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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 (PJP) prophylaxis and treatment
* Shigellosis
* Acute otitis media
* Acute exacerbations of chronic bronchitis
## Adult Dosing
* **UTIs, Shigellosis, Acute Otitis Media:** Typically 1 double-strength (DS) tablet (160 mg trimethoprim/800 mg sulfamethoxazole) twice daily for 3-7 days (UTIs, otitis media) or 5 days (shigellosis).
* **PJP Prophylaxis:** 1 DS tablet once daily, or 1 DS tablet three times weekly.
* **PJP Treatment:** 15-20 mg/kg/day of trimethoprim component divided into 3-4 doses, with a maximum of 800 mg trimethoprim per dose, administered orally or IV for 14-21 days.
* **Acute Exacerbations of Chronic Bronchitis:** 1 DS tablet twice daily for 5-7 days.
## Pediatric Dosing
Dosing is typically based on the trimethoprim component, 15-20 mg/kg/day, divided into 2-3 doses. For PJP treatment, doses are higher (see adult dosing).
* **PJP Prophylaxis:** 5 mg/kg/day of trimethoprim component, given as 250 mg/m²/day of sulfamethoxazole component, once daily.
* **UTIs/Acute Otitis Media:** 8-10 mg/kg/day of trimethoprim component divided into 2 doses. The dose for a DS tablet (160 mg trimethoprim) is typically limited to 1 DS tablet twice daily for children >12 years.
## Dose Adjustments
* **Renal Impairment:** Adjust dose based on creatinine clearance (CrCl).
* CrCl >30 mL/min: No adjustment needed.
* CrCl 15-30 mL/min: Give 1/2 the usual dose.
* CrCl <15 mL/min: Avoid use or give 1/4 the usual dose.
## Contraindications
* Known hypersensitivity to trimethoprim or sulfonamides.
* Documented anemia due to folate deficiency.
* Infants <2 months of age (risk of kernicterus).
* Severe renal or hepatic insufficiency when pharmacokinetic monitoring is unavailable.
## Adverse Effects
Common: Rash, nausea, vomiting, diarrhea, hyperkalemia.
Serious: Stevens-Johnson syndrome, toxic epidermal necrolysis, severe skin reactions, blood dyscrasias (anemia, leukopenia, thrombocytopenia), hyperkalemia, hyponatremia, hepatic injury, renal failure, photosensitivity.
## Key Drug Interactions
* **Warfarin:** Increased INR. Monitor INR closely.
* **Methotrexate:** Increased risk of myelosuppression.
* **ACE inhibitors, ARBs, Potassium-sparing diuretics:** Increased risk of hyperkalemia.
* **Cyclosporine:** Increased cyclosporine levels.
* **Potassium Supplements:** Increased risk of hyperkalemia.
* **Sulfonylureas:** Increased risk of hypoglycemia.
## Monitoring
* **Renal function:** Monitor serum creatinine and electrolytes, especially in patients with impaired renal function or those receiving other nephrotoxic agents.
* **Hematologic parameters:** Complete blood counts (CBC) with differential and platelet count, particularly with prolonged therapy or in immunocompromised patients.
* **Electrolytes:** Particularly potassium.
* **Therapeutic drug levels:** May be considered in patients with PJP treatment or impaired elimination.
## Clinical Pearls
* Administer with food or milk to minimize gastrointestinal upset.
* Ensure adequate fluid intake to prevent crystalluria.
* Discontinue at the first sign of rash or other hypersensitivity.
* Sulfonamides can displace bilirubin from albumin, increasing the risk of kernicterus in neonates. Avoid use in premature infants and during the first 2 months of life.
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*This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols before administering any medication.*
