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# Septran (Co-trimoxazole)
## Overview
Septran is a combination antibiotic consisting of trimethoprim and sulfamethoxazole. It is a synthetic broad-spectrum antibacterial agent.
## Primary Indications
* Urinary tract infections (UTIs)
* Pneumocystis jirovecii pneumonia (PJP) prophylaxis and treatment
* Acute exacerbations of chronic bronchitis
* Shigellosis
* Otitis media
## Adult Dosing
* **UTIs, Acute exacerbations of chronic bronchitis:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 DS tablet) every 12 hours for 7-14 days (UTIs) or 10-14 days (bronchitis).
* **PJP Treatment:** 15-20 mg/kg/day (based on trimethoprim component) divided into 3-4 doses every 24 hours for 14-21 days.
* **PJP Prophylaxis:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 DS tablet) daily. Alternative: 160 mg trimethoprim/800 mg sulfamethoxazole (1 DS tablet) three times a week.
* **Shigellosis:** 160 mg trimethoprim/800 mg sulfamethoxazole (1 DS tablet) every 12 hours for 5 days.
Dosing for other indications may vary and should be guided by local protocols or specific product monographs.
## Pediatric Dosing
Dosing is typically based on the trimethoprim component and weight.
* **UTIs, Otitis Media:** 8 mg/kg/day of trimethoprim plus 40 mg/kg/day of sulfamethoxazole, divided into two doses every 12 hours for 10 days.
* **PJP Treatment:** 15-20 mg/kg/day of trimethoprim plus 75-100 mg/kg/day of sulfamethoxazole, divided into 3-4 doses every 24 hours for 14-21 days.
* **PJP Prophylaxis:** 150 mg/m²/day of trimethoprim plus 750 mg/m²/day of sulfamethoxazole, divided into two doses daily. Alternative: 150 mg/m²/day of trimethoprim plus 750 mg/m²/day of sulfamethoxazole, divided into three doses three times a week.
Maximum dose in children is generally 320 mg trimethoprim/1600 mg sulfamethoxazole (2 DS tablets) per day.
## Dose Adjustments
* **Renal Impairment:** Adjust dose based on creatinine clearance (CrCl).
* CrCl > 30 mL/min: No adjustment needed.
* CrCl 15-30 mL/min: Administer usual dose every 18-24 hours.
* CrCl < 15 mL/min: Avoid use. If unavoidable, use 50% of usual dose every 24 hours and monitor drug levels.
## Contraindications
* Documented hypersensitivity to trimethoprim or sulfonamides.
* Infants less than 2 months of age (risk of kernicterus).
* Severe renal insufficiency when pharmacokinetic monitoring is not feasible.
* Severe hepatic insufficiency.
* Megaloblastic anemia due to folate deficiency.
## Adverse Effects
Common: Nausea, vomiting, diarrhea, rash.
Serious: Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), severe rash (e.g., AGEP), blood dyscrasias (anemia, leukopenia, thrombocytopenia, agranulocytosis, aplastic anemia), hyperkalemia, hyponatremia, crystalluria, photosensitivity, hepatic dysfunction, pseudomembranous colitis.
## Key Drug Interactions
* **Warfarin:** Increased INR. Monitor INR closely and adjust warfarin dose.
* **ACE inhibitors, ARBs, potassium-sparing diuretics:** Increased risk of hyperkalemia. Monitor potassium levels.
* **Methotrexate:** Increased risk of methotrexate toxicity. Avoid concomitant use or monitor methotrexate levels and folate status.
* **Phenytoin:** May increase phenytoin levels. Monitor phenytoin levels.
* **Potassium supplements, potassium-containing salt substitutes:** Increased risk of hyperkalemia.
* **Cyclosporine:** May increase cyclosporine levels. Monitor cyclosporine levels.
* **Diuretics (e.g., thiazides):** Increased risk of thrombocytopenia in elderly patients.
## Monitoring
* Complete blood counts (CBC) with differential periodically, especially with prolonged therapy or in elderly patients.
* Renal function (BUN, creatinine).
* Electrolytes (especially potassium).
* Liver function tests.
* For patients on warfarin, monitor INR.
* For patients on methotrexate, monitor methotrexate levels.
* For patients with impaired renal function, consider drug level monitoring.
* Urine output and pH to prevent crystalluria.
## Clinical Pearls
* Encourage adequate fluid intake to prevent crystalluria.
* Administer with food or milk to minimize gastrointestinal upset.
* Use with caution in patients with G6PD deficiency due to risk of hemolytic anemia.
* Discontinue at the first sign of rash, unless rash is clearly not drug-related.
* Trimethoprim can cause a reversible increase in serum creatinine without a significant change in glomerular filtration rate.
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*Disclaimer: This information is intended for healthcare professionals. Always consult the most current prescribing information and relevant literature before making clinical decisions. Dosing and recommendations may vary based on individual patient factors and local guidelines.*
