Association of Prednisone and Levofloxacin with Delirium

Both prednisone and levofloxacin are realistically associated with delirium, particularly in vulnerable populations such as elderly patients.

Prednisone and Delirium

Corticosteroids like prednisone can cause delirium, even at low doses (5-15mg) in vulnerable elderly patients 1
A case report documented severe delirium with agitation, verbal and physical aggression, and visual hallucinations developing just 3 days after starting low-dose prednisone in a 91-year-old man 1
The delirium resolved completely after discontinuation of prednisone, but resulted in a prolonged 36-day hospitalization and significant clinical deterioration 1
Systemic corticosteroids have shown mixed evidence regarding delirium risk, with some studies suggesting they increase the probability of delirium in ICU patients 2

Levofloxacin-induced delirium has been documented in multiple case reports, though it appears to be underrecognized and underdiagnosed 3, 4
One medical ward alone reported three cases of levofloxacin-induced delirium, suggesting this adverse effect may be more common than previously thought 3
Delirium associated with levofloxacin can present with agitation, hallucinations, and confusion 4
This serious adverse effect can occur even in patients with underlying psychiatric conditions, making diagnosis particularly challenging 5

Elderly patients are particularly vulnerable to medication-induced delirium 3, 6
Patients with renal impairment are at higher risk for neurological toxicity from antibiotics due to drug accumulation 7
Multiple comorbidities and polypharmacy increase the risk of medication-induced delirium 1
Fluoroquinolones like levofloxacin may cause CNS effects through several mechanisms, including GABA receptor antagonism 3

When prescribing prednisone to vulnerable elderly patients, use the lowest effective dose and monitor closely for neuropsychiatric effects 1
Consider alternative antibiotics to fluoroquinolones in elderly patients or those with risk factors for delirium 3, 4
Recognize that delirium symptoms may appear within days of starting these medications 1, 3
Prompt discontinuation of the offending medication can lead to resolution of delirium symptoms 1, 3

Always consider medication-induced delirium in the differential diagnosis of acute mental status changes, especially in elderly patients 3
Medications are one of the most common causes of delirium, with antibiotics being frequently overlooked contributors 3
Untreated infections can also cause delirium, so appropriate antimicrobial therapy remains important 2
In patients with asymptomatic bacteriuria and delirium, antibiotics should be avoided as they have not been shown to improve mental status and may lead to adverse outcomes 2

When these medications must be used in high-risk patients, implement delirium prevention strategies and close monitoring 3
If delirium develops, prompt discontinuation of the suspected causative agent should be considered 1, 3
Systematic screening for delirium using validated tools can help identify medication-induced delirium earlier 2
Adjust dosing of medications, particularly antibiotics, in patients with renal impairment to prevent neurotoxicity 7