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# Septran (Co-trimoxazole)
## Overview
Co-trimoxazole is a combination antibiotic of trimethoprim and sulfamethoxazole. It is a broad-spectrum agent effective against many gram-positive and gram-negative bacteria.
## Primary Indications
* Urinary tract infections (UTIs)
* Pneumocystis jirovecii pneumonia (PCP) prophylaxis and treatment
* Acute otitis media
* Acute exacerbations of chronic bronchitis
* Shigellosis
* Traveler's diarrhea (Enterotoxigenic E. coli)
## Adult Dosing
Dosing is typically based on the trimethoprim component. Standard dosing for most infections is **160 mg trimethoprim/800 mg sulfamethoxazole (1 DS tablet)** every 12 hours. Duration varies by indication. For PCP treatment, higher doses are used.
## Pediatric Dosing
Dosing is based on trimethoprim weight-based recommendations, often expressed as mg/kg/day divided into two doses. Common pediatric dosing for UTIs and other infections is **8 mg/kg/day of trimethoprim and 40 mg/kg/day of sulfamethoxazole**, given in two divided doses. For PCP prophylaxis, a lower daily dose is used.
## Dose Adjustments
* **Renal Impairment:** Adjust dose based on creatinine clearance (CrCl). Specific recommendations vary; consult prescribing information or local protocols. Generally, reduce dose or increase interval if CrCl < 30 mL/min.
* **Hepatic Impairment:** Use with caution.
## Contraindications
* Known hypersensitivity to trimethoprim, sulfamethoxazole, or sulfonamides.
* Documented megaloblastic anemia due to folate deficiency.
* Infants less than 2 months of age (due to risk of kernicterus).
* Severe renal or hepatic insufficiency where there is no practical way to monitor drug levels.
* History of drug-induced immune thrombocytopenia with prior use.
## Adverse Effects
* **Common:** Rash (including Stevens-Johnson syndrome/toxic epidermal necrolysis), nausea, vomiting, diarrhea, hyperkalemia.
* **Hematologic:** Megaloblastic anemia, leukopenia, thrombocytopenia, eosinophilia.
* **Renal:** Crystalluria (ensure adequate hydration).
* **Other:** Headache, dizziness, photosensitivity.
## Key Drug Interactions
* **Warfarin:** Increased anticoagulant effect. Monitor INR closely.
* **ACE Inhibitors/ARBs:** Increased risk of hyperkalemia.
* **Diuretics (e.g., thiazides, loop diuretics):** Increased risk of hyperkalemia, especially in elderly patients.
* **Methotrexate:** May increase methotrexate levels and toxicity; consider folate supplementation.
* **Potassium Supplements and Potassium-Sparing Diuretics:** Increased risk of hyperkalemia.
* **CYP2C9 Substrates:** Potential for increased levels (e.g., glyburide, glipizide, tolbutamide).
## Monitoring
* **Renal function (BUN, creatinine)**
* **Electrolytes (especially potassium)**
* **Complete Blood Count (CBC) with differential:** particularly with prolonged therapy or in immunocompromised patients.
* **Liver function tests (LFTs)**
* **Hydration status:** to prevent crystalluria.
## Clinical Pearls
* Administer with a full glass of water to minimize crystalluria.
* Adequate fluid intake is crucial, especially in patients with impaired renal function or at risk for crystalluria.
* PCP prophylaxis dose is typically lower than treatment dose.
* Sulfonamides can displace bilirubin from albumin; avoid in premature infants, infants with hyperbilirubinemia, or those receiving specific agents that cause displacement.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols for definitive guidance.*
