am I working with phenomenal ID providers, pharmacists, microbiologists, and other healthcare professionals but I also get to “work with” some pretty cool bugs/drugs!
Brief Biography: I currently work as the Antimicrobial Stewardship Coordinator for Nebraska Medicine and as a Clinical Professor at the Department of Pharmacy Practice at the University of Nebraska Medical Center. I am also the Program Director for the PGY2 Infectious Diseases Pharmacy Residency and conduct research in infectious diseases pharmacotherapy. My group’s current project is optimizing anti-infective use inside and outside of hospitals.
Scott Bergman, PharmD, FCCP, FIDSA, BCIDP
Pharmacist Coordinator, Antimicrobial Stewardship Program (ASP) – Nebraska Medicine
In case you missed it, there is still time to register online for the 2023 Antimicrobial Stewardship Summit. Registration closes this upcoming Tuesday, May 23rd. Read below for information regarding this great opportunity!
The Nebraska Antimicrobial Stewardship Assessment and Promotion Program (ASAP) will be hosting its annual Nebraska Antimicrobial Stewardship Summit in person on Friday, June 2, 2023, at the Embassy Suites LaVista Hotel and Conference Center. There will be a combined morning session followed by afternoon breakout sessions with targeted presentations in long-term care and acute care/outpatient settings tracks. Registration for the Summit is $99 per attendee, which includes parking, food, and CE credits for physicians, nurses, pharmacists, and medical laboratory scientists. Read on below for more information and to register!
TARGET AUDIENCE This accredited continuing education activity is designed for:
– Post-acute and long-term facilities: Long-term care providers, medical directors, infection preventionists, nurses, consultant pharmacists, directors of nursing, quality program leaders, and other health care providers interested in improving the management of common infections through the incorporation of antimicrobial stewardship principles.
– Outpatient facilities and acute care hospitals: Family medicine providers, internal medicine providers, ambulatory care providers, pharmacists, nurses, medical directors, quality program leaders, and other health care providers interested in improving the management of common infections through the incorporation of antimicrobial stewardship principles.
SUMMIT LOCATION Embassy Suites by Hilton Omaha La Vista Hotel & Conference Center 12520 Westport Parkway, La Vista, NE 68128
This #PharmToExamTable post exploring the pathophysiology and approach to cefepime neurotoxicity was authored by Xiaotong Zhang and Kaycee Bartels, 2023 PharmD candidates at the University of Nebraska Medical Center (UNMC).
Fast Facts: – Cefepime-induced neurotoxicity (CIN) is relatively rare and can be difficult to identify but should be considered if a patient begins experiencing altered mental status changes during cefepime therapy, especially in the setting of impaired renal function.
– When CIN is identified, cessation of cefepime, use of anti-epileptic drugs, and hemodialysis are management options. A note of the adverse reaction should be documented in the patient chart to alert future providers that neurotoxicity occurred during cefepime therapy. Careful evaluation of renal function or potentially avoiding cefepime should be considered in the future.
– Beta-lactam therapeutic drug monitoring is being researched to reduce the likelihood of adverse effects such as CIN, but there are no currently published national guidelines for practitioners to widely implement this process.
What is cefepime-induced neurotoxicity?
Kaycee Bartels, UNMC PharmD candidate and co-author of this post.
Cefepime-induced neurotoxicity (CIN) was first noted in a patient with end-stage renal disease on hemodialysis in 1999. This patient presented with altered mental status, myoclonus, and experienced a tonic-clonic seizure, but recovered after urgent hemodialysis.[1] It is estimated that CIN occurs in 3% of patients and mean onset of CIN symptoms is 5 days after cefepime initiation.[2] Cefepime is a fourth-generation cephalosporin that was FDA approved in 1996.[3] It has activity against gram-negative bacilli such as Pseudomonasaeruginosa, Klebsiella pneumoniae, and Serratia, gram-positive cocci including methicillin-susceptible Staphylococcus aureus and Streptococcus pneumoniae, and is effective against AmpC beta-lactamase-producing Enterobacterales.[2, 4] Cefepime can be utilized for the treatment of pneumonia, febrile neutropenia, urinary tract infections, uncomplicated skin and soft tissue infections, and complicated intra-abdominal infections.[3] It is primarily excreted by the kidneys (85% unchanged) and has a warning for neurotoxicity listed in the package insert. During post-marketing surveillance, serious adverse reactions have been reported including life-threatening or fatal occurrences of encephalopathy (disturbance of consciousness including confusion, hallucinations, stupor, and coma), myoclonus, seizures, and nonconvulsive status epilepticus. [3, 5]
What is the mechanism of cefepime-induced neurotoxicity (CIN)?
The proposed mechanism of cefepime-induced neurotoxicity is not well understood; however, it is thought to be caused by GABA-A receptor inhibition.[2, 6] This inhibition of GABA-A prevents influx of chloride ions into the postsynaptic neuron and causes an increase in action potential.[7] This increase in cellular excitability leads to altered mental status and seizures.[2, 8]
All beta-lactam antibiotics have the potential to cause neurotoxicity; however, it has been shown that cefepime carries a higher risk. In a retrospective study of patients treated with either cefepime or meropenem, cefepime carried a ten times higher risk of convulsions than meropenem.[9] There are certain risk factors that can increase the likelihood of experiencing CIN, including hematological malignancy, critical illness, older age, and renal dysfunction, which all lead to increased drug exposure.[10, 11] While there are many risk factors, the primary risk factor associated with CIN is renal dysfunction, as excessive serum concentrations of cefepime (>20 mg/L) have been associated with neurotoxic adverse effects.[9, 10]
Xiaotong Zhang, UNMC PharmD candidate and co-author of this post.
A retrospective cohort study analyzed the frequency of cefepime-associated neurotoxicity in patients with varying degrees of renal dysfunction. Only 4% of patients with eGFR > 90 mL/min/1.73m2 experienced neurotoxic symptoms, while 54% of patients with eGFR < 30 mL/min/1.73m2 experienced neurotoxic symptoms.[10] This study demonstrated the potential increased risk for cefepime neurotoxicity in patients with renal dysfunction.
How can cefepime neurotoxicity be prevented?
As mentioned above, higher serum concentrations could put patients at increased risk for neurotoxicity. Therefore, appropriate renal dose adjustments are necessary to ensure patients do not accumulate cefepime.
In addition to renal dose adjustments, dosing strategies to optimize time above the minimal inhibitory concentration (MIC) while minimizing total daily drug exposure can be utilized since cefepime is a beta-lactam with time-dependent bactericidal activity. To ensure effectiveness of therapy, free drug concentration should remain above the minimum inhibitory concentration (fT>MIC) 70% of the time.[12] Extended infusions or continuous infusions of cefepime have been shown to optimize time above MIC. A systematic review found that at the same total daily dose, administering cefepime as prolonged intermittent infusions over 3 to 4 hours or continuous infusions (4 grams every 24 hours) consistently improves achievement of PK-PD targets compared with traditional intermittent infusions over 30 minutes every 12 hours.[13] If an intermittent dosing regimen with a short infusion time of 30 minutes is used, smaller doses given more frequently will improve fT>MIC. A retrospective cohort study of inpatients with documented Gram-negative bacteremia or pneumonia described an alternate dosing regimen that replaced doses of 2 grams every 12 hours with 1 gram every 6 hours. The cefepime dosing regimen of 1 gram every 6 hours led to a higher probability of target attainment (PTA) and a similar clinical outcome compared to traditional dosing of 2 grams every 12 hours.[14]
When cefepime neurotoxicity is suspected, how can symptoms be managed?
When CIN is suspected, further work-up for etiology should be performed including an electroencephalogram to assess neurological symptoms, if available.[15] Cefepime therapy should be discontinued, and alternative antibiotic therapy should be initiated. Resolution of CIN occurs a median of 2 to 3 days after the interventions.[2, 11] When CIN occurs, appropriate renal dose reduction, cessation of cefepime, and use of anti-epileptic drugs have been demonstrated to provide clinical improvement.[5, 8, 10, 16] Hemodialysis should be considered a treatment option in patients with severe encephalopathy to rapidly decrease the blood and cerebrospinal fluid cefepime levels and shorten the duration of central nervous system toxicity.[15]
What’s on the horizon for prevention of CIN?
Beta-lactam therapeutic drug monitoring (TDM) is being studied as a strategy to prevent CIN. The pharmacokinetics of cefepime are altered under certain pathophysiological conditions, which may increase total cefepime exposure. Therapeutic drug monitoring of cefepime may be beneficial in certain patients including those who are critically ill, have life-threatening infections, have acute or chronic renal failure, or are infected with more resistant pathogens.[12]
A retrospective cohort study conducted at the University Hospital of Bern, Switzerland included 319 patients from whom TDM was performed during cefepime therapy. Cefepime was given three times a day with dosing adjustment for an estimated glomerular filtration rate (eGFR) of ≤ 50 mL/min/1.73 m2 according to the manufacturer’s recommendations. Cefepime trough concentrations were obtained < 1 hour prior to the next dose and the highest cefepime plasma trough concentration was used to assess the association between the incidence of CIN and cefepime plasma trough concentration. Results from multivariable logistic regression showed for every increase of 1 mg/L in the trough the risk of neurotoxicity increased by 33% (OR 1.33 [95% CI 1.23—1.45], p <0.001). Based on a fitted logistic regression model, the study found that the probability of neurotoxicity was 25% for cefepime trough concentrations ≥ 12 mg/L, 50% for cefepime concentration ≥ 16 mg/L, and no individual developed neurotoxicity at trough level < 7.7 mg/L.[10] A systematic review found that serum or plasma cefepime trough levels of >20 mg/L are related to higher risk for developing cefepime-induced neurotoxicity (CIN), while the trough levels under around 7 mg/L would result in a low risk of CIN.[8] TDM is one method to evaluate the risk for CIN, but further research on the thresholds of neurotoxicity and efficacy are needed to direct our utilization of levels in daily practice.[12]
1. Lee, S.-J., Cefepime-induced neurotoxicity. Journal of Neurocritical Care, 2019. 12(2): p. 74-84.
2. Maan, G., et al., Cefepime-induced neurotoxicity: systematic review. J Antimicrob Chemother, 2022. 77(11): p. 2908-2921.
3. FDA, CEFEPIME injection, for intravenous use. 1996.
4. Angelescu, M. and A. Apostol, [Cefepime (maxipime), large spectrum 4th generation cephalosporin, resistant to beta-lactamases]. Chirurgia (Bucur), 2001. 96(6): p. 547-52.
5. Appa, A.A., et al., Characterizing Cefepime Neurotoxicity: A Systematic Review. Open Forum Infect Dis, 2017. 4(4): p. ofx170.
6. Amakhin, D.V., et al., Paradoxical Anticonvulsant Effect of Cefepime in the Pentylenetetrazole Model of Seizures in Rats. Pharmaceuticals (Basel), 2020. 13(5).
7. Mihic, S.J. and R.A. Harris, GABA and the GABAA receptor. Alcohol Health Res World, 1997. 21(2): p. 127-31.
8. Maan, G., et al., Cefepime-induced neurotoxicity: systematic review. Journal of Antimicrobial Chemotherapy, 2022. 77(11): p. 2908-2921.
9. Tanaka, A., et al., Comparison of the prevalence of convulsions associated with the use of cefepime and meropenem. Int J Clin Pharm, 2013. 35(5): p. 683-7.
10. Boschung-Pasquier, L., et al., Cefepime neurotoxicity: thresholds and risk factors. A retrospective cohort study. Clinical Microbiology and Infection, 2020. 26(3): p. 333-339.
11. Payne, L.E., et al., Cefepime-induced neurotoxicity: a systematic review. Crit Care, 2017. 21(1): p. 276.
12. Pais, G.M., et al., Clinical Pharmacokinetics and Pharmacodynamics of Cefepime. Clin Pharmacokinet, 2022. 61(7): p. 929-953.
13. Burgess, S.V., et al., Evaluating outcomes of alternative dosing strategies for cefepime: a qualitative systematic review. Ann Pharmacother, 2015. 49(3): p. 311-22.
14. Gould, A., et al., Clinical Evaluation of an Alternate Cefepime Dosing Protocol for Gram-Negative Bloodstream and Respiratory Infections. Open Forum Infectious Diseases, 2016. 3(suppl_1).
15. Lindsay, H., S. Gruner, and J. Brackett, Cefepime-Induced Neurotoxicity Despite Dose Adjustment for Renal Disease: A Brief Report and Review of the Literature. Journal of the Pediatric Infectious Diseases Society, 2016. 6(2): p. 199-201.
16. Li, H.T., et al., Clinical, Electroencephalographic Features and Prognostic Factors of Cefepime-Induced Neurotoxicity: A Retrospective Study. Neurocrit Care, 2019. 31(2): p. 329-337.
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