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Bactrim IV (Trimethoprim and Sulfamethoxazole) - Description and Clinical Pharmacology



Bactrim (trimethoprim and sulfamethoxazole) IV Infusion, a sterile solution for intravenous infusion only, is a synthetic antibacterial combination product. Each 5 mL contains 80 mg trimethoprim (16 mg/mL) and 400 mg sulfamethoxazole (80 mg/mL) compounded with 40% propylene glycol, 10% ethyl alcohol and 0.3% diethanolamine; 1% benzyl alcohol and 0.1% sodium metabisulfite added as preservatives, water for injection, and pH adjusted to approximately 10 with sodium hydroxide.

Trimethoprim is 2,4-diamino-5-(3,4,5-trimethoxybenzyl)pyrimidine. It is a white to light yellow, odorless, bitter compound with a molecular weight of 290.3.

Sulfamethoxazole is N 1-(5-methyl-3-isoxazolyl)sulfanilamide. It is an almost white, odorless, tasteless compound with a molecular weight of 253.28.


Following a 1-hour intravenous infusion of a single dose of 160 mg trimethoprim and 800 mg sulfamethoxazole to 11 patients whose weight ranged from 105 lbs to 165 lbs (mean, 143 lbs), the peak plasma concentrations of trimethoprim and sulfamethoxazole were 3.4 ± 0.3 µg/mL and 46.3 ± 2.7 µg/mL, respectively. Following repeated intravenous administration of the same dose at 8-hour intervals, the mean plasma concentrations just prior to and immediately after each infusion at steady state were 5.6 ± 0.6 µg/mL and 8.8 ± 0.9 µg/mL for trimethoprim and 70.6 ± 7.3 µg/mL and 105.6 ± 10.9 µg/mL for sulfamethoxazole. The mean plasma half-life was 11.3 ± 0.7 hours for trimethoprim and 12.8 ± 1.8 hours for sulfamethoxazole. All of these 11 patients had normal renal function, and their ages ranged from 17 to 78 years (median, 60 years). 1

Pharmacokinetic studies in children and adults suggest an age-dependent half-life of trimethoprim, as indicated in the following table. 2

No. of
Mean TMP
Half-life (hours)
<1 2 7.67
1-10 9 5.49
10-20 5 8.19
20-63 6 12.82

Patients with severely impaired renal function exhibit an increase in the half-lives of both components, requiring dosage regimen adjustment (See DOSAGE AND ADMINISTRATION section).

Both trimethoprim and sulfamethoxazole exist in the blood as unbound, protein-bound and metabolized forms; sulfamethaxazole also exists as the conjugated form. The metabolism of sulfamethoxazole occurs predominately by N 4 -acetylation, although the glucuronide conjugate has been identified. The principal metabolites of trimethoprim are the 1- and 3-oxides and the 3'- and 4'-hydroxy derivatives. The free forms of trimethoprim and sulfamethoxazole are considered to be the therapeutically active forms. Approximately 44% of trimethoprim and 70% of sulfamethoxazole are bound to plasma proteins. The presence of 10 mg percent sulfamethoxazole in plasma decreases the protein binding of trimethoprim by an insignificant degree; trimethoprim does not influence the protein binding of sulfamethoxazole.

Excretion of trimethoprim and sulfamethoxazole is primarily by the kidneys through both glomerular filtration and tubular secretion. Urine concentrations of both trimethoprim and sulfamethoxazole are considerably higher than are the concentrations in the blood. The percent of dose excreted in urine over a 12-hour period following the intravenous administration of the first dose of 240 mg of trimethoprim and 1200 mg of sulfamethoxazole on day 1 ranged from 17% to 42.4% as free trimethoprim; 7% to 12.7% as free sulfamethoxazole; and 36.7% to 56% as total (free plus the N 4 -acetylated metabolite) sulfamethoxazole. When administered together as Bactrim, neither trimethoprim nor sulfamethoxazole affects the urinary excretion pattern of the other. Both trimethoprim and sulfamethoxazole distribute to sputum and vaginal fluid; trimethoprim also distributes to bronchial secretions, and both pass the placental barrier and are excreted in breast milk.

Microbiology: Sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with para -aminobenzoic acid (PABA). Trimethoprim blocks the production of tetrahydrofolic acid from dihydrofolic acid by binding to and reversibly inhibiting the required enzyme, dihydrofolate reductase. Thus, Bactrim blocks two consecutive steps in the biosynthesis of nucleic acids and proteins essential to many bacteria.

In vitro studies have shown that bacterial resistance develops more slowly with Bactrim than with either trimethoprim or sulfamethoxazole alone.

In vitro serial dilution tests have shown that the spectrum of antibacterial activity of Bactrim includes common bacterial pathogens with the exception of Pseudomonas aeruginosa. The following organisms are usually susceptible: Escherichia coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, indole-positive Proteus species including Proteus vulgaris, Haemophilus influenzae (including ampicillin-resistant strains), Streptococcus pneumoniae, Shigella flexneri and Shigella sonnei. It should be noted, however, that there are little clinical data on the use of Bactrim IV Infusion in serious systemic infections due to Haemophilus influenzae and Streptococcus pneumoniae.

TMP / SMX (1:20)
Bacteria TMP
Escherichia coli 0.05-1.5 1.0-245 0.05-0.5 0.95-9.5
Proteus species
(indole positive)
0.5-5.0 7.35-300 0.05-1.5 0.95-28.5
Morganella morganii 0.5-5.0 7.35-300 0.05-1.5 0.95-28.5
Proteus mirabilis 0.5-1.5 7.35-30 0.05-0.15 0.95-2.85
Klebsiella species 0.15-5.0 2.45 -245 0.05-1.5 0.95-28.5
Enterobacter species 0.15-5.0 2.45-245 0.05-1.5 0.95-28.5
Haemophilus influenzae 0.15-1.5 2.85-95 0.015-0.15 0.285-2.85
Streptococcus pneumoniae 0.15-1.5 7.35-24.5 0.05-0.15 0.95-2.85
Shigella flexneri * <0.01-0.04 <0.16->320 <0.002-0.03 0.04-0.625
Shigella sonnei * 0.02-0.08 0.625->320 0.004-0.06 0.08 -1.25
TMP = trimethoprim SMX = sulfamethoxazole * Rudoy RC, Nelson JD, Haltalin KC. Antimicrob Agents Chemother. May 1974;5:439-443.

The recommended quantitative disc susceptibility method may be used for estimating the susceptibility of bacteria to Bactrim. 3,4 With this procedure, a report from the laboratory of "Susceptible to trimethoprim and sulfamethoxazole" indicates that the infection is likely to respond to therapy with Bactrim. If the infection is confined to the urine, a report of "Intermediate susceptibility to trimethoprim and sulfamethoxazole" also indicates that the infection is likely to respond. A report of "Resistant to trimethoprim and sulfamethoxazole" indicates that the infection is unlikely to respond to therapy with Bactrim.

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