Amoxicillin-clavulanate–induced neurotoxicity in a patient with end-stage renal disease: a case of reversible encephalopathy

Beta-lactam antibiotics are a known but under-recognized cause of neurotoxicity, particularly in patients with renal impairment. While cefepime-associated neurotoxicity is well-described, less attention has been given to amoxicillin–clavulanate. We present a case of a 67-year-old male with end-stage renal disease (ESRD) on chronic intermittent hemodialysis for more than 5 years via a left upper extremity arteriovenous fistula who developed acute encephalopathy characterized by agitation, confusion, and fluctuating consciousness shortly after initiation of 875/125 mg amoxicillin–clavulanate twice daily following hospital discharge. Symptoms began approximately 48 h after antibiotic initiation after the patient had received approximately five total doses, including doses taken before and after a shortened outpatient dialysis session. Symptoms resolved after discontinuation of the medication and completion of inpatient hemodialysis. Extensive workup, including neuroimaging and electroencephalography, was unrevealing. Infectious and metabolic etiologies were excluded based on clinical evaluation and specialist consultation. This case highlights the importance of recognizing antibiotic-induced neurotoxicity in patients with ESRD and emphasizes the risks of inappropriate outpatient dosing at hospital discharge.