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# Septran (Co-Trimoxazole)
## Overview
Co-trimoxazole is a combination of trimethoprim and sulfamethoxazole, a synergistic antibacterial agent.
## Primary Indications
* Urinary tract infections (UTIs)
* Pneumocystis jirovecii pneumonia (PCP) prophylaxis and treatment
* *Shigella* gastroenteritis
* *Stenotrophomonas maltophilia* infections
* Bacterial prostatitis
## Adult Dosing
* **Uncomplicated UTIs:** 1 double-strength (DS) tablet (160 mg trimethoprim / 800 mg sulfamethoxazole) orally every 12 hours for 3 days. Alternatively, 2 single-strength tablets (80 mg trimethoprim / 400 mg sulfamethoxazole) every 12 hours.
* **Complicated UTIs/Prostatitis:** 1 DS tablet orally every 12 hours for 14 days for UTIs, or 14-28 days for prostatitis.
* **PCP Treatment:** 15 mg/kg/day of trimethoprim component, divided into 3 or 4 doses (maximum 640 mg trimethoprim per dose), given orally or IV for 14-21 days.
* **PCP Prophylaxis:** 1 DS tablet orally daily, or 1 DS tablet orally 3 times a week.
* **Shigellosis:** 1 DS tablet orally every 12 hours for 5 days.
## Pediatric Dosing
Dosing is based on the trimethoprim component, typically calculated as 8 mg/kg/day of trimethoprim, divided into two doses.
* **UTIs/Shigellosis:** 8 mg/kg/day of trimethoprim component, divided into 2 doses, orally every 12 hours for 3 days (UTI) or 5 days (Shigellosis).
* **PCP Treatment:** 15 mg/kg/day of trimethoprim component, divided into 3 or 4 doses, orally or IV for 14-21 days.
* **PCP Prophylaxis:** 5 mg/kg/day of trimethoprim component, divided into 2 doses, orally daily, or 150 mg/m²/day of trimethoprim component, divided into 2 doses, orally daily. Alternative: 1 DS tablet orally 3 times a week.
*Note: Pediatric dosing may depend on local protocols and specific product formulations.*
## Dose Adjustments
* **Renal Impairment:**
* CrCl > 30 mL/min: No adjustment needed.
* CrCl 15-30 mL/min: Administer usual dose every 18 hours.
* CrCl < 15 mL/min: Administer usual dose every 24 hours, or avoid use.
## Contraindications
* Known hypersensitivity to trimethoprim, sulfamethoxazole, or sulfonamides.
* Documented megaloblastic anemia due to folate deficiency.
* Infants less than 2 months of age (increased risk of kernicterus).
* Severe renal or hepatic impairment.
* History of drug-induced thrombocytopenia with sulfonamides or trimethoprim.
## Adverse Effects
Common: Nausea, vomiting, rash, hyperkalemia, increased serum creatinine.
Serious: Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), severe skin reactions, bone marrow suppression (anemia, leukopenia, thrombocytopenia), hepatic necrosis, hyperkalemia, hyponatremia, crystalluria, erythema multiforme, photosensitivity.
## Key Drug Interactions
* **ACE Inhibitors/ARBs/Potassium-Sparing Diuretics:** Increased risk of hyperkalemia.
* **Warfarin:** Increased INR; requires close monitoring.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **Digoxin:** Increased digoxin levels.
* **Potassium Supplements:** Increased risk of hyperkalemia.
* **Cyclosporine:** Increased cyclosporine levels, particularly in transplant patients.
* **Sulfonylureas:** Increased risk of hypoglycemia.
## Monitoring
* Complete blood count (CBC) with differential, especially with prolonged use or in immunocompromised patients.
* Renal function (serum creatinine, BUN).
* Electrolytes (especially potassium).
* Liver function tests.
* Skin examination for rash.
## Clinical Pearls
* Co-trimoxazole can cause crystalluria; ensure adequate fluid intake.
* Monitor for signs of hypersensitivity, particularly rash, which can be severe.
* Folic acid supplementation (1 mg daily) may be considered in patients receiving prolonged therapy to reduce the risk of hematologic adverse effects, especially in those with folate deficiency.
* Discontinue immediately if rash appears.
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*Disclaimer: This information is intended for healthcare professionals. Always verify current prescribing information and consult with a pharmacist or physician before making clinical decisions.*
