Trimethoprim-sulfamethoxazole: Difference between revisions

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−
== Identification ==
 +
== Background ==
−  
 
* Sulfonamide antibiotic
  
* Sulfonamide antibiotic
   
−
== Brand Names ==
 +
=== Brand Names ===
   
 
* Septra
  
* Septra
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== Dosing ==
  
== Dosing ==
   
−
Based on the trimethroprim component.
 +
* Traditionally based on the trimethroprim component
   
 
{| class="wikitable"
  
{| class="wikitable"
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! TMP
  
! TMP
 
! SMX
  
! SMX
  +
!Conversion
 
|-
  
|-
  +
| Intravenous
−
| Suspension
  
−
| 8 mg/ml
  
−
| 40 mg/ml
  
−
|-
  
−
| Injection
  
 
| 16 mg/ml
  
| 16 mg/ml
 
| 80 mg/ml
  
| 80 mg/ml
  +
|10 mL
  +
|-
  +
| Oral suspension
  +
| 8 mg/ml
  +
| 40 mg/ml
  +
|20 mL
 
|-
  
|-
−
| SS tab
 +
| Oral SS tab
 
| 80 mg
  
| 80 mg
 
| 400 mg
  
| 400 mg
  +
|2 tabs
 
|-
  
|-
−
| DS tab
 +
| Oral DS tab
 
| 160 mg
  
| 160 mg
 
| 800 mg
  
| 800 mg
  +
|1 tab
 
|}
  
|}
   
  +
* Resistant Gram-negative infections
−
Conversion: 2 SS tabs = 1 DS tab = 20 mL oral suspension = 10 mL IV
  
  +
** [[Cystitis]] or [[pyelonephritis]]: 160 mg/800 mg (1 DS tab) IV/PO q12h
  +
** Other infections: 8 to 12 mg/kg/day IV/PO divided q8-12h (max 960 mg total daily dose)
  +
*[[Nocardia]]: 10 mg/kg TDD
  +
*[[Pneumocystis jirovecii]]: 15-20 mg/kg TDD
  +
*CNS infections: 15-20 mg/kg TDD
   
 
=== Oral Dosing ===
  
=== Oral Dosing ===
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* 10 to 20 mg/kg TMP total daily dose, split TID to QID
  
* 10 to 20 mg/kg TMP total daily dose, split TID to QID
   
  +
{| class="wikitable"
−
=== TMP 10 mg/kg per day ===
  
  +
!Dose (TMP)
−  
−
{|
  
 
! Weight (kg)
  
! Weight (kg)
  +
! Total dose TMP (mg/day)
 
! Dose (IV)
  
! Dose (IV)
  +
!Dose (PO)
−
! Total dose TMP (mg/day)
  
 
|-
  
|-
  +
| rowspan="5" |10 mg/kg
 
| 40-49
  
| 40-49
−
| 10 mL q8h
  
 
| 480
  
| 480
  +
| 10 mL q8h
  +
|1 DS tab q8h
 
|-
  
|-
 
| 50-64
  
| 50-64
−
| 10 mL q6h
  
 
| 640
  
| 640
  +
| 10 mL q6h
  +
|1 DS tab q6h, or 2 DS tabs q12h
 
|-
  
|-
 
| 65-74
  
| 65-74
  +
| 720
 
| 15 mL q8h
  
| 15 mL q8h
  +
|3 SS tabs q8h
−
| 720
  
 
|-
  
|-
 
| 75-99
  
| 75-99
  +
| 960
 
| 15 mL q6h
  
| 15 mL q6h
  +
|2 DS tabs q8h, or 3 SS tabs q6h
−
| 960
  
 
|-
  
|-
 
| 100-129
  
| 100-129
  +
| 1280
 
| 20 mL q6h
  
| 20 mL q6h
  +
|2 DS tabs q6h
−
| 1280
  
−
|}
  
−  
−
=== TMP 15 mg/kg per day ===
  
−  
−
{|
  
−
! Weight (kg)
  
−
! Dose (IV)
  
−
! Total dose TMP (mg/day)
  
 
|-
  
|-
  +
| rowspan="9" |15 mg/kg
−
| 40-44
  
  +
|40-44
−
| 10 mL q6h
  
−
| 640
 +
|640
  +
|10 mL q6h
  +
|1 DS tab q6h, or 2 DS tabs q12h
 
|-
  
|-
−
| 45-49
 +
|45-49
  +
|720
−
| 15 mL q8h
  
  +
|15 mL q8h
−
| 720
  
  +
|3 SS tabs q8h
 
|-
  
|-
−
| 50-69
 +
|50-69
  +
|960
−
| 15 mL q6h
  
  +
|15 mL q6h
−
| 960
  
  +
|2 DS tabs q8h, or 3 SS tabs q6h
 
|-
  
|-
−
| 70-79
 +
|70-79
  +
|1200
−
| 25 mL q8h
  
  +
|25 mL q8h
−
| 1200
  
  +
|5 SS tabs q8h
 
|-
  
|-
−
| 80-89
 +
|80-89
  +
|1280
−
| 20 mL q6h
  
  +
|20 mL q6h
−
| 1280
  
  +
|2 DS tabs q6h
 
|-
  
|-
−
| 90-99
 +
|90-99
  +
|1440
−
| 30 mL q8h
  
  +
|30 mL q8h
−
| 1440
  
  +
|3 DS tabs q8h
 
|-
  
|-
−
| 100-109
 +
|100-109
  +
|1600
−
| 25 mL q6h
  
  +
|25 mL q6h
−
| 1600
  
  +
|2/2/3/3 DS tabs q6h, or 5 SS tabs q6h
 
|-
  
|-
−
| 110-119
 +
|110-119
  +
|1680
−
| 35 mL q8h
  
  +
|35 mL q8h
−
| 1680
  
  +
|7 SS tabs q8h
 
|-
  
|-
−
| 120-129
 +
|120-129
  +
|1920
−
| 30 mL q6h
  
  +
|30 mL q6h
−
| 1920
  
  +
|3 DS tabs q6h
−
|}
  
−  
−
=== TMP 20 mg/kg per day ===
  
−  
−
{|
  
−
! Weight (kg)
  
−
! Dose (IV)
  
−
! Total dose TMP (mg/day)
  
 
|-
  
|-
  +
| rowspan="7" |20 mg/kg
−
| 40-54
  
  +
|40-54
−
| 15 mL q6h
  
−
| 960
 +
|960
  +
|15 mL q6h
  +
|2 DS tabs q8h, or 3 SS tabs q6h
 
|-
  
|-
−
| 55-69
 +
|55-69
  +
|1280
−
| 20 mL q6h
  
  +
|20 mL q6h
−
| 1280
  
  +
|2 DS tabs q6h
 
|-
  
|-
−
| 70-79
 +
|70-79
  +
|1440
−
| 30 mL q8h
  
  +
|30 mL q8h
−
| 1440
  
  +
|3 DS tabs q8h
 
|-
  
|-
−
| 80-89
 +
|80-89
  +
|1600
−
| 25 mL q6h
  
  +
|25 mL q6h
−
| 1600
  
  +
|2/2/3/3 DS tabs q6h, or 5 SS tabs q6h
 
|-
  
|-
−
| 90-104
 +
|90-104
  +
|1920
−
| 30 mL q6h
  
  +
|30 mL q6h
−
| 1920
  
  +
|3 DS tabs q6h
 
|-
  
|-
−
| 105-119
 +
|105-119
  +
|2240
−
| 35 mL q6h
  
  +
|35 mL q6h
−
| 2240
  
  +
|3/3/4/4 DS tabs q6h, or 7 SS tabs q6h
 
|-
  
|-
−
| 120-134
 +
|120-134
  +
|2560
−
| 40 mL q6h
  
  +
|40 mL q6h
−
| 2560
  
  +
|4 DS tabs q6h
 
|}
  
|}
   
−
=== Renal Dosing ===
 +
==== Renal Dosing ====
   
  +
{| class="wikitable"
−
{|
  
 
! CrCl (mL/min)
  
! CrCl (mL/min)
 
! Bacterial infection (TMP)
  
! Bacterial infection (TMP)
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|}
  
|}
   
−
== Notable Side Effects ==
 +
== Adverse Drug Reactions ==
  +
* Systemic allergic reactions
−  
  +
**[[Adverse drug reaction::Anaphylaxis]]
−
* Allergic reactions, including anaphylaxis and a relatively high rate of SJS/TEN
  
  +
**[[Adverse drug reaction::Serum sickness]]
−
* GI upset, including nausea at higher doses
  
  +
*Cutaneous reactions
−
* Interactions
  
  +
**High rate of [[Adverse drug reaction::SJS]]/[[Adverse drug reaction::TEN]]
−
** Increases warfarin levels
  
  +
**Other non-specific rash
−
* Anemia, neutropenia and thrombocytopenia
  
  +
**[[Adverse drug reaction::Erythema multiforme]]
  +
**[[Adverse drug reaction::Urticaria]]
  +
**[[Adverse drug reaction::Photodermatitis]]
  +
* [[Adverse drug reaction::GI upset]], including nausea at higher doses
  +
* [[Adverse drug reaction::Drug-drug interactions]]
  +
** Increases [[warfarin]] levels
  +
* [[Adverse drug reaction::Anemia]], [[Adverse drug reaction::neutropenia]] and [[Adverse drug reaction::thrombocytopenia]]
 
** It is a mild folate antagonist
  
** It is a mild folate antagonist
−
* Hepatotoxicity
 +
* [[Adverse drug reaction::Hepatotoxicity]]
−
* Hyperkalemia
 +
* [[Adverse drug reaction::Hyperkalemia]]
  +
*[[Adverse drug reaction::Hyponatremia]]
−
* Hypoglycemia
  
  +
* [[Adverse drug reaction::Hypoglycemia]]
−
* Acute kidney injury, though it also increases tubular creatinine reabsorption
  
  +
* [[Adverse drug reaction::Acute kidney injury]], though it also increases tubular creatinine reabsorption
−
* Renal tubular acidosis
  
  +
* [[Adverse drug reaction::Renal tubular acidosis]]
   
 
== Further Reading ==
  
== Further Reading ==
   
−
* Review of adverse effects: [https://doi.org/10.1503/cmaj.111152 Considerations when prescribing trimethoprim-sulfamethoxazole]. ''CMAJ''. 2011(16):1851-1858
 +
* Considerations when prescribing trimethoprim-sulfamethoxazole. ''CMAJ''. 2011;183(16):1851-1858. doi: [https://doi.org/10.1503/cmaj.111152 10.1503/cmaj.111152]
  +
** Review of adverse events
   
 
[[Category:Antibiotics]]
  
[[Category:Antibiotics]]

Latest revision as of 14:04, 20 August 2024

Background

  • Sulfonamide antibiotic

Brand Names

  • Septra
  • Bactrim (US)
  • TMP-SMX

Dosing

  • Traditionally based on the trimethroprim component
Form TMP SMX Conversion
Intravenous 16 mg/ml 80 mg/ml 10 mL
Oral suspension 8 mg/ml 40 mg/ml 20 mL
Oral SS tab 80 mg 400 mg 2 tabs
Oral DS tab 160 mg 800 mg 1 tab
  • Resistant Gram-negative infections
    • Cystitis or pyelonephritis: 160 mg/800 mg (1 DS tab) IV/PO q12h
    • Other infections: 8 to 12 mg/kg/day IV/PO divided q8-12h (max 960 mg total daily dose)
  • Nocardia: 10 mg/kg TDD
  • Pneumocystis jirovecii: 15-20 mg/kg TDD
  • CNS infections: 15-20 mg/kg TDD

Oral Dosing

  • Ranges from 1 SS tab BID (160 mg TMP TDD) to 3 DS tabs TID (1440 mg TMP TDD)

Intravenous Dosing

  • 10 to 20 mg/kg TMP total daily dose, split TID to QID
Dose (TMP) Weight (kg) Total dose TMP (mg/day) Dose (IV) Dose (PO)
10 mg/kg 40-49 480 10 mL q8h 1 DS tab q8h
50-64 640 10 mL q6h 1 DS tab q6h, or 2 DS tabs q12h
65-74 720 15 mL q8h 3 SS tabs q8h
75-99 960 15 mL q6h 2 DS tabs q8h, or 3 SS tabs q6h
100-129 1280 20 mL q6h 2 DS tabs q6h
15 mg/kg 40-44 640 10 mL q6h 1 DS tab q6h, or 2 DS tabs q12h
45-49 720 15 mL q8h 3 SS tabs q8h
50-69 960 15 mL q6h 2 DS tabs q8h, or 3 SS tabs q6h
70-79 1200 25 mL q8h 5 SS tabs q8h
80-89 1280 20 mL q6h 2 DS tabs q6h
90-99 1440 30 mL q8h 3 DS tabs q8h
100-109 1600 25 mL q6h 2/2/3/3 DS tabs q6h, or 5 SS tabs q6h
110-119 1680 35 mL q8h 7 SS tabs q8h
120-129 1920 30 mL q6h 3 DS tabs q6h
20 mg/kg 40-54 960 15 mL q6h 2 DS tabs q8h, or 3 SS tabs q6h
55-69 1280 20 mL q6h 2 DS tabs q6h
70-79 1440 30 mL q8h 3 DS tabs q8h
80-89 1600 25 mL q6h 2/2/3/3 DS tabs q6h, or 5 SS tabs q6h
90-104 1920 30 mL q6h 3 DS tabs q6h
105-119 2240 35 mL q6h 3/3/4/4 DS tabs q6h, or 7 SS tabs q6h
120-134 2560 40 mL q6h 4 DS tabs q6h

Renal Dosing

CrCl (mL/min) Bacterial infection (TMP) PJP (TMP)
> 30 8-12 mg/kg/day in 2-4 divided doses 15-20 mg/kg/day in 2-4 divided doses
10 to 29 75% of usual dose 12-15 mg/kg/day in 2-4 divided doses
< 10, including PD Generally not recommended; use 50% of usual dose Generally not recommended; use 7.5-10 mg/kg/day in 2-4 divided doses
Hemodialysis 50% of usual dose, scheduled post-dialysis 50% of usual dose, scheduled post-dialysis
CRRT 7.5 mg/kg/day in 2-4 divided doses 15 mg/kg/day in 2-4 divided doses

Adverse Drug Reactions

Further Reading

  • Considerations when prescribing trimethoprim-sulfamethoxazole. CMAJ. 2011;183(16):1851-1858. doi: 10.1503/cmaj.111152
    • Review of adverse events
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