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"
{|
! Form
! Form
! 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 sortable"
=== 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 16:37, 27 September 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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