Trimethoprim Sulfamethoxazole

TMP-SMX (Septra, Bactrim) is used in the treatment of genitourinary, GI, and respiratory tract infections caused by susceptible bacteria. E. coli, enterococci, P. mirabilis, some indole-positive strains of Proteus spp., and Klebsiella pneumoniae are usually sensitive to this combination therapy for both chronic and recurrent UTIs. Trimethoprim is present in vaginal secretions in high enough levels to be active against many of the organisms found in the introital area that are often responsible for recurrent UTIs. In some patients with recurrent UTIs, most notably women of childbearing age, the long-term use of one tablet taken at night is an effective form of chemoprophylaxis. The drug is approved for use by the U. S. Food and Drug Administration (FDA) for treating UTIs in both children and adults.

TMP-SMX is also used in the treatment of infection caused by ampicillin-resistant Shigella spp. and for antibiotic-resistant Salmonella spp.. The combination is also effective for covering the carrier state of Salmonella typhi, the agent of typhoid fever, and other Salmonella spp.. Successful treatment of traveler's diarrhea due to susceptible E. coli is another advantage of the use of this combination. The combination is not indicated in the therapy of enterohemorrhagic E. coli strains such as O157:H7 because of the risk of developing hemolytic-uremic syndrome associated with the release of the cytotoxic enterotoxin by the drugs.

Because trimethoprim accumulates in the prostate, TMP-SMX is used to treat prostatitis caused by sensitive organisms. Therapy can be prolonged (4-6 weeks) and repeat courses of therapy may be necessary. Trimethoprim alone, because of its lipid solubility, can be effectively used when patients exhibit an allergic response to the sulfonamide component.

Otitis media in children and purulent exacerbations of chronic bronchitis respond well to TMP-SMX because of its activity against both susceptible Streptococcus pneumoniae and Haemophilus influenzae type b (Hib); the latter organism is now a much less frequent pathogen in otitis because of the use of the Hib vaccine.

Gonorrhea, typhoid fever, and brucellosis have been treated with TMP-SMX with cure rates comparable to those attained by standard therapy. It also has been used in the treatment of nocardial infections.

TMP-SMX remains the antimicrobial therapy of choice in both the treatment and prevention of infections caused by P. carinii, a protozoan that produces serious pneumonitis in patients with hematological malignancies and AIDS. In those with AIDS, treatment is more prolonged and relapse is common. These patients are at increased risk for untoward effects such as fever, hepatitis, rash, and leukopenia.

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