thrombocytopenia.tinnitus.tremor.uveitis.vasculitis.
vertigo.wheezing
▶Frequency not knownGastrointestinal disorder.
megaloblastic anaemia.methaemoglobinaemia
lPREGNANCYTeratogenic risk infirst trimester (folate
antagonist). Manufacturers advise avoid during pregnancy.
lBREAST FEEDINGPresent in milk—short-term use not
known to be harmful.
lRENAL IMPAIRMENT
Dose adjustmentsUse half normal dose after 3 days if
estimated glomerularfiltration rate
15 – 30 mL/minute/ 1. 73 m^2.
Use half normal dose if estimated glomerularfiltration
rate less than 15 mL/minute/ 1. 73 m^2.
MonitoringMonitor plasma-trimethoprim concentration if
estimated glomerularfiltration rate less than
10 mL/minute/ 1. 73 m^2.
lMONITORING REQUIREMENTSManufacturer recommends
blood counts on long-term therapy (but evidence of
practical value unsatisfactory).
lPATIENT AND CARER ADVICE
Blood disordersOn long-term treatment, patients and their
carers should be told how to recognise signs of blood
disorders and advised to seek immediate medical attention
if symptoms such as fever, sore throat, rash, mouth ulcers,
purpura, bruising or bleeding develop.
Medicines for Children leaflet: Trimethoprim for bacterial
infectionswww.medicinesforchildren.org.uk/trimethoprim-for-
bacterial-infectionslMEDICINAL FORMS
There can be variation in the licensing of different medicines
containing the same drug. Forms available from special-order
manufacturers include: oral suspension, oral solution
Oral suspension
CAUTIONARY AND ADVISORY LABELS 9
▶Trimethoprim (Non-proprietary)
Trimethoprim 10 mg per 1 mlTrimethoprim 50 mg/ 5 ml oral
suspension sugar free sugar-free| 100 mlP£ 5. 24 DT = £ 2. 30
▶Monotrim(Chemidex Pharma Ltd)
Trimethoprim 10 mg per 1 mlMonotrim 50 mg/ 5 ml oral suspension
sugar-free| 100 mlP£ 1. 77 DT = £ 2. 30
Tablet
CAUTIONARY AND ADVISORY LABELS 9
▶Trimethoprim (Non-proprietary)
Trimethoprim 100 mgTrimethoprim 100 mg tablets|
28 tabletP£ 9. 99 DT = £ 0. 86
Trimethoprim 200 mgTrimethoprim 200 mg tablets| 6 tabletP
£ 2. 15 DT = £ 0. 31 | 14 tabletP£ 9. 99 DT = £ 0. 73
Combinations available:Co-trimoxazole,p. 3502.1 Anthrax
Anthrax
Treatment and post-exposure prophylaxis
Inhalationorgastro-intestinal anthraxshould be treated
initially with either ciprofloxacin p. 348 or, in patients over
12 years, doxycycline p. 352 [unlicensed indication]
combined with one or two other antibacterials (such as
amoxicillin p. 339 , benzylpenicillin sodium p. 338 ,
chloramphenicol p. 354 , clarithromycin p. 330 , clindamycin
p. 327 , imipenem with cilastatin p. 315 , rifampicin p. 364
[unlicensed indication], and vancomycin p. 325 ). When the
condition improves and the sensitivity of theBacillus
anthracisstrain is known, treatment may be switched to a
single antibacterial. Treatment should continue for 60 days
because germination may be delayed.
Cutaneous anthraxshould be treated with either
ciprofloxacin [unlicensed indication] or doxycycline[unlicensed indication] for 7 days. Treatment may be
switched to amoxicillin if the infecting strain is susceptible.
Treatment may need to be extended to 60 days if exposure is
due to aerosol. A combination of antibacterials for^14 days is
recommended for cutaneous anthrax with systemic features,
extensive oedema, or lesions of the head or neck.
Ciprofloxacin or doxycycline may be given forpost-
exposure prophylaxis. If exposure is confirmed, antibacterial
prophylaxis should continue for 60 days. Antibacterial
prophylaxis may be switched to amoxicillin after 10 – 14 days
if the strain ofB. anthracisis susceptible. Vaccination against
anthrax may allow the duration of antibacterial prophylaxis
to be shortened.2.2 Lyme disease
Lyme disease
Treatment
Amoxicillin p. 339 [unlicensed indication], cefuroxime p. 319
(as cefuroxime axetil) or doxycycline p. 352 are the
antibacterials of choice forearly Lyme diseaseorLyme
arthritisbut doxycycline should only be used in children over
12 years of age. If these antibacterials are contra-indicated, a
macrolide(e.g. clarithromycin p. 330 ) can be used for early
Lyme disease. Intravenous administration of ceftriaxone
p. 322 , cefotaxime p. 320 , or benzylpenicillin sodium p. 338
is recommended for Lyme disease associated with cardiac or
neurological complications. The duration of treatment is
usually 2 – 4 weeks; Lyme arthritis may require further
treatment.2.3 Methicillin-resistant
staphylococcus aureus
MRSA
Management
Infection fromStaphylococcus aureusstrains resistant to
meticillin [now discontinued] (meticillin-resistantStaph.
aureus, MRSA) and toflucloxacillin p. 345 can be difficult to
manage. Treatment is guided by the sensitivity of the
infecting strain.
Rifampicin p. 364 or fusidic acid p. 357 shouldnotbe used
alone because resistance may develop rapidly. Clindamycin
p. 327 alone or a combination of rifampicin and fusidic acid
can be used forskinandsoft-tissue infectionscaused by
MRSA; atetracyclineis an alternative in children over
12 years of age. Aglycopeptide(e.g. vancomycin p. 325 )can
be used for severe skin and soft-tissue infections associated
with MRSA. A combination of a glycopeptide and fusidic acid
or a glycopeptide and rifampicin can be considered for skin
and soft-tissue infections that have failed to respond to a
single antibacterial. Linezolid p. 358 should be reserved for
skin and soft-tissue infections that have not responded to
other antibacterials or for children who cannot tolerate other
antibacterials.
Aglycopeptidecan be used forpneumoniaassociated with
MRSA. Linezolid should be reserved for hospital-acquired
pneumonia that has not responded to other antibacterials or
for children who cannot tolerate other antibacterials.
Trimethoprim p. 359 or nitrofurantoin p. 369 can be used
forurinary-tract infectionscaused by MRSA; atetracyclineis
an alternative in children over 12 years of age. A
glycopeptidecan be used for urinary-tract infections that
are severe or resistant to other antibacterials.360 Bacterial infection BNFC 2018 – 2019
Infection5