Too Much, Too Little Sleep Linked With Greater Infection Risk

A recent study conducted in Norway found that too much or too little self-reported sleep was associated with 44% and 25% greater risk of infection, respectively, and higher antibiotic use.

Self-reports of short or long sleep duration, chronic insomnia, chronic insomnia disorder, and chronic sleep problems were associated with higher prevalence of infection and antibiotic use, supporting an association between sleep and infection, according to a study published in Frontiers in Psychiatry.

This study was conducted because there is rising evidence that sleep problems and short sleep duration raise the risk of infection. No previous observational studies have included circadian preference or antibiotic use, and few have used validated instruments for sleep disturbance assessment.

Therefore, the researchers were trying to assess if whether chronic insomnia disorder, chronic sleep problems, sleep duration, and circadian preference based on self-report were linked with infection risk and antibiotic use in patients visiting their general practitioner (GP).

“Sleep is an important determinant of health and wellbeing. Insomnia is the most common sleep problem with a prevalence of 10–20% in the general population. In Norway, among patients in general practice, the prevalence of insomnia has been found to be as high as 54%,” the authors noted.

The researchers conducted a cross-sectional study of 1848 unselected patients who saw their GP in 2020. Patients filled out a 1-page questionnaire while waiting at the GP’s office, and the questionnaire included the validated Bergen Insomnia Scale (BIS), questions on self-assessed sleep problem, sleep duration, and circadian preference, and whether the patients had any infections or used antibiotics in the last 3 months.

Most of the patients (60.6%) were female, with a mean age of 52. A little more than a third had children living at home and 38% had higher education.

Chronic insomnia disorder based on Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria was found in 48.3% of participants, while 46.9% met the criteria for chronic sleep problem.

After the questionnaires were analyzed with modified Poisson regression, it was found that the risk of infection was 25% (95% CI, relative risk [RR], 1.11–1.46) in patients sleeping <6 hours and 44% higher (95% CI, 1.12–1.84) in patients sleeping >9, compared with those sleeping 7-8 hours. Increased risk for infection was also found in patients with chronic insomnia disorder or a chronic sleep problem. Antibiotic use was higher for patients sleeping <6 hours and for those who had chronic insomnia disorder or a chronic sleep problem.

Patients who had a sleep duration of <6 hours or >9 hours as well as those with a chronic sleep problem had a higher risk of gastrointestinal infection. Urinary tract infection risk higher for patients with chronic insomnia disorder.

Researchers were surprised by the lack of statistically significant associations for risk of respiratory tract infection (RTI), which has been found in other research, some of which included provider-diagnosed pneumonia, not self-reports. Their study may have been limited by the smaller sample size compared with these other studies as well as well as the fact that their study did not include specific types of RTIs.

In addition, the study was that it did not include any clinical assessment of sleep problems, chronotype, or infection, and researchers did not know why the patient visited their GP. Recall bias could also be present with patients, and the presence of the COVID-19 pandemic may have made patients more aware of respiratory infections while at the same time probably also resulted in a lower prevalence of common RTIs because of infection control measures.

Overall, however, the findings indicate that sleep could be a possible target when creating measures to prevent infections and reduce antibiotic use.

“More longitudinal studies in the general population and among patients in general practice, as well as clinical studies on the effect of treatment of insomnia on risk of infection, are needed. Data on different groups of infections and their potential differences in associations with sleep could give us important clues about potential underlying mechanisms,” the authors concluded.


Forthun I, Eliassen KER, Emberland KE, Bjorvatn B. The association between self-reported sleep problems, infection, and antibiotic use in patients in general practice. Front Psychiatry. Published online March 2, 2023. doi: 10.3389/fpsyt.2023.1033034

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