JMCR: Clinical Minute

Amoxicillin-clavulanate–induced neurotoxicity in a patient with end-stage renal disease: a case of reversible encephalopathy Walz D, Klair N, Pennacchia N, et al. Journal of Medical Case Reports (2026). DOI: 10.1186/s13256-026-06389-x
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The Case

  • A 67-year-old man with end-stage renal disease on chronic hemodialysis was discharged on amoxicillin-clavulanate 875/125 mg twice daily for concern regarding ongoing osteomyelitis.
  • Approximately 48 hours after starting treatment, he developed progressive confusion, agitation, decreased communication, and ultimately incoherent speech.
  • CT and MRI showed no acute intracranial abnormality; EEG demonstrated diffuse slowing without epileptiform activity.
  • An extensive metabolic and infectious evaluation did not identify an alternative explanation.
  • Amoxicillin-clavulanate was discontinued, and after resumption of full hemodialysis sessions, the patient returned to his neurologic baseline.
  • The Naranjo score was 3, supporting a possible rather than definite adverse drug reaction.

Clinical Pearl

Beta-lactam neurotoxicity should be considered whenever a patient with severe renal impairment develops otherwise unexplained acute encephalopathy after starting an antibiotic.

Standard outpatient doses may produce drug accumulation when renal function and dialysis timing are not appropriately considered. Medication reconciliation at hospital discharge therefore represents an important opportunity to prevent neurotoxicity.

Take-Home Message

New delirium or encephalopathy in a dialysis patient? Review the medication list early. Recognition of potentially neurotoxic renally cleared drugs, prompt withdrawal of the suspected agent, and appropriate dialysis may result in complete neurologic recovery.