Supplementary Material for: Cephalosporin related neurotoxicity in a ceftriaxone treated critically ill child, a case report.

We describe a four-year-old girl who presented with meningococcal sepsis. According to protocol, she was treated with intravenous ceftriaxone and supportive therapy. As she improved rapidly, inotropic and respiratory support could be stopped within two days. However, the girl developed renal failure and, on day four, deteriorated neurologically. Research into the cause of her encephalopathy revealed supra-therapeutic ceftriaxone concentrations with greatly increased unbound fractions leading to the diagnosis of cephalosporin related neurotoxicity. Ceftriaxone treatment was discontinued. As renal failure progressed, renal replacement therapy was initiated on day six. With both discontinuation of ceftriaxone and renal replacement therapy the girl’s condition improved rapidly. We postulate that in the described case both renal impairment and hypoalbuminemia played an important role in the development of high unbound ceftriaxone serum levels. We advocate therapeutic drug monitoring for ceftriaxone in critically ill children with renal failure or hypoalbuminemia.