Real-world evaluation of linezolid-associated serotonin toxicity with and without concurrent serotonergic agents

Int J Antimicrob Agents. 2023 Jul;62(1):106843. doi: 10.1016/j.ijantimicag.2023.106843. Epub 2023 May 7.


Background: The risk of linezolid-associated serotonin toxicity remains unclear. This study sought to evaluate the incidence of serotonin toxicity among hospitalized patients who received linezolid with or without concurrent serotonergic agents (SAs). Secondary outcomes were to assess the dose, agent selection and number of SAs.

Methods: A single-centre, retrospective cohort study of hospitalized patients aged ≥18 years who received at least one dose of linezolid with or without SAs between 1 January 2014 and 30 June 2021 was performed. Patients were excluded if they were aged <18 years, had linezolid ordered but not administered, were pregnant or were incarcerated. Up to five concurrent SAs were assessed, and dose category was classed as low, moderate or high (dose <33%, 33-66% or >66% of maximum daily dose, respectively). Serotonin toxicity was identified by searching patients' electronic medical records. If identified, the Sternbach criteria and Hunter criteria were applied.

Results: Of 2022 patients screened, 1743 were included in this study. Mean age, weight and linezolid duration were 58.5 years, 90.7 kg and 3.8 days, respectively. Approximately 67% (1168/1743) of patients received linezolid with at least one SA, and several patients received multiple SAs. Most patients (53.8%; 616/1144) received moderate- and/or high-dose SAs. Only two patients (0.11%) were identified as possible cases of serotonin toxicity based on the electronic medical record search. However, the incidence of serotonin toxicity was 0.06% (1/1743) based on the Sternbach criteria and 0% (0/1743) based on the Hunter criteria.

Conclusions: Serotonin toxicity among hospitalized patients who received linezolid with or without SAs was exceedingly rare, even among those who received multiple and high-dose SAs.

Keywords: Linezolid; SSRI; Serotonin; Serotonin syndrome; Serotonin toxicity.

MeSH terms

  • Acetamides
  • Adolescent
  • Adult
  • Humans
  • Linezolid / toxicity
  • Middle Aged
  • Oxazolidinones* / adverse effects
  • Retrospective Studies
  • Serotonin
  • Serotonin Agents
  • Serotonin Syndrome* / chemically induced
  • Serotonin Syndrome* / epidemiology


  • Linezolid
  • Serotonin
  • Oxazolidinones
  • Acetamides
  • Serotonin Agents