Annals of Long Term Care

Author Affiliations: Dr. Sohn is Associate Director, Sepulveda VA Nursing Home Care Unit, VA Greater Los Angeles Health Care System, and Assistant Clinical Professor, UCLA School of Medicine/Geriatrics, CA.
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Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic. The newer drugs in this class differ from earlier agents with increased potency, broader spectrum of antibacterial activity, and pharmacokinetics that permit treatment of systemic bacterial infections. The fluoroquinolone antibiotics have a relatively benign side-effect profile, but there have been case reports of behavioral changes in patients after initiation of this class of antibiotics.

We present a case of mania after ciprofloxacin antibiotic use. Elderly patients are especially at risk for adverse effects of medications. Multiple medical comorbidities, polypharmacy, and the potential of drug-drug interactions all increase the risk. Changes in mood or behavior such as mania are a serious adverse effect that can occur. Adverse drug reactions after the addition of a new medication always need to be considered.

The Case

Mr. W is an 85-year-old Caucasian male who was admitted for long-term care (LTC) to the Nursing Home Care Unit (NHCU) in November 2000 due to an inability to care for himself. He is a World War II veteran. One morning several years after his admission he was noted to be talking incessantly with an elevated mood. He was alert and oriented on interview; however, it was difficult to engage him in a focused conversation. He insisted on telling stories from his past and was difficult to interrupt. He stated that he had not slept for the past 25 years and admitted to having racing thoughts and feeling “out of control.” Prior to this episode he was described as a calm, pleasant man of few words who enjoyed reading the newspaper.

Mr. W’s medical conditions included a past history of chronic paranoid schizophrenia, dementia, depression, Parkinson’s disease, glaucoma, degenerative joint disease, benign prostatic hypertrophy, and recurrent urinary tract infections (UTIs). Schizophrenia had not been an active problem for him for several years. He had been tapered off antipsychotics several years ago. His depression was well controlled on mirtazapine, which was started in September 2005. No other family members were known to have psychiatric diagnoses.

Carbidopa/levodopa was cautiously started in February 2006 for Parkinson’s disease. He responded well to the carbidopa/levodopa with improvement in his spontaneous movements and facial expressions. Mr. W was started and maintained on carbidopa 25 mg and levodopa 100 mg five times a day. His benign prostatic hypertrophy was managed with tamsulosin and finasteride. He required use of a condom catheter. For his glaucoma he was prescribed travoprost and metipranolol ophthalmic solutions.

Ciprofloxacin was started on February 26, 2007, for increased lethargy and poor oral intake. Preliminary lab tests were consistent with a UTI. On March 1, 2007, the patient was noted to be talking incessantly with an elevated mood. On exam, he was lying in bed comfortably, well groomed, speech was pressured, and mood was elevated. His affect was excited, and he was often laughing inappropriately. His thought process was tangential and appeared delusional. Ciprofloxacin was the only new medication that had been started. It was immediately discontinued. Mr. W returned to his baseline after stopping the ciprofloxacin.

Discussion

This elderly resident exhibited an acute change in his behavior after starting ciprofloxacin. As with many other older patients, he had multiple comorbidities and was taking multiple medications. Mental status evaluation clearly showed abnormalities in speech, mood, affect, thought process, and content consistent with mania. After stopping the ciprofloxacin, the patient’s episode of acute mania resolved.