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August 14, 2013

Infections and Acute Psychosis: An Opportunity for Relapse Prevention?

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Brian Miller, MD, PhD, MPH

Georgia Regents University, Augusta

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Infections are associated with acute psychosis. This relationship is not new—the association between psychosis and comorbid urinary tract infection (UTI) in the context of dementia or delirium is well known. However, while working as a psychiatrist on our acute care inpatient unit, I found myself frequently prescribing antibiotics to inpatients with psychotic disorders. In some patients, acute psychosis resolved following antibiotic treatment, often without changes in psychotropic medications.

Could this result be more than just a chance association? Our research team has explored the relationship between UTI and acute psychosis. Even with our clinical experience treating UTIs, our findings have been striking.

Among 57 acutely ill inpatients with relapsed schizophrenia, 35% had a UTI (including 28% of men).1 Patients with schizophrenia were almost 29 times more likely to have a UTI than controls, and a sobering finding was that only 40% of the UTIs were recognized and treated with antibiotics during hospitalization. By contrast, we found no association with UTI between stable outpatients with schizophrenia and controls.

In a second, larger sample, we found that 21% of 134 acutely ill inpatients with non-affective psychosis had a UTI.2 Patients with non-affective psychosis were almost 11 times more likely to have a UTI than controls. Interestingly, we also found that 18% of 101 acutely ill inpatients with affective psychoses had a UTI. We did not identify any clinical features that were more common in subjects with acute psychosis and comorbid UTI versus no UTI.

So which comes first: UTI or psychosis? Acute psychosis may be associated with decreased self-care or other behaviors that could increase the risk of UTI. Alternatively, UTI might precede and even precipitate acute psychosis. Several case reports and case series support the plausibility of the latter hypothesis, in that treatment of UTI was associated with amelioration of psychosis.3–5 Given evidence for abnormal immune function in schizophrenia, we wondered if the host inflammatory response to infection might contribute to relapse in susceptible patients. We recently found that differential white blood cell counts may predict UTI.6

What are the next steps? We encourage replication of our findings, including if the association extends to affective psychoses. Longitudinal studies are needed to investigate the temporal relationship between UTI and acute psychosis, which would inform on the potential mechanism(s) of the association. Future studies should assess levels of self-care and urinary symptoms and diagnose UTIs according to the gold standard of urine cultures. Measurement of inflammatory markers such as blood and urinary cytokines could inform on the role of the immune response to infection in mediating this association. Does the association with acute psychosis extend to other common infections, such as cellulitis and pneumonia?

Presently, our findings highlight the potential importance of monitoring for comorbid infections in acute psychiatric inpatients and raise the possibility of infections as a risk factor for relapse in psychotic disorders.

What are your clinical experiences with infections and acute psychosis in patients with psychotic disorders?

Financial disclosure:Dr Miller has received grant/research support from NIMH and has received honoraria from Medscape, Insight Consulting, and Decision Resources Group.

References

1. Miller BJ, Graham KL, Bodenheimer CM, et al. A prevalence study of urinary tract infections in acute relapse of schizophrenia. J Clin Psychiatry. 2013;74(3):271–277. Abstract

2. Bodenheimer CM, Graham KL, Ezeoke A, et al. Urinary tract infections in acute relapse of psychosis. Paper presented at: 166th Annual Meeting of the American Psychiatric Association; May 23, 2013; San Francisco, CA. SCR33-1. www.psych.org/File%20Library/Learn/Archives/am_syllabus_2013.pdf. Accessed June 3, 2013.

3. Salviati M, Bersani FS, Macrì F, et al. Capgras-like syndrome in a patient with an acute urinary tract infection. Neuropsychiatr Dis Treat. 2013;9:139-142. PubMed

4. Rajagopalan M, Varma SL. Urinary tract infection and delusion of pregnancy. Aust N Z J Psychiatry. 1997;31(5):775-776. PubMed

5. Yeh YW, Kuo SC, Chen CY. Urinary tract infection complicated by urine retention presenting as pseudocyesis in a schizophrenic patient. Gen Hosp Psychiatry. 2012;34(1):101. PubMed

6. Miller BJ, Bodenheimer CM, Culpepper NH, et al. Differential white blood cell counts may predict urinary tract infection in acute non-affective psychosis. Schizophr Res. 2013;147(2–3):400–401. PubMed

Category: Medical Conditions , Psychosis , Schizophrenia
Link to this post: https://www.psychiatrist.com/blog/infections-and-acute-psychosis-an-opportunity-for-relapse-prevention/
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6 thoughts on “Infections and Acute Psychosis: An Opportunity for Relapse Prevention?”

  2. A.j. is an 88 year old woman with no previous history of mental health problems. She has been widowed for mroe than 30 years. She worked as an RN for 37 years, and retired more than 20 years ago. Since then, she has taken in teenaged foster boys, often boys who would have been incarcerated had there been no one willing to have them in a family home.

    10 months ago she had an episode of acute depression. She was treated with sertraline, but showed only very modest response. She was hospitalized and it was found on her routine urinalysis that she had a severe UTI. She was treated with antibiotics and a sulfa drug. On release, she was negative for uti symptoms and her depression had lifted.
    Two months later, she began to experience what she called “hallucinations.” She believed she saw people sitting on her sofa, or heard indistinct voices talking in another room of the house. When she checked closer, she realized that these were not real. She feared she was “going insane.” She was checked and again had a UTI. She also showed signs of early cardiac failure and stage 3 kidney failure. She was put on Lasix (40mg qd) to address fluid overload, but had to have thoracentesis to clear her lungs. 998cc was removed from her right lung and 877cc from her left. She was discharged as improved but placed in a rehab center to regain lost strength.

    Unfortunately, in the rehab center she caught a bacterial pneumonia and again had a UTI which was diagnosed as due to MERSA. She was treated with IV antibiotics. The hallucinations returned, mostly at night, but were more frightening. She began to wonder if they were real or not, rather than being able to check them and verify that these were imaginary. Her kidney function improved with the Creatinine dropping from 3.2 to 1.7 after treatment. But her mood continued to be anxious and depressed.

    She was discharged after medicare refused to continue to pay for treatment in the rehabilitation center after five weeks there. Her condition on discharge was far less robust than it had been when she entered. She was now on full time 02, at 2.5-3.0 liters.minute. Additionally, she had been given a sulfa drug again, and her renal function had again been negatively impacted.

    It is now four months later. The renal function has returned to her baseline, 1.7, and she is tolerating the 40mg/qd lasix well. The cardiologist just allowed her to D/C the 02, and she is happy about that as it made it impossible for her to leave the facility she was in, and she was essentially a shut in due to staff limitations, and institutional regulations. But the hallucinations have not changed. Recently, she was found to have yet another UTI, and has not yet been treated medically for it, due to a vacation on the part of her regular medical provider!

    Recent reports indicate that cardiac failure patients are frequently subject to depression, and are well treated by SSRI’s such as sertraline. Psychotherapy is also helpful to these patients. But getting her physician to prescribe another medication in an already complex regimen is impossible. As a psychiatrist, I have little standing in this kind of complicated medical management situation. This is especially true when I am unable to reach her primary care provider. So cognitive/behavioral therapy and supportive counseling is about all the treatment I can provide.

    Are other providers faced with similar situations? Have you found better ways to handle them?

  4. @Katherine M. Thank you for sharing this interesting, complex case. It sounds like your patient might benefit from antibiotic prophylaxis, given the clear relationship with severe psychiatric (and other medical) sequelae from recurrent UTI. I agree that it’s always best to work collaboratively with other providers, but in certain instances (such as PCP is on vacation), I believe as psychiatric physicians we have a duty to act with beneficence. In this case, I myself would treat the patient’s UTI (of course, with clear documentation as to why I’m treating her). Being at an academic medical center, I am fortunate to have colleagues in internal medicine that I can “curbside consult” for recommendations on specific agents, especially for patients with significant medical comorbidities. Is her cardiologist more readily available than her PCP to discuss these issues, including consideration of starting her on an SSRI?
  5. @Brian. Thanks for your comment. In our studies (references 1, 2, 6), which were retrospective chart reviews, standardized cognitive assessments were not routinely used. All acutely ill subjects in these studies were inpatients hospitalized for psychosis. Delirium (based on the assessment of the admitting and/or treating psychiatrist) was an exclusion criteria for the studies.
  6. In 1961 the Russians published a paper suggesting an association between first psychotic event and acute viral illness There has been theorizing that schizophrenia was a slow viral disease and that that stressors either physical or mental that compromise the immune system could trigger a psychotic recurrence

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