Cotrimoxazole, the magic little pill

Cotrimoxazole (also known as septrin, bactrim and   TMP-SMX, CTX) is an antibiotic that consists of two drugs, trimethoprim and sulfamethoxazole.

Cotrimoxazole is a prophylactic i.e. a chemical agent taken for the prevention of a disease or condition. People with HIV have a weak immune system and are thus susceptible to opportunistic infections.

Cotrimoxazole is used in the treatment and prevention of several opportunistic infections—pneumonia (specifically PCP – Pneumocystis jiroveci pneumonia), toxoplasmosis, tuberculosis, bacterial pneumonia, malaria, and septicaemia.

The most common dose for prophylaxis is one double strength (960 mg) tablet every day. An alternative dose is one tablet three times a week. Although the drug is widely available in both syrup and pill form at low cost in most places, many countries have still failed to implement policies to provide nationwide coverage of the drug.

The World Health Organisation recommends the following groups of people take cotrimoxazole: HIV-exposed infants and children, HIV-positive children, HIV-positive adults and adolescents who have mild, advanced or severe symptoms of HIV disease, or a CD4 count below 350 cells per ml.

In general, treatment of adults and children should continue indefinitely, though it may sometimes be stopped following successful antiretroviral treatment.

Drug prophylaxis is sometimes recommended even for those who have started ART if they have very weak immune systems or are otherwise considered to be especially vulnerable. They may be advised to stop taking the drugs if their immune system recovers.

Cotrimoxazole can cause a high level of side-effects. The most common reactions are rash, fever, nausea, low white blood cells and liver inflammation. Nausea may be reduced if the drug is taken with food.

It should be taken with plenty of water. Skin rashes due to cotrimoxazole are common among HIV-positive people. These should be taken seriously and treatment stopped or the dose reduced because some people can develop a potentially fatal allergy called Stevens-Johnson syndrome.

In Malawi, following a stakeholder’s meeting held by the HIV Department of the Ministry of Health in 2005, a national policy for free provision of cotrimoxazole to adults and children living with HIV and Aids was developed. Malawi’s policy and guidelines were in line with those subsequently released by WHO in 2006.

Since the implementation of the cotrimoxazole national policy as of December 2010, 95% of the 250,987 patients on ART were on cotrimoxazole. The number of people dying soon after starting antiretroviral therapy has decreased considerably; this may be due to initiation of cotrimozaxole prop.

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