II. Indications
- Organisms
- Enteric Gram Negative Bacteria (esp. Urinary Tract Infections)
- Conditions
- Urinary Tract Infection
- Pneumocystis carinii prophylaxis and treatment
- MRSA Skin Infections
III. Contraindications
- Avoid in infant under age 2 months (Kernicterus risk)
- Sulfonamide Allergy
- G6PD Deficiency
- Avoid in Streptococcal Pharyngitis, Acute Otitis Media and Acute Sinusitis (high Antibiotic Resistance rates)
- Stage 5 Chronic Kidney Disease (eGFR <15 ml/min)
IV. Mechanism
- See Sulfonamide
V. Precautions
- Prolonged use may cause very severe adverse reactions
- Follow Complete Blood Count (CBC) in prolonged use
- Hyperkalemia risk (especially in Renal Insufficiency, related to trimethoprim component)
VI. Medications
- Double Strength (DS)
- Trimethoprim 160 mg
- Sulfamethoxazole 800 mg
- Single Strength (SS)
- Trimethoprim 80 mg
- Sulfamethoxazole 400 mg
- Pediatric Suspension (40/200 per 5 ml)
- Trimethoprim 40 mg per 5 ml
- Sulfamethoxazole 200 mg per 5 ml
VII. Dosing: Directions (regarding Sulfonamide component)
- Take on an empty Stomach
- Take more than 1 hour before or two hours after food
VIII. Dosing: Adult (or child weight >40 kg)
- See Pneumocystis Prophylaxis
- See PCP Pneumonia
- Standard Dosing (e.g. Urinary Tract Infection)
- Take 1 DS tablet (160/800 mg) orally twice daily
- Higher Dosing (e.g. MRSA Cellulitis)
- Take 1-2 DS tablet orally twice daily
IX. Dosing: Child (weight <40 kg)
- Avoid in age <2 months old (Kernicterus risk), G6PD or marked Hyperbilirubinemia (see above)
- Dosing uses 40/200 mg per 5 ml suspension
- Treatment (e.g. Urinary Tract Infection)
- Dose 1 ml/kg/day divided twice daily orally (40/200 per 5 ml suspension)
- Alternatively dose 8 mg/kg/day of TMP component orally divided twice daily
- Doses up to 1.5 ml/kg/day may be used in MRSA Skin Infections (see Cellulitis)
- Maximum: 20 ml (160/800 mg) orally twice daily
- For each 10 kg weight, dose 5 ml suspension twice daily (up to maximum of 20 ml/dose)
- Age 2 months (5 kg): 2.5 ml orally twice daily
- Age 1 year (10 kg): 5.0 ml orally twice daily
- Age 3 years (15 kg): 7.5 ml orally twice daily
- Age 5 years (20 kg): 10 ml orally twice daily
- Dose 1 ml/kg/day divided twice daily orally (40/200 per 5 ml suspension)
- Prophylaxis of Urinary Tract Infections
- Dose: 4 mg/kg/day of Trimethoprim dosed once daily
X. Dosing: Renal (eGFR <30 ml/min)
- eGFR 15 to 30 ml/min (Stage 4 Chronic Kidney Disease)
- Decrease Trimethoprim-Sulfamethoxazole dose by 50%
- eGFR <15 ml/min (Stage 5 Chronic Kidney Disease)
- Avoid the use of Trimethoprim Sulfamethoxazole
XI. Dosing: HIV
- Pneumocystis Treatment
- Take 15 to 20 mg/kg/day of TMP component orally or IV divided every 8 hours for 21 days
- Adult with mild to moderate infections
- Take 2 DS tablets orally three times daily for 21 days
- Child
- Take 5 ml suspension (40/200 mg) per every 8 kg orally every 6 hours for 21 days
-
Pneumocystis Prophylaxis
- Adult
- Take one tablet DS orally daily (per FDA labeling) OR
- Take one tablet SS orally daily (off label use)
- Child
- Take 150 mg/m2/day of TMP component orally divided twice daily on 3 consecutive days per week
- Adult
XII. Adverse Effects: General
- See Sulfonamide
- Allergic Reaction or Anaphylaxis
-
Bone Marrow suppression (Agranulocytosis)
- Highest risk with prolonged use, or high dose IV use
- Steven's Johnson Syndrome
- Toxic Epidermal Necrolysis
-
Hyperkalemia
- Related to trimethoprim component
- Higher risk with underlying Renal Insufficiency
- Exacerbated by ACE Inhibitor, Angiotensin Receptor Blocker, and Potassium supplements
-
Neonatal Hyperbilirubinemia and Kernicterus
- Sulfonamides compete with Bilirubin for albumin binding
- Results in increased free Bilirubin, with risk of Neonatal Hyperbilirubinemia and Kernicterus
- Propylene glycol toxicity
- Associated with high dose IV use (e.g. PCP Pneumonia)
XIII. Adverse Effects: HIV patients (40-60% within 3 weeks)
- Hepatitis
- Neutropenia
- Anemia
- Hyponatremia
- Hyperkalemia (6% of patients, esp. elderly)
- Nausea or Vomiting
- Rash
- Fever
XIV. Safety
- Pregnancy
- Avoid in first and third trimesters (considered safe in second trimester)
-
Lactation
- Avoid in first month of life (HyperbilirubinemiaKernicterus risk)
- Avoid in maternal or infant G6PD Deficiency
- Otherwise considered safe in Lactation after first month of life
XV. Drug Interactions
- Other drugs decrease Trimethoprim Sulfamethoxazole levels
- Trimethoprim Sulfamethoxazole increases other drug levels
-
Hyperkalemia risk
- Increased risk with ACE Inhibitors, Angiotensin Receptor Blockers, Spironolactone
- Higher risk with age >65 years, Renal Insufficiency, Diabetes Mellitus and Heart Failure
- Significantly increased rate of hospitalization and sudden death
- Avoid Septra use for longer than three days with these agents and comorbidities in age >65 years
- Consider alternative Antibiotics, holding Antihypertensive or recheck Serum Potassium in 4-5 days
- Fralick (2014) BMJ 349:g6196 +PMID:25359996 [PubMed]
- References
- (2014) Presc lett 21(8): 47
XVI. Resources
- Trimethoprim Sulfamethoxazole Tablet (DailyMed)
- Trimethoprim Sulfamethoxazole Suspension (DailyMed)
- Trimethoprim Sulfamethoxazole Injection Solution (DailyMed)
XVII. References
- Hamilton (2020) Tarascon Pocket Pharmacopoeia
- Kemnic (2023) Trimethoprim Sulfamethoxazole, StatPearls, Treasure Island, Florida
Images: Related links to external sites (from Bing)
Related Studies
sulfatrim (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing) | ||
SULFATRIM PEDIATRIC SUSPENSION | Generic | $0.06 per ml |
Ontology: Trimethoprim-Sulfamethoxazole Combination (C0041044)
Definition (NCI_NCI-GLOSS) | An antibiotic drug used to treat infection and prevent pneumocystis carinii pneumonia. |
Definition (NCI) | A synthetic combination of two antibacterial agents, trimethoprim and sulfamethoxazole. This synergistic combination, also known as Co-Trimoxazole, inhibits two sequential steps in the bacterial metabolism of folic acid. Trimethoprim is a pyrimidine inhibitor of dihydrofolate reductase; sulfamethoxazole is a sulfamide inhibitor of bacterial dihydrofolate synthase. |
Definition (MSH) | This drug combination has proved to be an effective therapeutic agent with broad-spectrum antibacterial activity against both gram-positive and gram-negative organisms. It is effective in the treatment of many infections, including PNEUMOCYSTIS PNEUMONIA in AIDS. |
Definition (PDQ) | A synthetic combination of two antibacterial agents, trimethoprim and sulfamethoxazole. This synergistic combination, also known as co-trimoxazole, inhibits two sequential steps in the bacterial metabolism of folic acid. Trimethoprim is a pyrimidine inhibitor of dihydrofolate reductase; sulfamethoxazole is a sulfamide inhibitor of bacterial dihydrofolate synthetase. Check for "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39724&idtype=1" active clinical trials or "http://www.cancer.gov/Search/ClinicalTrialsLink.aspx?id=39724&idtype=1&closed=1" closed clinical trials using this agent. ("http://nciterms.nci.nih.gov:80/NCIBrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&code=C909" NCI Thesaurus) |
Concepts | Organic Chemical (T109) , Pharmacologic Substance (T121) |
MSH | D015662 |
SnomedCT | 13939004, 398731002, 324367007, 387079003, 324356006, 703745000 |
LNC | LP16302-9, MTHU008494 |
English | Centran, Centrin, Eslectin, Insozalin, Trimedin, Trimethoprim Sulfamethoxazole, Trimethoprim Sulfamethoxazole Combination, Trimethoprim-Sulfamethoxazole, Trimezole, Sulfamethoxazole-Trimethoprim Combination, Sulfamethoxazole Trimethoprim Combination, Benzenesulfonamide, 4-amino-N-(5-methyl-3-isoxazolyl)-, mixt. with 5-((3,4,5-trimethoxyphenyl)methyl)-2,4-pyrimidinediamine, Bactrimel, Co Trimoxazole, TMP SMX, TMP-SMX, trimethoprim-sulfamethoxazole, SULFAMETHOXAZOLE/TRIMETHOPRIM, Co-trimoxazole [generic], Co-trimoxazole [proprietary], Co-trimazole, trimethoprim + sulfamethoxazole, trimethoprim + sulfamethoxazole (medication), Sulfamethoxazole-Trimethoprim, sulfamethoxazole-trimethoprim, Trimethoprim-Sulfamethoxazole Combination [Chemical/Ingredient], Sulfamethoxazole / Trimethoprim, smx tmp, tmp smx, trimezole, cotrimoxazole, smz tmp, co-trimazole, smz-tmp, tmp-smx, trimethoprim sulfamethoxazole, trimethoprim-sulphamethoxazole, co trimoxazole, smx-tmp, centrin, sulfamethoxazole trimethoprim, Trimethoprim-Sulfamethoxazole Combination, sulfamethoxazole and trimethoprim, Co-trimoxazole [proprietary] (product), Trimethoprim-sulfamethoxazole, Sulphamethoxazole-trimethoprim, Co-trimoxazole (product), SMX-TMP, Trimethoprim-sulphamethoxazole, Sulfamethoxazole-trimethoprim, Co-trimoxazole [generic] (product), Co-trimoxazole (substance), Trimethoprim+Sulfamethoxazole, Co-trimoxazole, co-trimoxazole, Sulfamethoxazole + trimethoprim (substance), Sulfamethoxazole + trimethoprim (product), Sulfamethoxazole + trimethoprim, Sulphamethoxazole + trimethoprim, Co-trimoxazole [generic] (substance), Co-trimoxazole [proprietary] (substance), Co-Trimoxazole, Cotrimoxazole, SMZ-TMP, Sulfamethoxazole and Trimethoprim |
German | Trimezole, Eslectin, Centrin, Centran, Insozalin, Trimedin, TMP-SMX, Co-Trimoxazole, Trimethoprim-Sulfamethoxazol, Sulfamethoxazol-Trimethoprim-Kombination, Trimethoprim-Sulfamethoxazol-Kombination |
Swedish | Trimetoprim-sulfametoxazolkombination |
Czech | trimethoprim-sulfamethoxazol kombinace |
Finnish | Trimetopriimi-sulfametoksatsoliyhdistelmä |
Russian | TRIMETOPRIM-SUL'FAMETOKSAZOLA SOEDINENIE, ТРИМЕТОПРИМ-СУЛЬФАМЕТОКСАЗОЛА СОЕДИНЕНИЕ |
Japanese | トリメトプリム-スルファメトキサゾール配合製剤, スルファメトキサゾール-トリメトプリム配合製剤, ST合剤, TMP-SMX合剤 |
French | TMPSMX, Association triméthoprime-sulfaméthoxazole, TMP-SMX |
Italian | TMP-SMX, Trimedin, Centrin, Trimezole, TMP SMX, Co-trimoxazolo, Cotrimoxazolo, Insozalin, Trimetoprim-sulfametossazolo, Eslectin, Centran, Combinazione di trimetoprim e sulfametazolo |
Polish | Połączenie trimetoprimu z sulfametoksazolem |
Spanish | cotrimoxazol [genérico] (producto), cotrimoxazol, trimetoprima-sulfametoxazol, cotrimoxazol [genérico], trimetoprima - sulfametoxazol [genérico], co - trimoxazol (sustancia), cotrimoxazol [marca registrada], cotrimoxazol [marca registrada] (producto), co - trimoxazol, cotrimoxazol (producto), Cotrimoxazol, co - trimoxazol [genérico] (producto), co - trimoxazol [genérico], co - trimoxazol [marca registrada] (producto), co - trimoxazol [marca registrada], cotrimazol (producto), cotrimazol (sustancia), cotrimazol, sulfametoxazol + trimetoprima (producto), sulfametoxazol + trimetoprima, sulfametoxazol-trimetoprima, Combinación Trimetoprim-Sulfametoxazol |
Portuguese | Cotrimoxazol, Combinação Trimetoprima-Sulfametoxazol |
Ontology: Bactrim (C0591139)
Definition (CHV) | brand name of an antibiotic |
Definition (CHV) | brand name of an antibiotic |
Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
MSH | D015662 |
German | Bactrim |
English | bactrim [brand name], bactrim, Bactrim |
Ontology: Septra (C0699595)
Concepts | Pharmacologic Substance (T121) , Organic Chemical (T109) |
MSH | D015662 |
German | Septra |
English | septra, Septra |
Ontology: Sulfatrim (C0723514)
Concepts | Organic Chemical (T109) , Pharmacologic Substance (T121) |
English | Sulfatrim, sulfatrim |