UTIs caused by susceptible strains of Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris Pyelonephritis: 1 DS tab or 2 regular-strength tabs PO q12hr x 14 days Prostatitis: 1 DS tab or 2 regular-strength tabs PO q12hr x 14 days or 2-3 months if chronic infection A 3 to 5 day course may be used for acute, uncomplicated cystitis Prophylaxis (off-label): Various regimens exist; may use regular-strength tablet once/twice per week Anorexia Nausea Vomiting Vertigo Seizure Peripheral neuritis Erythema multiforme Hyperkalemia Rash Urticaria Immune hypersensitivity reaction Stevens-Johnson syndrome Toxic epidermal necrolysis Agranulocytosis Aplastic anemia Hyponatremia Disorder of hematopoietic structure Fulminant hepatic necrosis Thrombotic thrombocytopenia purpura Idiopathic thrombocytopenic purpura QT prolongation resulting in ventricular tachycardia and torsade de pointes Embryo-fetal toxicity Hypersensitivity and other fatal reactions Thrombocytopenia Clostridium difficile-associated diarrhea Sulfite sensitivity Risk associated with concurrent use of leucovorin for Pneumocystis jirovecii Pneumonia Infusion reactions Hypoglycemia Electrolyte abnormalities Thrombophlebitis Propylene glycol Toxicity Metabolic acidosis 10% Trimethoprim decreases urinary potassium excretion; may cause hyperkalemia, particularly with high doses, renal insufficiency, or when combined with other drugs that cause hyperkalemia Severe and symptomatic hyponatremia reported with high dose trimethoprim Rare fatalities reported with sulfonamides due to Stevens-Johnson syndrome, toxic epidermal necrolysis, fulminant hepatic necrosis, agranulocytosis, aplastic anemia, and other blood dyscrasias Caution when used in elderly individuals; risk of bone marrow suppression PCP prophylaxis with AIDS: Rash, fever, leukopenia, and elevated transaminase values reported; hyperkalemia and hyponatremia also appear to be increased Severe cases (including fatalities) of immune-mediated thrombocytopenia reported; monitor patients for hematologic toxicity Sulfonamides should not be used to treat group A beta-hemolytic streptococcal infections; they will not eradicate streptococcus or prevent rheumatic fever Clostridium difficile-associated diarrhea reported Coadministration with leucovorin for the treatment of HIV-positive patients with PCP resulted in treatment failure and excess mortality in a randomized, placebo-controlled trial; avoid coadministration Development of drug-resistant bacteria may occur when prescribed in absence of strongly suspected bacterial infection or prophylactic indication Prolonged use may result in fungal or bacterial superinfection Caution with impaired renal or hepatic function, patients with possible folate deficiency (eg, the elderly, chronic alcoholics, patients receiving anticonvulsant therapy, patients with malabsorption syndrome, and patients in malnutrition states), and patients with severe allergies or bronchial asthma Hemolysis may occur if administered to patients with G6PD deficiency Hypoglycemia (rare) reported in nondiabetic patients; patients with renal dysfunction, liver disease, or malnutrition or those receiving high doses at particular risk Trimethoprim may impair phenylalanine metabolism Caution with porphyria or thyroid dysfunction; sulfonamides can precipitate porphyria crisis and hypothyroidism; avoid use in patients with porphyria or thyroid dysfunction Complete blood counts should be done frequently in patients receiving therapy; discontinue therapy if a significant reduction in count of any formed blood element is noted’ perform urinalyses with careful microscopic examination and renal function tests during therapy, particularly for those patients with impaired renal function When administered at high doses as for the treatment of P. jirovecii pneumonia, monitor for total daily intake of propylene glycol from all sources and for acid-base disturbances; discontinue therapy if propylene glycol toxicity suspected Therapy may cause fetal harm if administered to pregnant woman; some epidemiologic studies suggest that exposure to drug during pregnancy may be associated with increased risk of congenital malformations, particularly neural tube defects, cardiovascular abnormalities, urinary tract defects, oral clefts, and club foot Urinary tract infection in pregnancy is associated with adverse perinatal outcomes such as preterm birth, low birth weight, and pre-eclampsia, and increased mortality to pregnant woman P. jirovecii pneumonia in pregnancy is associated with preterm birth and increased morbidity and mortality for the pregnant woman Use during pregnancy only if potential benefit justifies potential risk to fetus Levels of drug in breast milk are approximately 2 to 5% of recommended daily dose for pediatric patients over two months of age; there is no information regarding effect of therapy on breastfed infant or effect on milk production; because of potential risk of bilirubin displacement and kernicterus on breastfed child, advise women to avoid breastfeeding during therapy Blocks 2 consecutive steps in the biosynthesis of nucleic acids and proteins essential to many bacteria Trimethoprim: Inhibits dihydrofolate reductase, thereby blocking production of tetrahydrofolic acid from dihydrofolic acid Sulfamethoxazole: Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid Additive: Fluconazole, linezolid, verapamil Y-site: Cisatracurium (incompatible at 2 mg/m L cisatra; may be compatible at much lower concs), fluconazole, foscarnet (may be compatible at very low TMP/SMX concs), midazolam, vinorelbine The above information is provided for general informational and educational purposes only. 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