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# Septran (Co-trimoxazole)
## Overview
Septran is a combination antibiotic containing trimethoprim and sulfamethoxazole. It is a bacteriostatic agent that inhibits folic acid synthesis.
## Primary Indications
* Urinary tract infections (UTIs)
* Pneumocystis jirovecii pneumonia (PJP) prophylaxis and treatment
* Shigellosis
* Acute otitis media
* Bronchitis (acute exacerbations)
* Traveler's diarrhea
## Adult Dosing
* **Urinary Tract Infections (UTIs):** 160 mg trimethoprim/800 mg sulfamethoxazole (1 double-strength tablet) every 12 hours for 3-7 days.
* **Pneumocystis jirovecii pneumonia (PJP) Prophylaxis:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 double-strength tablet) daily or 3 times a week.
* **Pneumocystis jirovecii pneumonia (PJP) Treatment:** 15-20 mg/kg/day trimethoprim with 75-100 mg/kg/day sulfamethoxazole, divided into 4 doses for 14-21 days. Maximum daily dose is 1200 mg trimethoprim and 6000 mg sulfamethoxazole.
* **Shigellosis:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 double-strength tablet) every 12 hours for 5 days.
* **Traveler's Diarrhea:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 double-strength tablet) every 12 hours for 3-5 days.
## Pediatric Dosing
Pediatric dosing is generally based on the trimethoprim component. Dosing varies significantly by indication.
* **UTIs and Shigellosis:** 8 mg/kg/day trimethoprim and 40 mg/kg/day sulfamethoxazole, divided into 2 doses. Maximum daily dose is 320 mg trimethoprim and 1600 mg sulfamethoxazole.
* **PJP Prophylaxis:** 5 mg/kg/day trimethoprim with 25 mg/kg/day sulfamethoxazole, divided into 2 doses, given on 3 days per week (e.g., Monday, Tuesday, Wednesday). Or 10 mg/kg/day trimethoprim and 50 mg/kg/day sulfamethoxazole, divided into 2 doses, given daily.
* **PJP Treatment:** 15-20 mg/kg/day trimethoprim with 75-100 mg/kg/day sulfamethoxazole, divided into 4 doses for 14-21 days.
*Note: Pediatric suspension is typically 200 mg trimethoprim/40 mg sulfamethoxazole per 5 mL.*
## Dose Adjustments
* **Renal Impairment:** Dose adjustment is necessary in patients with significant renal impairment. Consult specific guidelines or prescribing information based on creatinine clearance.
## Contraindications
* Known hypersensitivity to trimethoprim or sulfonamides.
* Documented megaloblastic anemia due to folate deficiency.
* Infants less than 2 months of age.
* Severe renal or hepatic insufficiency when analytical monitoring is unavailable.
## Adverse Effects
* **Common:** Rash, nausea, vomiting, diarrhea, hyperkalemia.
* **Serious:** Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), severe rash (e.g., DRESS), bone marrow suppression (anemia, leukopenia, thrombocytopenia), hyperkalemia, hyponatremia, renal failure, photosensitivity, C. difficile-associated diarrhea.
## Key Drug Interactions
* **Warfarin:** Increased INR. Monitor INR closely.
* **ACE inhibitors, ARBs, Potassium-sparing diuretics, Potassium supplements:** Increased risk of hyperkalemia.
* **Methotrexate:** May increase methotrexate levels and toxicity.
* **Digoxin:** May increase digoxin levels.
* **Cyclosporine:** Increased risk of nephrotoxicity.
* **Potassium levels:** Monitor potassium in patients receiving concomitant drugs that can increase potassium.
## Monitoring
* **Renal function:** Creatinine and BUN.
* **Electrolytes:** Especially potassium.
* **Complete blood count (CBC):** With differential and platelet count, particularly with prolonged use or in patients with G6PD deficiency.
* **Skin:** Monitor for rash.
* **Therapeutic drug monitoring:** Not routinely required but may be considered in specific situations.
## Clinical Pearls
* Advise patients to drink plenty of fluids to prevent crystalluria.
* Instruct patients to report any new rash, fever, sore throat, or signs of infection immediately.
* Sulfonamides can displace bilirubin from albumin; therefore, co-trimoxazole should not be used in newborns or premature infants during the first few weeks of life.
* Use with caution in patients with G6PD deficiency due to potential for hemolytic anemia.
* The combination provides synergistic activity, making it effective against a broader spectrum of organisms and reducing the emergence of resistance.
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*Disclaimer: This information is intended for healthcare professionals and is not a substitute for professional medical advice. Always consult the most current prescribing information and relevant clinical guidelines for specific patient care decisions.*
