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# Septran (Co-trimoxazole)
## Overview
Septran is a combination antibiotic containing trimethoprim and sulfamethoxazole in a 1:5 ratio.
## Primary Indications
* Urinary tract infections (UTIs)
* Pneumocystis jirovecii pneumonia (PJP) prophylaxis and treatment
* *Shigella* and *Salmonella* infections
* *Haemophilus influenzae* otitis media
## Adult Dosing
* **UTIs:** 1 double-strength (DS) tablet (160 mg trimethoprim/800 mg sulfamethoxazole) every 12 hours for 3-7 days.
* **PJP Treatment:** 2 DS tablets (160 mg trimethoprim/800 mg sulfamethoxazole) every 6 hours for 14-21 days.
* **PJP Prophylaxis:** 1 DS tablet (160 mg trimethoprim/800 mg sulfamethoxazole) daily or 1 DS tablet three times weekly.
* **Other Infections:** Dosing varies. A common regimen is 1-2 DS tablets every 12 hours.
## Pediatric Dosing
Dosing is based on trimethoprim component, typically 5-10 mg/kg/day divided into two doses, not to exceed adult doses.
* **General Infections:** 5 mg/kg/day of trimethoprim, divided into 2 doses, every 12 hours.
* **Severe Infections:** Up to 10 mg/kg/day of trimethoprim, divided into 2 doses, every 12 hours.
* **PJP Prophylaxis:** 5 mg/kg/day of trimethoprim, divided into 2 doses, every 12 hours.
* **PJP Treatment:** 15 mg/kg/day of trimethoprim, divided into 4 doses, every 6 hours.
## Dose Adjustments
* **Renal Impairment:**
* CrCl >30 mL/min: No adjustment needed.
* CrCl 15-30 mL/min: Half the usual dose.
* CrCl <15 mL/min: Avoid use or use with extreme caution and monitor drug levels.
## Contraindications
* Documented hypersensitivity to trimethoprim or sulfonamides.
* History of drug-induced immune thrombocytopenia with previous use of trimethoprim or sulfonamides.
* Megaloblastic anemia due to folate deficiency.
* Infants less than 2 months of age (risk of kernicterus).
* Severe renal or hepatic insufficiency when pharmacokinetic monitoring is unavailable.
* Porphyria.
## Adverse Effects
* **Common:** Rash (can be severe and include Stevens-Johnson syndrome/toxic epidermal necrolysis), nausea, vomiting, diarrhea, hyperkalemia.
* **Hematologic:** Aplastic anemia, agranulocytosis, leukopenia, thrombocytopenia (often reversible with folate supplementation).
* **Hepatic:** Elevated transaminases, hepatitis.
* **Renal:** Interstitial nephritis.
* **Dermatologic:** Photosensitivity.
## Key Drug Interactions
* **Warfarin:** Increased INR. Monitor INR closely and consider dose reduction of warfarin.
* **ACE Inhibitors/ARBs/Potassium-Sparing Diuretics:** Increased risk of hyperkalemia.
* **Methotrexate:** Increased methotrexate levels and toxicity.
* **Potassium Chloride:** Increased risk of hyperkalemia.
* **Cyclosporine:** Increased cyclosporine levels, particularly in renal transplant patients.
* **Digoxin:** Increased digoxin levels.
* **Sulfonylureas:** Enhanced hypoglycemic effect.
## Monitoring
* Complete blood counts (CBC) with differential and platelet count, especially with prolonged therapy or in immunocompromised patients.
* Renal function (BUN, creatinine).
* Electrolytes (especially potassium).
* Liver function tests.
* Therapeutic drug monitoring (TDM) is generally not routinely recommended but may be considered in severe infections or renal impairment.
* Monitor for signs and symptoms of hypersensitivity reactions.
## Clinical Pearls
* Instruct patients to drink plenty of fluids to prevent crystalluria.
* Advise patients to report any rash, sore throat, fever, or mouth sores immediately.
* Folic acid supplementation (5-10 mg daily) is recommended for patients on long-term therapy to prevent hematologic side effects.
* Avoid in neonates due to risk of kernicterus.
* The DS tablet contains 800 mg sulfamethoxazole and 160 mg trimethoprim.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and local protocols for definitive guidance.*
