REVIEW ARTICLE
Antibiotic-Associated Psychosis During Treatment of Urinary Tract Infections A Systematic Review Safinaz Mostafa, MBBS and Brian J. Miller, MD, PhD, MPH
Abstract: There have been a number of case reports of antibioticassociated psychosis in the literature that have not been systematically reviewed. Urinary tract infections (UTIs) are among the most common bacterial infections and have also been associated with acute psychosis. We performed a systematic review of cases of antibiotic-associated acute psychosis during treatment of a UTI and evaluated the strength of the association for each case. We identified reports by searching PubMed, PsychINFO, and Web of Knowledge, and the reference lists of identified reports. We systematically evaluated the quality of the causal relationship between antibiotic treatment of UTI and psychosis. Fourteen articles (describing 15 different cases) met the inclusion criteria. The primary findings were as follows: (1) a majority (60%) of reported cases were ‘‘highly suggestive’’ of a potential causal relationship between antibiotic treatment and psychosis, including 3 cases with a recurrence of psychosis after rechallenge with the same antibiotic; (2) 3 different classes of antibiotics were implicated in this association, including fluoroquinolones, penicillins, and trimethoprim-sulfamethoxazole; (3) for most of the reported cases, both the onset and resolution of psychosis occurred within 1 week of initiation and discontinuation of the antibiotic, respectively; (4) approximately half of the cases did not require treatment with antipsychotics; and (5) affected men were significantly more likely to have a psychiatric history. Our findings suggest that acute psychosis is a potential adverse effect of antibiotic treatment of UTI, although the mechanism(s) underlying this association remains unclear. Key Words: antibiotics, psychotic disorders, urinary tract infection, cystitis (J Clin Psychopharmacol 2014;34: 483Y490)
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sychiatric adverse reactions, especially in elderly patients, are a known complication of antibiotic treatment of infections. Psychotic symptoms after treatment with penicillins have been termed Hoigne syndrome.1 Abouesh et al2 performed a systematic review of antimicrobial-induced mania (termed antibiomania), including 21 published case reports, 82 reported cases from the World Health Organization, and 61 reported cases from the Food and Drug Administration, noting that many of these cases had comorbid psychotic symptoms. There have also been a number of case reports of antibiotic-associated psychosis in the literature, in adolescent, adult, and geriatric patients, which have not been systematically reviewed. In some instances, psychotic symptoms resolved after discontinuation but recurred with rechallenge of the antibiotic, suggesting a From the Department of Psychiatry and Health Behavior, Georgia Regents University, Augusta, GA. Received August 20, 2013; accepted after revision January 21, 2014. Reprints: Brian J. Miller, MD, PhD, MPH, Department of Psychiatry and Health Behavior, Georgia Regents University, 997 St Sebastian Way, Augusta, GA 30912 (e
Antibiotic-Associated Psychosis During Treatment of Urinary Tract Infections A Systematic Review Safinaz Mostafa, MBBS and Brian J. Miller, MD, PhD, MPH
Abstract: There have been a number of case reports of antibioticassociated psychosis in the literature that have not been systematically reviewed. Urinary tract infections (UTIs) are among the most common bacterial infections and have also been associated with acute psychosis. We performed a systematic review of cases of antibiotic-associated acute psychosis during treatment of a UTI and evaluated the strength of the association for each case. We identified reports by searching PubMed, PsychINFO, and Web of Knowledge, and the reference lists of identified reports. We systematically evaluated the quality of the causal relationship between antibiotic treatment of UTI and psychosis. Fourteen articles (describing 15 different cases) met the inclusion criteria. The primary findings were as follows: (1) a majority (60%) of reported cases were ‘‘highly suggestive’’ of a potential causal relationship between antibiotic treatment and psychosis, including 3 cases with a recurrence of psychosis after rechallenge with the same antibiotic; (2) 3 different classes of antibiotics were implicated in this association, including fluoroquinolones, penicillins, and trimethoprim-sulfamethoxazole; (3) for most of the reported cases, both the onset and resolution of psychosis occurred within 1 week of initiation and discontinuation of the antibiotic, respectively; (4) approximately half of the cases did not require treatment with antipsychotics; and (5) affected men were significantly more likely to have a psychiatric history. Our findings suggest that acute psychosis is a potential adverse effect of antibiotic treatment of UTI, although the mechanism(s) underlying this association remains unclear. Key Words: antibiotics, psychotic disorders, urinary tract infection, cystitis (J Clin Psychopharmacol 2014;34: 483Y490)
P
sychiatric adverse reactions, especially in elderly patients, are a known complication of antibiotic treatment of infections. Psychotic symptoms after treatment with penicillins have been termed Hoigne syndrome.1 Abouesh et al2 performed a systematic review of antimicrobial-induced mania (termed antibiomania), including 21 published case reports, 82 reported cases from the World Health Organization, and 61 reported cases from the Food and Drug Administration, noting that many of these cases had comorbid psychotic symptoms. There have also been a number of case reports of antibiotic-associated psychosis in the literature, in adolescent, adult, and geriatric patients, which have not been systematically reviewed. In some instances, psychotic symptoms resolved after discontinuation but recurred with rechallenge of the antibiotic, suggesting a From the Department of Psychiatry and Health Behavior, Georgia Regents University, Augusta, GA. Received August 20, 2013; accepted after revision January 21, 2014. Reprints: Brian J. Miller, MD, PhD, MPH, Department of Psychiatry and Health Behavior, Georgia Regents University, 997 St Sebastian Way, Augusta, GA 30912 (e
