Antibiotic-induced Bartter-like syndrome: a systematic review

Abstract

Background: Bartter syndrome encompasses salt-losing tubulopathies characterized by hypokalaemia, hypochloremic metabolic alkalosis and hyperreninemic hyperaldosteronism with normal blood pressure and renal function. Acquired Bartter-like syndrome (ABLS) is commonly associated with diuretics and antibiotics such as aminoglycosides, colistin and amphotericin B. This review aims to understand the timing of Bartter syndrome onset after exposure to inciting drugs and explore its progression and management.

Methods: A systematic review was conducted following PRISMA guidelines. Databases searched include PubMed, Embase, medRxiv and bioRxiv. Case reports, case series and review articles from 1986 to March 2022 were screened. Forty-three cases were included, consisting of five case series and the rest as case reports.

Results: The most common antimicrobial associated with ABLS was gentamicin (41.8%), followed by colistin (32.5%). The most frequent symptoms were paraesthesias (27.9%) and carpopedal spasms (27.9%), while 32.5% of patients were asymptomatic. Laboratory findings showed hypokalaemia (100%), metabolic alkalosis (97.2%), hypocalcaemia (92.5%) and hypomagnesaemia (100%), with renal wasting of these electrolytes but normal serum creatinine. The median time for Bartter-like syndrome to appear post-drug exposure was 10 days (IQR 7-18 days), with resolution occurring within 14 days (IQR 7-31 days) after drug discontinuation. Symptoms resolved completely upon cessation of the offending agent.

Conclusions: ABLS, though rare, should be suspected in patients on antimicrobials presenting with salt-losing tubulopathy. Aminoglycosides are the most frequently implicated drugs. Discontinuation of the offending drug, along with fluid and electrolyte management, leads to complete recovery.