Trimethoprim-sulfamethoxazole patients

Patients who have previously experienced spontaneous bacterial peritonitis and have low-protein ascites (ascitic fluid albumin less than 1 g/dL [less than 10 g/L]) are candidates for long-term prophylactic therapy. Recommended regimens include either a single trimethoprim-sulfamethoxazole doublestrength tablet 5 days per week (Monday through Friday) or ciprofloxacin 750 mg once weekly.19,46 Any patient who has experienced an episode of variceal bleeding should also receive prophylactic antibiotics. 

In patients with normal gallbladder function, effective agents for eradication of chronic carriage include amoxicillin (3 g divided three times a day in adults for 3 months), trimethoprim-sulfamethoxazole (one double-strength tablet twice a day for 3 months), and ciprofloxacin (750 mg twice daily for 4 weeks). In patients with anatomic abnormalities, such as biliary or kidney stones, surgery combined with antibiotic therapy is indicated. 

The cornerstone of cholera treatment is fluid replacement. Without treatment, the case-fatality rate for severe cholera is approximately 50%. For cholera, rice-based ORT is better than glucose-based ORT because it reduces the number of stools.21 Patients with significant disease should receive a short antibiotic course, 1 to 3 days, to shorten the duration of illness and decrease the number of stools. Doxycycline 300 mg once daily is the drug of choice. Other antibiotics shown to be effective include erythromycin, azithromycin, trimethoprim-sulfamethoxazole, and ciprofloxacin.2 Antibiotic resistance has been documented in V cholerae since 1977.2 Antibiotic prophylaxis is not warranted. 

Prophylactic trimethoprim-sulfamethoxazole is recommended for all patients receiving alemtuzumab. 

Trimethoprim-sulfamethoxazole DS BID for 2 days each week for patients who require any corticosteroids... 

The answer is d. (Hardman, p 989.) Both trimethoprim-sulfamethoxazole and pentamidine are effective in pneumonia caused by E carinii. This protozoal disease usually occurs in immunodeficient patients, such as those with AIDS. Nifurtimox is effective in trypanosomiasis and metronidazole in amebiasis and leishmaniasis, as well as in anaerobic bacterial infections. Penicillins are not considered drugs of choice for this particular disease state. 

Trimethoprim-sulfamethoxazole (or trimethoprim alone) is a second-line oral agent that may be used for patients who do not tolerate tetracyclines and erythromycin or in cases of resistance to these antibiotics. The adult dose is usually 800 mg sulfamethoxazole and 160 mg trimethoprim twice daily. 

Treatment with trimethoprim-sulfamethoxazole or parenteral pentamidine is associated with a 60% to 100% response rate. Trimethoprim-sulfamethoxazole is the regimen of choice for treatment and subsequent prophylaxis of PCP in patients with and without HIV. 

Trimethoprim-sulfamethoxazole is usually initiated by the IV route, although oral therapy (as oral absorption is high) may suffice in mildly ill and reliable patients or to complete a course of therapy after a response has been achieved with IV administration. 

Patients with noninfected bite injuries should be given prophylactic antibiotic therapy for 3 to 5 days. Amoxicillin-clavulanic acid (500 mg every 8 hours) is commonly recommended. Alternatives for penicillin-allergic patients include fluoroquinolones or trimethoprim-sulfamethoxazole in combination with clindamycin or metronidazole. First-generation cephalosporins, macrolides, clindamycin alone, or aminoglycosides are not recommended, as the sensitivity to E. corrodens is variable. 

Craniotomy S. aureus, 5. epidermidis Cefazolin 1 g x 1 or cefotaxime 1 g x 1 Trimethoprim-sulfamethoxazole (160/800 mg) IV x 1 can be substituted for patients with penicillin allergy IA... 

Single-dose or short-course therapy with trimethoprim-sulfamethoxazole has been used effectively, and prolonged courses of therapy are not necessary for the majority of patients. 

In women who experience symptomatic reinfections in association with sexual activity, voiding after intercourse may help prevent infection. Also, self-administered, single-dose prophylactic therapy with trimethoprim-sulfamethoxazole taken after intercourse has been found to significantly reduce the incidence of recurrent infection in these patients. 

The majority of patients can be managed with oral antimicrobial agents, such as trimethoprim-sulfamethoxazole or the fluoroquinolones (ciprofloxacin, levofloxacin). When IV treatment is necessary, IV to oral sequential therapy with trimethoprim-sulfamethoxazole or a fluoroquinolone, such as ciprofloxacin or ofloxacin, would be appropriate. 

Pneumocystitis carinii pneumonia (PCP) Prevention of PCP in patients who are intolerant to trimethoprim-sulfamethoxazole (TMP-SMZ). 

Note that in addition to the adverse events due to trimethoprim the combination trimethoprim-sulfamethoxazole may cause all of the untoward reactions associated with sulfonamides. In HIV positive patients the incidence of rashes can increase to 50%. Desensibilisation with increasing doses of co-trimoxazole has been successful. 

Patients with end-stage cirrhosis of the liver are given trimethoprim-sulfamethoxazole or the quinolone norfloxacin in order to avoid relapses... 

Dapsone, combined with other antUeprosy agents like rifampin and clofazimine, is used in the treatment of both multibacillary and paucibacillary M. leprae infections. Dapsone is also used in the treatment and prevention of Pneumocystis carinii pneumonia in AIDS patients who are allergic to or intolerant of trimethoprim-sulfamethoxazole. 

The most common adverse effects of lamivudine seen at doses used to treat HBV are mild they include headache, malaise, fatigue, fever, insomnia, diarrhea, and upper respiratory infections. Elevated alanine aminotransferase (ALT), serum lipase, and creatine kinase may also occur. The safety and efficacy of lamivudine in patients with decompensated liver disease have not been established. Dosage adjustment is required in individuals with renal impairment. Coadministration of trimethoprim-sulfamethoxazole decreases the renal clearance of lamivudine. 

Pentamidine is active against Pneumocystis carinii, trypanosomes, and leishmaniasis unresponsive to pentavalent antimonials. It is an alternative agent for the treatment of P. carinii pneumonia. Although it is more toxic than trimethoprim-sulfamethoxazole, it has been widely used in patients with acquired immunodeficiency syndrome (AIDS), in whom P. carinii infection is common. 

Reserve for patients intolerant of or refractory to trimethoprim-sulfamethoxazole... 

Clindamycin is indicated for the treatment of skin and soft-tissue infections caused by streptococci and staphylococci. It is often active against community-acquired strains of methicillin-resistant S aureus, an increasingly common cause of skin and soft tissue infections. Clindamycin is also indicated for treatment of anaerobic infection caused by bacteroides and other anaerobes that often participate in mixed infections. Clindamycin, sometimes in combination with an aminoglycoside or cephalosporin, is used to treat penetrating wounds of the abdomen and the gut infections originating in the female genital tract, eg, septic abortion and pelvic abscesses and aspiration pneumonia. Clindamycin is now recommended rather than erythromycin for prophylaxis of endocarditis in patients with valvular heart disease who are undergoing certain dental procedures. Clindamycin plus primaquine is an effective alternative to trimethoprim-sulfamethoxazole for moderate to moderately severe Pneumocystis jiroveci pneumonia in AIDS patients. It is also used in combination with pyrimethamine for AIDS-related toxoplasmosis of the brain. 

Pneumocystis jiroveci pneumonia (PCP) High-risk patients (eg, AIDS, leukemia, transplant) Trimethoprim-sulfamethoxazole, dapsone, or atovaquone Excellent... 

Toxoplasmosis HIV-infected patients with IgG antibody to Toxoplasma and CD4 count < lOO/M L Trimethoprim- sulfamethoxazole Good... 

Atovaquone is an alternative therapy for P jiroveci infection, although its efficacy is lower than that of trimethoprim-sulfamethoxazole. Standard dosing is 750 mg taken with food twice daily for 21 days. Adverse effects include fever, rash, nausea, vomiting, diarrhea, headache, and insomnia. Serious adverse effects appear to be minimal, although experience with the drug remains limited. Atovaquone has also been effective in small numbers of immunocompromised patients with toxoplasmosis unresponsive to other agents, although its role in this disease is not yet defined. 

Pentamidine is a well-established alternative therapy for pulmonary and extrapulmonary disease caused by P jiroveci. The drug has somewhat lower efficacy and greater toxicity than trimethoprim-sulfamethoxazole. The standard dosage is 3 mg/kg/d intravenously for 21 days. Significant adverse reactions are common, and with multiple regimens now available to treat P jiroveci infection, pentamidine is best reserved for patients with severe disease who cannot tolerate or fail other drugs. 

Trimethoprim-sulfamethoxazole and metabolic acidosis in HIV-infected patients. Ann Pharmacother 1998 32(2) 185-9. 

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