trimethoprim--sulfamethoxazole-drug-combination and Spinal-Cord-Injuries

Forty two paraplegic and quadriplegic hospitalized spinal cord injured patients with urinary tract infections (UTI) were included in a double blind, randomized treatment study comparing 7 days ofloxacin (300 mg bd) with trimethoprim-sulphamethoxazole (TMPSMX; 160-800 mg bd) or an alternative, chosen because of resistance to TMPSMX. The 4-day clinical cure rate, defined as an asymptomatic patient with sterile urine, was 90% (19/21) with ofloxacin, significantly greater than 48% (10/21) for the comparison group (P=0.003) and the rate at end of therapy was 90% (19/21) with ofloxacin, against 57% (12/21) (P=0.015). Bacterial biofilms were detected on bladder epithelial cells in 39/41 (95%) patients. The biofilm score fell significantly following ofloxacin therapy (P < 0.001) or alternative therapy (P < 0.001). Ofloxacin treatment led to significantly more biofilm eradication than the other antibiotic group on day 4 (62 vs. 24%) (P=0.005) and day 7 (67 vs. 35%) (P=0.014). The study showed that ofloxacin was better than TMPSMX and alternatives at relieving clinical infection and eradicating bladder cell biofilms.

Topics: Administration, Oral; Adolescent; Adult; Aged; Anti-Infective Agents, Urinary; Biofilms; Double-Blind Method; Female; Humans; Male; Middle Aged; Ofloxacin; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder; Urinary Tract Infections; Urothelium

Spinal cord injured patients are highly prone to urinary tract infections. The high frequency of recurrences, the problems with drug resistance and the difficulties associated with diagnosis complicate the management. In a preliminary retrospective study of 30 patient files, we discovered that prophylactic antimicrobial therapy with trimethoprim-sulfamethoxazole, significantly reduced the incidence of symptomatic urinary tract infections. The prevention of infection resulted in cheaper healthcare expenses than treatment. ONe problematic outcome was that antibiotic therapy resulted in a dramatic change in the population of uropathogens infecting the host, from a predominantly Gram negative type to one dominated by Enterococcus faecalis.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Anti-Infective Agents, Urinary; Child; Costs and Cost Analysis; Female; Humans; Male; Middle Aged; Retrospective Studies; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Catheterization; Urinary Tract Infections

Suppressive therapy with antibiotics has long been thought to decrease the number of complications from the neuropathic bladder in spinal cord injury patients, but it may also induce resistance to antibiotics which subsequently causes difficulties in treating symptomatic urinary tract infections. Forty-three chronic spinal cord injury patients were randomized to continue to receive daily trimethoprim-sulfamethoxazole (TMP-SMX) urinary tract prophylaxis versus discontinuing antibiotic prophylaxis. Patients were all at least 6 months after spinal cord injury. Patients were followed for a minimum of 3 months, with weekly catheter urine cultures. The difference in the colonization rate at onset and after 3 months (percent of cultures with asymptomatic bacteriuria) between the control and prophylaxis group was not statistically significant (P > 0.1). There was a significant decrease in the percentage of TMP-SMX resistant asymptomatic bacteriuria in the control group, 78.8%, compared to 94.1% in the suppressive group (P < 0.05). There was no significant difference in the number of symptomatic urinary tract infections following the withdrawal of suppressive therapy between the control group, 0.035/week, and the prophylaxis group, 0.043/week (P > 0.5). There was a larger percentage of TMP-SMX resistant symptomatic urinary tract infections in the treated group, 42.5% versus 37.5% in the control group, but the difference was not significant (P > 0.5). Irrespective of the method of bladder management, suppressive therapy with TMP-SMX did not reduce the incidence of symptomatic bacteriuria and did increase the percentage of cultures resistant to TMP-SMX in asymptomatic patients.

Topics: Adult; Aged; Aged, 80 and over; Bacteriuria; Chronic Disease; Humans; Male; Middle Aged; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

To determine the efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) for prophylaxis of urinary tract infection in persons with recent spinal cord injury, during the first 4 months of intermittent catheterization.. One hundred twenty-nine adults (112 men, 17 women) with recent acute spinal cord injury participated in a randomized, double-blind, placebo-controlled trial, and were studied for up to 16 weeks. Low-dose TMP-SMX (TMP 40 mg, SMX 200 mg) or placebo was given once daily. Clinical observations, urine cultures, and cultures of rectal and urethral swabs were made weekly. Subjects who developed breakthrough bacteriuria received conventional antimicrobial therapy and prophylaxis was continued.. Sixty-six TMP-SMX recipients (57 men, 9 women) and 60 placebo recipients (52 men, 8 women) are evaluable for efficacy. Among male subjects, bacteriuria was present during 50% or more of study weeks in 30% of TMP-SMX recipients and in 56% of placebo recipients (p = 0.003). The interval to the onset of bacteriuria was prolonged in TMP-SMX recipients (p < 0.0001). TMP-SMX recipients without bacteriuria in any given week had a lower probability of having bacteriuria the subsequent week (0.26) than did placebo recipients (0.49) (p < 0.0001). At least 1 episode of definite symptomatic bacteriuria (bacteriuria and fever and at least 1 classical manifestation of urinary infection) occurred in 4 of 57 TMP-SMX-treated men and in 18 of 52 placebo-treated men (p < 0.0003). We observed similar trends in women, but differences did not reach statistical significance, perhaps because the number of females was small. Adverse events suspected to be due to medications were frequent in this population of patients with recent severe injuries and led to discontinuation of the study in 10% of the TMP-SMX group and 8% of the placebo group. Adverse events included neutropenia (TMP-SMX: two; placebo: three), pseudomembranous colitis (TMP-SMX: one), severe skin rash (TMP-SMX: two; placebo: one), and drug fever (TMP-SMX: one). The proportion of all episodes of bacteriuria that were due to TMP-SMX-resistant organisms was unexpectedly high in the placebo group (51%), and increased progressively according to year of enrollment in the study. By Year 3, all subjects in the placebo group had at least one episode of TMP-SMX-resistant bacteriuria. Gram-negative enteric bacilli resistant to TMP-SMX were recovered from rectal swabs (TMP-SMX 49%, placebo 42%) and urethral swabs (TMP-SMX 33%, placebo 26%) in similar proportions of subjects in the two study groups.. Prophylaxis with TMP-SMX significantly reduces bacteriuria and symptomatic urinary tract infection in persons with recent acute spinal cord injury during bladder retraining using intermittent catheterization. However, adverse reactions attributable to TMP-SMX are common in this population. Colonization and breakthrough bacteriuria with TMP-SMX-resistant organisms are frequent and may seriously limit the usefulness of this strategy, particularly in an institutional setting.

Topics: Adolescent; Adult; Aged; Bacteriuria; Double-Blind Method; Drug Resistance, Microbial; Female; Humans; Male; Middle Aged; Prospective Studies; Sex Factors; Spinal Cord Injuries; Time Factors; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder; Urinary Catheterization; Urinary Tract Infections

We conducted 202 trials in 161 male hospital patients to determine if prophylactic administration of ascorbic acid or antibacterials (trimethoprim-sulfamethoxazole, nalidixic acid, methenamine hippurate or nitrofurantoin macrocrystals) would prevent bacteriuria infections in spinal cord injury patients who had had at least 1 bout of bacteriuria. None of the drugs tested appeared to be statistically effective in the doses used in preventing bacteriuria in these patients. Moreover, sensitivities were lost to several drugs other than those used prophylactically. We conclude that use of prophylactic doses of ascorbic acid or antibacterials has not proved to be beneficial in spinal cord injury patients free of indwelling catheters.

Topics: Anti-Infective Agents, Urinary; Ascorbic Acid; Bacteriuria; Clinical Trials as Topic; Drug Combinations; Humans; Male; Methenamine; Nalidixic Acid; Nitrofurantoin; Spinal Cord Injuries; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Catheterization

Reversible myoclonus, tremor, and asterixis induced by high dose trimethoprim-sulfamethoxazole.. The patient was a 66-year-old male with T9 AIS(1) C quadriplegia secondary to spinal cord compression by a tumor due to large B cell lymphoma. Subsequent to tumor resection and chemotherapy, the patient was discovered to have Pneumocystis jiroveci pneumonia (PJP). Once started on high dose trimethoprim-sulfamethoxazole (TMP-SMX) therapy (15.6 mg/kg/day of trimethoprim) for the treatment of PJP, he displayed bilateral upper extremity myoclonic jerks at rest, asterixis, and postural tremor. Symptoms resolved once TMP-SMX therapy was discontinued.. Myoclonus, asterixis, and tremor have been linked to high dose TMP-SMX therapy as a toxic side effect. Our patient's symptoms did improve with levetiracetam therapy, but did not fully resolve until TMP-SMX was discontinued.. This is thought to be the first reported case of reversible myoclonus, tremor, and asterixis induced by high dose TMP-SMX in the spinal cord injury population. Early recognition of TMP-SMX induced complications were of key importance as they negatively impacted the rehabilitation process. We also recommend consideration of symptomatic treatment with levetiracetam for the duration of required TMP-SMX therapy as it appeared to mitigate the severity of our patient's movement disorders.

Topics: Aged; Anti-Bacterial Agents; Dyskinesia, Drug-Induced; Humans; Male; Pneumonia, Pneumocystis; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination

To investigate the microbiologic outcome after antibiotic treatment of bacterial prostatitis in men with spinal cord injury (SCI).. A retrospective investigation was done in an SCI rehabilitation center. The microbiologic culture results of urine and ejaculate or prostatic fluid samples were collected from 34 men with SCI presenting with recurrent urinary tract infections and bacterial prostatitis. Furthermore, patient characteristics, bladder diary details, and the administered antibiotic treatment were collected.. The median age of the 34 investigated men was 42.5 years (lower quartile, 31.8; upper quartile, 46.1 years), and they had sustained SCI a median of 15.2 years (lower quartile, 4.7; upper quartile, 22.9 years) ago. The majority (24 of 34 patients; 71%) evacuated their bladder with intermittent catheterization. The most commonly used antibiotics to treat bacterial prostatitis were fluoroquinolones (n = 41) followed by trimethoprim-sulfamethoxazole (n = 8) and second-generation cephalosporins (n = 7). In merely 2 men, antibiotic treatment resulted in bacterial eradication from the prostate. A shift in the bacteria species identified in the ejaculate or prostatic fluid cultures was observed during the follow-up. Most men (28 of 34; 82%) presented with mostly the same bacteria (55 of 62, 89%) in the urine as in the ejaculate or prostate samples.. Antibiotic treatment did not result in the eradication of bacteria from the prostate of men with SCI. The antibiotic treatment of bacterial prostatitis in men with SCI should aim at eradicating symptoms and not bacteria.

Topics: Adult; Anti-Bacterial Agents; Bacterial Infections; Cephalosporins; Fluoroquinolones; Humans; Intermittent Urethral Catheterization; Male; Middle Aged; Prostate; Prostatitis; Retrospective Studies; Semen; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination; Urine

Documentation of possible usefulness of phenazopyridine in the management of autonomic dysreflexia (AD) associated with urinary tract infection.. Veterans Administration Spinal Cord Injury Center.. A 36-year-old man with tetraplegia and AD triggered by cystitis improved both subjectively and objectively following the institution of a 2-day course of phenazopyridine.. Phenazopyridine may be useful in the management of AD associated with cystitis.

Topics: Administration, Oral; Adult; Anesthetics, Local; Autonomic Dysreflexia; Cystitis; Dose-Response Relationship, Drug; Drug Administration Schedule; Humans; Male; Neurologic Examination; Phenazopyridine; Quadriplegia; Secondary Prevention; Spasm; Spinal Cord Injuries; Staphylococcal Infections; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder

To report a case of erythema multiforme (EM) major treated with cyclophosphamide and prednisone.. General medicine and dermatology consult services, Department of Veterans Affairs Medical Center.. A 44-year-old man with C4-C5 quadriplegia developed a skin reaction characterized by a painful, generalized maculopapular rash, bullae, ulceronecrotic lesions, and mucosal and epidermal sloughing after taking trimethoprim/sulfamethoxazole. The patient was treated with intravenous cyclophosphamide 150 mg infused over 1 hour every 24 hours and oral prednisone 15 mg every 6 hours. After two doses of cyclophosphamide, formation of bullae and epidermal sloughing had ceased, and the erythema was markedly diminished. Cyclophosphamide was discontinued before the third dose because of evolving leukopenia. Prednisone therapy was continued until the patient was discharged on hospital day 5, at which time the dosage was tapered.. Cyclophosphamide has been used extensively for other dermatologic reactions. Relief of pain and regression of the lesions in our patient occurred more quickly than anticipated.. Treatment of EM major with cyclophosphamide combined with prednisone appeared to be highly successful in this patient. Cyclophosphamide may be an effective, empiric initial treatment in reversing EM major.

Topics: Adult; Alkylating Agents; Anti-Infective Agents, Urinary; Anti-Inflammatory Agents; Cyclophosphamide; Drug Therapy, Combination; Humans; Injections, Intravenous; Male; Prednisone; Quadriplegia; Spinal Cord Injuries; Stevens-Johnson Syndrome; Trimethoprim, Sulfamethoxazole Drug Combination

An examination of transitional bladder epithelial cells from 69 urine specimens from 23 spinal cord injury patients showed the presence of adherent bacterial biofilms in 66 cases (96%). All patients were receiving antimicrobial therapy, primarily trimethoprim-sulfamethoxazole (41 of 69), without any apparent effect on the bladder colonization. The large number of bacteria that emerged with highly virulent and potentially multi-drug resistant characteristics, especially Enterococcus faecalis (33% of isolates), was of concern. These findings raise questions about the proved efficacy and effectiveness of antibiotics against uropathogenic biofilms adherent to tissues.

Topics: Adolescent; Adult; Aged; Anti-Bacterial Agents; Bacterial Adhesion; Child; Female; Humans; Male; Middle Aged; Spinal Cord Injuries; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder; Urinary Bladder Diseases; Urinary Tract Infections; Urine

Topics: Aminoglycosides; Bacteriuria; Catheters, Indwelling; Cephalosporins; Drug Combinations; Humans; Male; Methenamine; Nitrofurantoin; Prognosis; Spinal Cord Injuries; Sulfamethoxazole; Tetracyclines; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder; Urinary Catheterization

Antibiotic-associated colitis (pseudomembranous colitis) developed in four patients with spinal cord injury and taking oral trimethoprim-sulfamethoxazole. One hundred forty-eight (59%) of 251 patients with spinal cord injury who were evaluated had received this drug. Two of the four patients with pseudomembranous colitis did not promptly respond to therapy, and all four suffered significant further immobilization because of the disease. Pseudomembranous colitis readily occurs in at least certain population groups receiving trimethoprim-sulfamethoxazole.

Topics: Adult; Anti-Infective Agents, Urinary; Clostridium Infections; Diarrhea; Drug Combinations; Enterocolitis, Pseudomembranous; Humans; Male; Middle Aged; Premedication; Spinal Cord Injuries; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Tract Infections

A total of 50 patients with recent spinal cord injury secondary to trauma participated in a prospective study of urinary complications during an interval of clean intermittent catheterization at initial hospitalization in a spinal cord injury unit. Patients were assigned randomly to groups receiving or not receiving a prophylactic antibacterial preparation. Both groups were divided further into subgroups in which laboratory infections (bacteriuria more than 100,000 organisms per ml.) were treated with definitive antibiotics or in which antibiotic treatment was given only for clinical infections (fever more than 100F or urethral discharge and bacteriuria). Antibacterial prophylaxis significantly reduced the probability of laboratory infection but not the probability of clinical infection, although a trend was noted toward fewer clinical infections. No significant reduction was noted in the probability of clinical infection in subgroups treated promptly for laboratory infection.

Topics: Anti-Infective Agents, Urinary; Bacteriuria; Drug Combinations; Female; Hospitalization; Humans; Male; Prospective Studies; Random Allocation; Self Care; Spinal Cord Injuries; Sulfamethoxazole; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Urinary Bladder, Neurogenic; Urinary Catheterization

Eight acute spinal injury patients with deep vein thrombosis and/or pulmonary emboli are presented witn an in-depth analysis and management of anticoagulation therapy. Special considerations for acute spinal cord injury patients with regards to prophylactic and therapeutic anticoagulation by heparin and coumadin are discussed. There was a wide variation in the requirement of heparin and/or coumadin to maintain effective coagulability which could only be elicited by frequent laboratory monitoring. Inadequate dose and shorter duration of administration of anticoagulant resulted in recurrence of thromboembolism in three out of eight patients in the present series. Haemorrhagic complications were minor and easily manageable. Co-trimoxazole potentiation of coumadin action occurred in two of our patients and it requires special mention as the drug is used increasingly in the treatment of urinary tract infections.

Topics: Administration, Oral; Adult; Anticoagulants; Drug Combinations; Drug Interactions; Hematuria; Heparin; Humans; Injections, Subcutaneous; Male; Middle Aged; Pulmonary Embolism; Spinal Cord Injuries; Sulfamethoxazole; Thrombophlebitis; Time Factors; Trimethoprim; Trimethoprim, Sulfamethoxazole Drug Combination; Warfarin