Co-trimoxazole (Systemic) 46067 AHFS Essentials ASHPI

46067
AHFS Essentials
ASHPI
BATCH
RIGHT
Co-trimoxazole
41
A drug of choice for treatment of upper respiratory tract infections and bronchitis
Co-trimoxazole (Systemic)
Antibacterial; fixed combination of sulfamethoxazole (intermediate-acting sulfonamide)
and trimethoprim; both sulfamethoxazole and trimethoprim are folate-antagonist antiinfectives.
Class: Sulfonamides 8:12.20 (AHFS primary); AP100 (VA primary)
Brands*: Bactrim; Bactrim DS; Septra; Septra DS; Sulfatrim
*also available generically
caused by H. influenzae; an alternative to penicillin G or penicillin V for treatment
of respiratory tract infections caused by S. pneumoniae.
Alternative for treatment of infections caused by Legionella micdadei† (L. pittsburgensis) or L. pneumophila†.
Urinary Tract Infections (UTIs)
Treatment of UTIs caused by susceptible E. coli, Klebsiella, Enterobacter, Morganella morganii, Proteus mirabilis, or P. vulgaris. A drug of choice for empiric treatment of acute uncomplicated UTIs.
Brucellosis
Treatment of brucellosis†; alternative when tetracyclines are contraindicated (e.g.,
children). Used alone or in conjunction with other anti-infectives (e.g., streptomycin or gentamicin and/or rifampin), especially for severe infections or when there
are complications (e.g., endocarditis, meningitis, osteomyelitis).
Synonyms: Sulfamethoxazole-Trimethoprim
Abbreviations: SMX-TMP
Uses
Acute Otitis Media
Treatment of acute otitis media (AOM) in adults† and children caused by susceptible Streptococcus pneumoniae or Haemophilus influenzae when the clinician
makes the judgment that the drug offers some advantage over use of a single
anti-infective.
Not a drug of first choice; considered an alternative for treatment of AOM, especially for those with type I penicillin hypersensitivity. Because amoxicillin-resistant
S. pneumoniae frequently are resistant to co-trimoxazole, the drug may not be effective in patients with AOM who fail to respond to amoxicillin.
Data are limited regarding safety of repeated use of co-trimoxazole in pediatric
patients ⬍2 years of age; the drug should not be administered prophylactically or
for prolonged periods for treatment of AOM in any age group.
Burkholderia Infections
Treatment of infections caused by Burkholderia cepacia†. Co-trimoxazole considered drug of choice; ceftazidime, chloramphenicol, or imipenem are alternatives.
Treatment of melioidosis† caused by susceptible B. pseudomallei; used in multiple-drug regimen with chloramphenicol and doxycycline. Ceftazidime or imipenem
monotherapy may be preferred. B. pseudomallei is difficult to eradicate and relapse of melioidosis is common.
Cholera
Treatment of cholera† caused by Vibrio cholerae. Alternative to tetracyclines; used
as an adjunct to fluid and electrolyte replacement in moderate to severe disease.
Cyclospora Infections
Treatment of infections caused by Cyclospora cayetanensis†. The drug of choice.
GI Infections
Granuloma Inguinale (Donovanosis)
Treatment of travelers’ diarrhea caused by susceptible enterotoxigenic Escherichia
Treatment of granuloma inguinale (donovanosis) caused by Calymmatobacterium
top of rh
base of rh
cap height
base of text
coli. Replacement therapy with oral fluids and electrolytes may be sufficient for
mild to moderate disease; those who develop diarrhea with ⱖ3 loose stools in an
8-hour period (especially if associated with nausea, vomiting, abdominal cramps,
fever, or blood in the stools) may benefit from short-term anti-infectives. Fluoroquinolones (ciprofloxacin, levofloxacin, norfloxacin, ofloxacin) usually drugs of
choice when treatment indicated; co-trimoxazole also has been recommended as
an alternative when fluoroquinolones cannot be used (e.g., in children).
Prevention of travelers’ diarrhea† in individuals traveling forrelatively short periods
to areas where enterotoxigenic E. coli and other causative bacterial pathogens
(e.g., Shigella) are known to be susceptible to the drug. CDC and others do not
recommend anti-infective prophylaxis in most individuals traveling to areas of risk;
the principal preventive measures are prudent dietary practices. If prophylaxis is
used (e.g., in immunocompromised individuals such as those with HIV infection),
a fluoroquinolone (ciprofloxacin, levofloxacin, ofloxacin, norfloxacin) is preferred.
Resistance to co-trimoxazole is common in many tropical areas.
Treatment of enteritis caused by susceptible Shigella flexneri or S. sonnei when
anti-infectives are indicated.
Treatment of dysentery caused by enteroinvasive E. coli† (EIEC). AAP suggests
that an oral anti-infective (e.g., co-trimoxazole, azithromycin, ciprofloxacin) can be
used if the causative organism is susceptible.
Treatment of diarrhea caused by enterotoxigenic E. coli† (ETEC) in travelers to resource-limited countries. Optimal therapy not established, but AAP suggests that
use of co-trimoxazole, azithromycin, or ciprofloxacin be considered if diarrhea is
severe or intractable and if in vitro testing indicates the causative organism is
susceptible. A parenteral regimen should be used if systemic infection is suspected.
Role of anti-infectives in treatment of hemorrhagic colitis caused by shiga toxinproducing E. coli† (STEC; formerly known as enterohemorrhagic E. coli) is unclear;
most experts would not recommend use of anti-infectives in children with enteritis
caused by E. coli 0157:H7.
Treatment of GI infections caused by Yersinia enterocolitica† or Y. pseudotuberculosis†. These infections usually are self-limited, but IDSA, AAP, and others recommend anti-infectives for severe infections, when septicemia or other invasive disease occurs, and in immunocompromised patients. Other than decreasing the
duration of fecal excretion of the organism, a clinical benefit of anti-infectives in
management of enterocolitis, pseudoappendicitis syndrome, or mesenteric adenitis
caused by Yersinia has not been established.
Respiratory Tract Infections
Treatment of acute exacerbation of chronic bronchitis caused by susceptible S.
pneumoniae or H. influenzae when the clinician makes the judgment that the drug
offers some advantage over use of a single anti-infective.
granulomatis†. CDC recommends doxycycline or co-trimoxazole.
Isosporiasis
Treatment of isosporiasis† caused by Isospora belli. The drug of choice.
Listeria Infections
Treatment of infections caused by Listeria monocytogenes†; a preferred alternative
to ampicillin in penicillin-allergic patients.
Mycobacterial Infections
Treatment of cutaneous infections caused by Mycobacterium marinum†; alternative to minocycline.
Nocardia Infections
Treatment of infections caused by Nocardia†, including N. asteroides, N. brasiliensis, and N. caviae. Drugs of choice are co-trimoxazole or a sulfonamide alone
(e.g., sulfisoxazole, sulfamethoxazole).
Pertussis
Treatment of the catarrhal stage of pertussis† to potentially ameliorate the disease
and reduce its communicability. Recommended by CDC, AAP, and others as an
alternative to erythromycin.
Prevention of pertussis† in household and other close contacts (e.g., day-care facility attendees) of patients with the disease. Alternative to erythromycin.
Plague
Has been used for postexposure prophylaxis of plague†. Although recommended
by CDC and others for such prophylaxis in infants and children ⬍8 years of age,
efficacy of the drug for prevention of plague is unknown. Most experts (e.g., CDC,
AAP, the US Working Group on Civilian Biodefense, US Army Medical Research
Institute of Infectious Diseases) recommend oral ciprofloxacin or doxycycline for
postexposure prophylaxis in adults and most children. Postexposure prophylaxis
recommended after high-risk exposures to plague, including close exposure to individuals with naturally occurring plague, during unprotected travel in active epizootic or epidemic areas, or laboratory exposure to viable Yersinia pestis.
Has been used for treatment of plague†, but appears to be less effective than
other anti-infectives used for treatment of the disease (e.g., streptomycin, gentamicin, tetracycline, doxycycline, chloramphenicol). Because of lack of efficacy,
some experts state that co-trimoxazole should not be used for the treatment of
pneumonic plague.
short
stand
46067
42
AHFS Essentials
ASHPI
BATCH
LEFT
top of rh
base of rh
Co-trimoxazole
Pneumocystis jiroveci (Pneumocystis carinii) Pneumonia
Treatment of Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia
(PCP). Initial drug of choice for most patients with PCP, including HIV-infected individuals.
Prevention of initial episodes of PCP (primary prophylaxis) in immunocompromised
individuals at increased risk, including HIV-infected individuals. Drug of choice. up
to 14
Long-term suppressive or chronic maintenance therapy (secondary prophylaxis) to
prevent recurrence following an initial PCP episode in immunocompromised patients, including HIV-infected individuals. Drug of choice.
Toxoplasmosis
Prevention of toxoplasmosis† encephalitis (primary prophylaxis) in HIV-infected
adults, adolescents, and children who are seropositive for Toxoplasma IgG antibody. Drug of choice.
Not recommended for long-term suppressive or chronic maintenance therapy (secondary prophylaxis) to prevent recurrence of toxoplasmosis encephalitis; regimen
of choice for secondary prophylaxis of toxoplasmosis is sulfadiazine and pyrimethamine (with leucovorin).
Typhoid Fever and Other Salmonella Infections
Alternative for treatment of typhoid fever† (enteric fever) caused by susceptible
Salmonella typhi. Drugs of choice are fluoroquinolones and third generation cephalosporins (e.g., ceftriaxone, cefotaxime); consider that multidrug-resistant strains
of S. typhi (strains resistant to ampicillin, amoxicillin, chloramphenicol, and/or cotrimoxazole) reported with increasing frequency.
Alternative for treatment of gastroenteritis caused by nontyphoidal Salmonella†.
Wegener’s Granulomatosis
Treatment of Wegener’s granulomatosis†. Effect on long-term morbidity and mortality unclear, but may prevent relapse and reduce need for cytotoxic (e.g., cyclophosphamide) and corticosteroid therapy in some patients.
Whipple’s Disease
Treatment of Whipple’s disease† caused by Tropheryma whippelii. Alternative or
follow-up to penicillin G.
Dosage and Administration
Administration
Administer orally or by IV infusion. Do not administer by rapid IV infusion or injection and do not administer IM.
An adequate fluid intake should be maintained during co-trimoxazole therapy to
prevent crystalluria and stone formation.
IV Administration
Dilution
Co-trimoxazole concentrate for injection must be diluted prior to IV infusion.
Each 5 mL of the concentrate for injection containing 80 mg of trimethoprim
should be added to 125 mL of 5% dextrose in water. In patients in whom fluid intake
is restricted, each 5 mL of the concentrate may be added to 75 mL of 5% dextrose in
water.
Rate of Administration
IV solutions should be infused over a period of 60– 90 minutes.
Dosage
Available as fixed combination containing sulfamethoxazole and trimethoprim; dosage expressed as both the sulfamethoxazole and trimethoprim content or as the trimethoprim content.
Pediatric Patients
Acute Otitis Media
Oral: Children ⱖ2 months of age: 8 mg/kg of trimethoprim and 40 mg/kg
of sulfamethoxazole daily in 2 divided doses every 12 hours. Usual duration is 10 days.
GI Infections
⬎Shigella Infections
Oral: Children ⱖ2 months of age: 8 mg/kg of trimethoprim and 40 mg/kg
of sulfamethoxazole daily in 2 divided doses every 12 hours. Usual duration is 5 days.
IV: Children ⱖ2 months of age: 8– 10 mg/kg of trimethoprim daily (as cotrimoxazole) in 2– 4 equally divided doses given for 5 days.
Urinary Tract Infections (UTIs)
Oral: Children ⱖ2 months of age: 8 mg/kg of trimethoprim and 40 mg/kg
of sulfamethoxazole daily in 2 divided doses every 12 hours. Usual duration is 10 days.
cap height
base of text
⬎Severe UTIs
IV: Children ⱖ2 months of age: 8– 10 mg/kg of trimethoprim daily (as cotrimoxazole) in 2– 4 equally divided doses given for up to 14 days.
Brucellosis†
Oral: 10 mg/kg daily (up to 480 mg daily) of trimethoprim (as co-trimoxazole) in 2 divided doses for 4– 6 weeks.
Cholera†
Oral: 4– 5 mg/kg of trimethoprim (as co-trimoxazole) twice daily given for
3 days.
Cyclospora Infections†
Oral: 5 mg/kg of trimethoprim and 25 mg/kg of sulfamethoxazole twice
daily given for 7– 10 days. HIV-infected patients may require higher dosage and longer treatment.
Granuloma Inguinale (Donovanosis)†
Oral: Adolescents: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily given for ⱖ3 weeks or until all lesions have healed completely; consider adding IV aminoglycoside (e.g., gentamicin) if improvement is not evident within the first few days of therapy and in
HIV-infected patients.
Relapse can occur 6– 18 months after apparently effective treatment.
Isosporiasis†
Oral: 5 mg/kg of trimethoprim and 25 mg/kg of sulfamethoxazole twice
daily. Usual duration of treatment is 10 days; higher dosage or more prolonged treatment necessary in immunocompromised patients.
Pertussis†
Oral: 8 mg/kg of trimethoprim and 40 mg/kg of sulfamethoxazole daily in 2
divided doses. Usual duration is 14 days for treatment or prevention.
Plague†
⬎Postexposure Prophylaxis†
Oral: Children ⱖ2 months of age: 320– 640 mg of trimethoprim (as cotrimoxazole) daily in 2 divided doses given for 7 days. Alternatively, 8 mg/
kg daily of trimethoprim (as co-trimoxazole) in 2 divided doses given for 7
days.
Pneumocystis jiroveci (Pneumocystis carinii) Pneumonia
⬎Treatment
Oral: Children ⱖ2 months of age: 15– 20 mg/kg of trimethoprim and 75–
100 mg/kg of sulfamethoxazole daily in 3 or 4 divided doses. Usual duration is 14– 21 days.
IV: Children ⱖ2 months of age: 15– 20 mg/kg of trimethoprim daily (as
co-trimoxazole) in 3 or 4 equally divided doses. Usual duration is 14– 21
days.
⬎Primary Prophylaxis in Infants and Children
Oral: 150 mg/m2 of trimethoprim and 750 mg/m2 of sulfamethoxazole daily
in 2 divided doses given on 3 consecutive days each week. Total daily
dose should not exceed 320 mg of trimethoprim and 1.6 g of sulfamethoxazole.
Alternatively, 150 mg/m2 of trimethoprim and 750 mg/m2 of sulfamethoxazole can be administered as a single dose 3 times each week on consecutive days, in 2 divided doses daily 7 days each week, or in 2 divided
daily doses given 3 times each week on alternate days.
CDC, USPHS/IDSA, AAP, and others recommend that primary prophylaxis
be initiated in all infants born to HIV-infected women starting at 4– 6
weeks of age, regardless of their CD4⫹ T-cell count. Infants who are first
identified as being HIV-exposed after 6 weeks of age should receive primary prophylaxis beginning at the time of identification.
Primary prophylaxis should be continued until 12 months of age in all HIVinfected infants and infants whose infection status has not yet been determined; it can be discontinued in those found not to be HIV-infected.
The need for subsequent prophylaxis should be based on age-specific
CD4⫹ T-cell count thresholds. In HIV-infected children 1– 5 years of age,
primary prophylaxis should be initiated if CD4⫹ T-cell counts are ⬍500/
mm3 or CD4⫹ percentage is ⬍15%. In HIV-infected children 6– 12 years of
age, primary prophylaxis should be initiated if CD4⫹ T-cell counts are
⬍200/mm3 or CD4⫹ percentage is ⬍15%.
The safety of discontinuing prophylaxis in HIV-infected children receiving
potent antiretroviral therapy has not been extensively studied.
short
stand
46067
AHFS Essentials
ASHPI
BATCH
RIGHT
Co-trimoxazole
⬎Prevention of Recurrence (Secondary Prophylaxis) in Infants and
Children
Oral: 150 mg/m2 of trimethoprim and 750 mg/m2 of sulfamethoxazole daily
in 2 divided doses given on 3 consecutive days each week. Total daily
dose should not exceed 320 mg of trimethoprim and 1.6 g of sulfamethoxazole.
2
2
Alternatively, 150 mg/m of trimethoprim and 750 mg/m of sulfamethoxazole can be administered as a single daily dose given for 3 consecutive
days each week, in 2 divided doses daily, or in 2 divided daily doses
given 3 times a week on alternate days.
The safety of discontinuing secondary prophylaxis in HIV-infected children
receiving potent antiretroviral therapy has not been extensively studied.
Children who have a history of PCP should receive life-long suppressive
therapy to prevent recurrence.
⬎Primary and Secondary Prophylaxis in Adolescents
Oral: Dosage for primary or secondary prophylaxis against P. jiroveci pneumonia in adolescents and criteria for initiation or discontinuance of such
prophylaxis in this age group are the same as those recommended for
adults. (See Adult Dosage under Dosage and Administration.)
Toxoplasmosis†
⬎Primary Prophylaxis in Infants and Children†
Oral: 150 mg/m2 of trimethoprim and 750 mg/m2 of sulfamethoxazole daily
in 2 divided doses.
The safety of discontinuing toxoplasmosis prophylaxis in HIV-infected children receiving potent antiretroviral therapy has not been extensively studied.
Primary Prophylaxis in Adolescents†
Oral: Dosage for primary prophylaxis against toxoplasmosis in adolescents
and criteria for initiation or discontinuance of such prophylaxis in this age
group are the same as those recommended for adults. (See Adult Dosage
under Dosage and Administration.)
Adults
GI Infections
⬎Treatment of Travelers’ Diarrhea
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole every 12
hours given for 3– 5 days. A single 320-mg dose of trimethoprim (as cotrimoxazole) also has been used.
⬎Prevention of Travelers’ Diarrhea
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole once daily
during the period of risk. Use of anti-infectives for prevention of travelers’
diarrhea generally is discouraged.
⬎Shigella Infections
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole every 12
hours given for 5 days.
IV: 8– 10 mg/kg of trimethoprim daily (as co-trimoxazole) in 2– 4 equally
divided doses given for 5 days.
Respiratory Tract Infections
⬎Acute Exacerbations of Chronic Bronchitis
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole every 12
hours given for 14 days.
Urinary Tract Infections (UTIs)
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole every 12
hours.
Usual duration of treatment is 10– 14 days. A 3-day regimen may be effective for acute, uncomplicated cystitis in women.
⬎Severe UTIs
IV: 8– 10 mg/kg of trimethoprim daily (as co-trimoxazole) in 2– 4 equally
divided doses given for up to 14 days.
Cholera†
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole every 12
hours given for 3 days.
Cyclospora Infections†
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily
given for 7– 10 days. HIV-infected patients may require higher dosage and
longer-term treatment.
Granuloma Inguinale (Donovanosis)†
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily
given for ⱖ3 weeks or until all lesions have healed completely; consider
adding IV aminoglycoside (e.g., gentamicin) if improvement is not evident
within the first few days of therapy and in HIV-infected patients.
Relapse can occur 6– 18 months after apparently effective treatment.
43
Isosporiasis†
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily.
Usual duration of treatment is 10 days; higher dosage or more prolonged
treatment necessary in immunocompromised patients.
top of rh
base of rh
cap height
base of text
Mycobacterial Infections†
⬎Mycobacterium marinum Infections
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily
given for ⱖ3 months recommended by ATS for treatment of cutaneous
infections. A minimum of 4– 6 weeks of treatment usually is necessary to
determine whether the infection is responding.
Pertussis†
Oral: 320 mg of trimethoprim (as co-trimoxazole) daily in 2 divided doses.
Usual duration is 14 days for treatment or prevention.
Pneumocystis jiroveci (Pneumocystis carinii) Pneumonia
⬎Treatment
Oral: 15– 20 mg/kg of trimethoprim and 75– 100 mg/kg of sulfamethoxazole daily in 3 or 4 divided doses. Usual duration is 14– 21 days.
IV: 15– 20 mg/kg of trimethoprim daily in 3 or 4 equally divided doses
every 6 or 8 hours given for up to 14 days. Some clinicians recommend
15 mg/kg of trimethoprim and 75 mg/kg of sulfamethoxazole daily in 3 or
4 divided doses for 14– 21 days.
⬎Primary Prophylaxis
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole once daily.
Alternatively, 80 mg of trimethoprim and 400 mg of sulfamethoxazole can
be given once daily.
Initiate primary prophylaxis in patients with CD4⫹ T-cell counts ⬍200/mm3
or a history of oropharyngeal candidiasis. Also consider primary prophylaxis if CD4⫹ T-cell percentage is ⬍14% or there is a history of an AIDSdefining illness.
Primary prophylaxis can be discontinued in adults and adolescents responding to potent antiretroviral therapy who have a sustained (ⱖ3
months) increase in CD4⫹ T-cell counts from ⬍200/mm3 to ⬎200/mm3.
However, it should be restarted if CD4⫹ T-cell count decreases to ⬍200/
mm3.
⬎Prevention of Recurrence (Secondary Prophylaxis)
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole once daily.
Alternatively, 80 mg of trimethoprim and 400 mg of sulfamethoxazole can
be given once daily.
Initiate long-term suppressive therapy or chronic maintenance therapy
(secondary prophylaxis) in those with a history of P. jiroveci pneumonia to
prevent recurrence.
Discontinuance of secondary prophylaxis is recommended in those who
have a sustained (ⱖ3 months) increase in CD4⫹ T-cell counts to ⬎200/
mm3 since such prophylaxis appears to add little benefit in terms of disease prevention and discontinuance reduces the medication burden, the
potential for toxicity, drug interactions, selection of drug-resistant pathogens, and cost.
Reinitiate secondary prophylaxis if CD4⫹ T-cell count decreases to ⬍200/
mm3 or if P. jiroveci pneumonia recurs at a CD4⫹ T-cell ⬎200/mm3. It
probably is prudent to continue secondary prophylaxis for life in those
who had P. jiroveci episodes when they had CD4⫹ T-cell counts ⬎200/
mm3.
Toxoplasmosis†
⬎Primary Prophylaxis
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole once daily.
Alternatively, 80 mg of trimethoprim and 400 mg of sulfamethoxazole may
be used.
Initiate primary prophylaxis against toxoplasmosis in HIV-infected adults
and adolescents who are seropositive for Toxoplasma IgG antibody and
have CD4⫹ T-cell counts ⬍100/mm3.
Consideration can be given to discontinuing primary prophylaxis in adults
and adolescents who have a sustained (ⱖ3 months) increase in CD4⫹ Tcell counts to ⬎200/mm3 since such prophylaxis appears to add little benefit in terms of disease prevention for toxoplasmosis, and discontinuance
reduces the pill burden, the potential for toxicity, drug interactions, selection of drug-resistant pathogens, and cost.
Reinitiate primary prophylaxis against toxoplasmosis if CD4⫹ T-cell count
decreases to ⬍100– 200/mm3.
Wegener’s Granulomatosis†
Oral: 160 mg of trimethoprim and 800 mg of sulfamethoxazole twice daily.
short
stand
46067
AHFS Essentials
44
ASHPI
LEFT
top of rh
base of rh
Co-trimoxazole
Perform urinalysis with careful microscopic examination and renal function tests
during co-trimoxazole therapy, especially in patients with impaired renal function.
Special Populations
Renal Impairment
In patients with Clcr 15– 30 mL/minute, use 50% of usual dosage.
Use not recommended in those with Clcr ⬍15 mL/minute.
Geriatric Patients
No dosage adjustments except those related to renal impairment. (See Renal
Impairment under Dosage and Administration.)
Cautions
Contraindications
•
•
•
BATCH
Known hypersensitivity to sulfonamides or trimethoprim.
Documented megaloblastic anemia due to folate deficiency.
Children ⬍2 months of age, pregnant women at term, and nursing women.
Warnings/Precautions
Warnings
Severe Reactions related to the Sulfonamide Component
Severe (sometimes fatal) reactions, including Stevens-Johnson syndrome, toxic
epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, and
other blood dyscrasias, have been reported with sulfonamides.
Rash, sore throat, fever, arthralgia, pallor, purpura, or jaundice may be early indications of serious reactions. Discontinue co-trimoxazole at the first appearance of rash
or any sign of adverse reactions.
Superinfection/Clostridium difficile-associated Colitis
Possible emergence and overgrowth of nonsusceptible bacteria or fungi. Institute
appropriate therapy if superinfection occurs.
Treatment with anti-infectives may permit overgrowth of clostridia. Consider Clostridium difficile-associated diarrhea and colitis (antibiotic-associated pseudomembranous colitis) if diarrhea develops and manage accordingly.
Some mild cases of C. difficile-associated diarrhea and colitis may respond to discontinuance alone. Manage moderate to severe cases with fluid, electrolyte, and protein supplementation; appropriate anti-infective therapy (e.g., oral metronidazole or
vancomycin) recommended if colitis is severe.
Sensitivity Reactions
Hypersensitivity Reactions
Cough, shortness of breath, and pulmonary infiltrates are hypersensitivity reactions
of the respiratory tact that have been reported with sulfonamides.
Use with caution in patients with severe allergy or bronchial asthma.
Sulfite Sensitivity
Concentrate for injection contains a sulfite, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in
certain susceptible individuals.
General Precautions
Patients with Folate Deficiency or G6PD Deficiency
Hemolysis may occur in individuals with glucose-6-phosphate dehydrogenase
(G6PD) deficiency; this effect may be dose-related.
Use with caution in patient with possible folate deficiency (e.g., geriatric patients,
chronic alcoholics, patients receiving anticonvulsant therapy, patients with malabsorption syndrome, patients with malnutrition).
Patients with Pneumocystis jiroveci (Pneumocystis carinii)
Pneumonia
HIV-infected patients with Pneumocystis jiroveci pneumonia may have an increased incidence of adverse effects during co-trimoxazole therapy (particularly rash,
fever, leukopenia, increased liver enzymes) compared with HIV-seronegative patients.
The incidence of hyperkalemia and hyponatremia also may be increased in HIV-infected patients.
Adverse effects generally are less severe in those receiving co-trimoxazole for
prophylaxis rather than treatment.
A history of mild intolerance to co-trimoxazole in HIV-infected patients does not
appear to predict intolerance to subsequent use of the drug for secondary prophylaxis. However, use of the drug should be reevaluated in patients who develop rash
or any sign of adverse reaction.
Concomitant use of leucovorin and co-trimoxazole for acute treatment of P. jiroveci pneumonia in HIV-infected patients has been associated with increased rates of
treatment failure and morbidity.
Laboratory Monitoring
Perform CBCs frequently during co-trimoxazole therapy; discontinue the drug if a
significant reduction in any formed blood element occurs.
cap height
base of text
Selection and Use of Anti-infectives
To reduce development of drug-resistant bacteria and maintain effectiveness of
co-trimoxazole and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.
When selecting or modifying anti-infective therapy, use results of culture and in
vitro susceptibility testing.
Because S. pyogenes (group A ␤-hemolytic streptococci) may not be eradicated
by co-trimoxazole, do not use the drug for treatment of infections caused by this organism since it cannot prevent sequelae such as rheumatic fever.
Specific Populations
Pregnancy
Category C.
Because sulfonamides may cause kernicterus in neonates, co-trimoxazole is contraindicated in pregnant women at term.
Lactation
Both sulfamethoxazole and trimethoprim distributed into milk. Co-trimoxazole contraindicated in nursing women.
Pediatric Use
Safety and efficacy not established in children ⬍2 months of age.
Geriatric Use
Geriatric patients may be at increased risk of severe adverse reactions, particularly if they have impaired hepatic and/or renal function or are receiving concomitant
drug therapy.
The most frequent adverse reactions in geriatric patients are severe skin reactions, generalized bone marrow suppression, or a specific decrease in platelets (with
or without purpura). Those receiving concurrent therapy with a diuretic (principally
thiazides) are at increased risk of thrombocytopenia with purpura.
Dosage adjustments are necessary based on age-related decreases in renal function.
Hepatic Impairment
Use with caution in patients with impaired hepatic function.
Renal Impairment
Use reduced dosage in patients with Clcr 15– 30 mL/minute.
Do not use in patients with Clcr ⬍15 mL/minute.
Common Adverse Effects
GI effects (nausea, vomiting, anorexia); dermatologic and sensitivity reactions
(rash, urticaria).
Interactions
Specific Drugs and Laboratory Tests
Drug or Test
Interaction
Amantadine
Toxic delirium reported in
an individual who received amantadine and
co-trimoxazole concomitantly
Antidepressants, tricyclics
Possible decreased efficacy
of the tricyclic antidepressant
Cyclosporine
Reversible nephrotoxicity reported in renal transplant
recipients receiving cyclosporine and co-trimoxazole concomitantly
Digoxin
Possible increased digoxin
concentrations, especially
in geriatric patients
Diuretics
Possible increased incidence
of thrombocytopenia and
purpura if certain diuretics (principally thiazides)
are used concomitantly,
especially in geriatric patients
Hypoglycemic agents, oral
Possible potentiation of hypoglycemic effects
Comments
Monitor serum digoxin concentrations in patients receiving co-trimoxazole
concomitantly
short
stand
46067
AHFS Essentials
ASHPI
BATCH
RIGHT
Co-trimoxazole
Indomethacin
Possible increased sulfamethoxazole concentrations
Methotrexate
Co-trimoxazole can displace Use caution if methotrexate
methotrexate from plasma
and co-trimoxazole used
protein-binding sites reconcomitantly
sulting in increased free
methotrexate concentrations
Possible interference with serum methotrexate assays if
competitive protein binding technique is used with
a bacterial dihydrofolate
reductase as the binding
protein; interference does
not occur if methotrexate
is measured using radioimmunoassay
Co-trimoxazole may inhibit
metabolism and increase
half-life of phenytoin
Phenytoin
Monitor for possible increased phenytoin effects
Tests for creatinine
Possible interference with
Jaffe alkaline picrate assay
resulting in falsely elevated creatinine concentrations
Warfarin
Possible inhibition of warfarin clearance and prolonged PT
mately 45– 85% of a sulfamethoxazole dose and 50– 67% of a trimethoprim dose are
excreted in urine.
Only small amounts of trimethoprim are excreted in feces via biliary elimination.
top of rh
base of rh
cap height
base of text
Half-life
Serum half-lives of sulfamethoxazole and trimethoprim are approximately 10– 13
and 8– 11 hours, respectively, in adults with normal renal function.
Special Populations
Patients with impaired renal function: Half-lives of both sulfamethoxazole and trimethoprim may be prolonged.
In adults with Clcrⱕ10 mL/minute, serum half-life of trimethoprim may increase to
⬎26 hours. In adults with chronic renal failure, sulfamethoxazole half-life may be 3
times that in patients with normal renal function.
Stability
Storage
Oral
Tablets
15– 25C; protect from light.
Megaloblastic anemia reported when co-trimoxazole used concomitantly
with pyrimethamine dosages ⬎25 mg weekly (for
malaria prophylaxis)
Pyrimethamine
45
Suspension
15– 25C; protect from light.
Parenteral
Concentrate for Injection
5– 25C; do not refrigerate.
Following dilution in 125 or 100 mL of 5% dextrose in water, use within 6 or 4
hours, respectively. If diluted in 75 mL of 5% dextrose in water, use within 2 hours.
Compatibility
Monitor PT closely and adjust warfarin dosage if cotrimoxazole used concomitantly
For information on systemic interactions resulting from concomitant use, see Interactions.
Parenteral
Solution Compatibility
Compatible
Pharmacokinetics
Absorption
Bioavailability
Sulfamethoxazole and trimethoprim are rapidly and well absorbed from the GI tract
following oral administration of the fixed combination preparation (co-trimoxazole).
Peak serum concentrations of both sulfamethoxazole and trimethoprim are attained
within 1– 4 hours.
Co-trimoxazole contains a 1:5 ratio of trimethoprim to sulfamethoxazole, but the
trimethoprim:sulfamethoxazole ratio in serum after administration of the fixed-combination preparation is about 1:20 at steady-state.
Dextrose 5% in sodium chloride 0.45%
Ringer’s injection, lactated
Variable
Dextrose 5% in water
Incompatible
Fluconazole
Linezolid
Extent
Acyclovir sodium
Aldesleukin
Allopurinol sodium
Amifostine
Amphotericin B cholesteryl sulfate complex
Atracurium besylate
Aztreonam
Bivalirudin
Cefepime HCl
Cyclophosphamide
Dexmedetomidine HCl
Diltiazem HCl
Docetaxel
Doxorubicin HCl liposome injection
Enalaprilat
Esmolol HCl
Etoposide phosphate
Fenoldopam mesylate
Filgrastim
Fludarabine phosphate
Gatifloxacin
Gemcitabine HCl
Sulfamethoxazole is approximately 70% and trimethoprim is approximately 44%
bound to plasma proteins. Presence of sulfamethoxazole decreases protein binding of
trimethoprim.
Elimination
Metabolism
Both sulfamethoxazole and trimethoprim are metabolized in the liver.
Elimination Route
Both sulfamethoxazole and trimethoprim are rapidly excreted in urine by glomerular filtration and active tubular secretion. In adults with normal renal function, approxi-
Verapamil HCl
⬎Y-Site Compatibility
Compatible
Plasma Protein Binding
Sodium chloride 0.9%
Drug Compatibility
⬎Admixture Compatibility
Distribution
Widely distributed into body tissues and fluids, including sputum, aqueous humor,
middle ear fluid, bronchial secretions, prostatic fluid, vaginal fluid, and bile.
In patients with uninflamed meninges, trimethoprim and sulfamethoxazole concentrations in CSF are about 50 and 40%, respectively, of concurrent serum concentrations.
Both sulfamethoxazole and trimethoprim readily cross the placenta and are distributed into milk.
Sodium chloride 0.45%
Granisetron HCl
Hetastarch in lactated electrolyte injection
(Hextend)
Hydromorphone HCl
Labetalol HCl
Lorazepam
Magnesium sulfate
Melphalan HCl
Meperidine HCl
Morphine sulfate
Nicardipine HCl
Pancuronium bromide
Perphenazine
Piperacillin sodium-tazobactam sodium
Remifentanil HCl
Sargramostim
Tacrolimus
Teniposide
Thiotepa
Vecuronium bromide
Zidovudine
short
stand
46067
AHFS Essentials
46
ASHPI
BATCH
top of rh
base of rh
Co-trimoxazole
Incompatible
Tablets
Fluconazole
Midazolam HCl
Vinorelbine tartrate
Trimethoprim 80 mg and Sulfamethoxazole 400 mg*
Variable
Foscarnet sodium
Trimethoprim 160 mg and Sulfamethoxazole 800 mg*
Actions and Spectrum
•
•
•
•
•
•
•
•
•
LEFT
A fixed combination of sulfamethoxazole and trimethoprim; both drugs are folateantagonists and sequentially inhibit enzymes of the folic acid pathway in susceptible bacteria.
Sulfamethoxazole inhibits formation of dihydrofolic acid from p-aminobenzoic acid
and trimethoprim inhibits formation of tetrahydrofolic acid (the metabolically active
form of folic acid).
Sulfamethoxazole is bacteriostatic and trimethoprim usually is bactericidal; the
fixed combination generally is bactericidal when synergism is achieved.
Susceptibility to trimethoprim is more critical to efficacy of co-trimoxazole than
susceptibility to sulfamethoxazole. Co-trimoxazole is active against many organisms resistant to sulfamethoxazole but susceptible to trimethoprim.
Spectrum of activity includes many gram-positive and -negative aerobic bacteria
and some protozoa. Inactive against most anaerobic bacteria and inactive against
fungi and viruses.
Gram-positive aerobes: Active against Staphylococcus aureus (including penicillinase-producing strains), Streptococcus pneumoniae, S. pyogenes (group A ␤-hemolytic streptococci), and some strains of enterococci (e.g., Enterococcus faecalis).
Also active against Nocardia, but Bacilllus anthracis may be resistant.
Gram-negative aerobes: Active against Acinetobacter, Enterobacter, Escherichia
coli, Klbesiella pneumoniae, Morganella morganii, Proteus mirabilis, Salmonella,
and Shigella. Also active against Haemophilus influenzae (including ampicillin-resistant strains), H. ducreyi, and Neisseria gonorrhoeae. Pseudomonas aeruginosa is
resistant.
Other organisms: Active in vitro and in vivo against Pneumocystis jiroveci (Pneumocystis carinii). Most anaerobes, including Bacteroides and Clostridium, are resistant.
Resistance to co-trimoxazole has been reported in some Enterobacteriaceae and
H. influenzae.
Parenteral
For injection concentrate, for IV
infusion
Trimethoprim 16 mg/mL and Sulfamethoxazole 80 mg/mL
Bactrim (scored), Women First
HealthCare
Septra (with povidone; scored),
Monarch
Sulfamethoxazole and Trimethoprim Tablets, Teva, United
Research
Bactrim DS, Women First
HealthCare
Septra DS (with povidone;
scored), Monarch
cap height
base of text
Sulfamethoxazole and Trimethoprim Concentrate for Injection (with alcohol 10%, benzyl
alcohol 1%, diethanolamine 0.3%,
propylene glycol 40%, and sodium
metabisulfite 0.1%), Sicor
*available generically
†Use is not currently included in the labeling approved by the US Food and Drug Administration
Selected Revisions July 2005, Copyright, May 2004, American Society of Health-System Pharmacists, Inc.
Advice to Patients
•
•
•
•
•
•
Importance of completing full course of therapy, even if feeling better after a few
days.
Advise patients to maintain an adequate fluid intake to prevent crystalluria and
stone formation.
Importance of discontinuing drug and informing clinician if rash or any sign of adverse reaction (sore throat, fever, arthralgia, pallor, purpura, jaundice) occurs.
Importance of informing clinicians of existing or contemplated therapy, including
prescription and OTC drugs, and any concomitant illnesses.
Importance of women informing clinicians if they are or plan to become pregnant
or to breast-feed.
Importance of advising patients of other important precautionary information. (See
Cautions.)
Preparations
Co-trimoxazole
Oral
Suspension
Trimethoprim 40 mg/5 mL and
Sulfamethoxazole 200 mg/5 mL*
Septra Suspension (with
0.26% alcohol, 0.1% methylparaben, and 0.1% sodium benzoate),
Monarch
Septra Grape Suspension
(with 0.26% alcohol, 0.1% methylparaben, and 0.1% sodium benzoate), Monarch
Sulfatrim Pediatric Suspension, Alpharma
Sulfatrim Suspension, Alpharma, United Research
short
stand