FL, a 29 year old woman, has complained to her care provider of painful urinary frequency and

urgency. The patient has an elevated temperature. A urine specimen indicates that FL has a urinary
tract infection (UTI). The health care provider prescribes Trimethoprim-sulfamethoxazole (TMP-SMZ)
double strength tablets. (trimethoprim 160 mg, sulfamethoxazole 800 mg.) twice a day for 14 days.

1. What other information should the health care provider obtain from the patient?

The antibiotics sulfamethoxazole and trimethoprim are combined in this medicine. It's used to treat a
number of different bacterial illnesses such as middle ear, urine, respiratory, and intestinal infections.
It is also used to prevent and treat a specific kind of pneumonia, pneumocystis-type. This medicine
should not be given to children under the age of 2 months owing to the risk of significant adverse
effects. This medication exclusively treats certain illnesses. It is ineffective against viral infections
such as flu. Any antibiotic's efficacy might be reduced if it is used or misused unnecessarily.

Patients with an uncomplicated UTI have a normal, unobstructed genitourinary tract, no recent
instrumentation history, and symptoms that are limited to the lower urinary tract. Young, sexually
active women are more likely to have uncomplicated UTIs. Dysuria, urine frequency, urinary urgency,
and/or suprapubic discomfort are common symptoms. Upper urinary tract involvement is indicated by
fever or costovertebral angle pain.

Monitoring the health status of patient

Keep an eye on the CBC and white cell differential. Keep an eye out for signs of blood dyscrasias. Be
on the lookout for erythema multiforme. Early indications should be reported before the disorder
progresses to Stevens-Johnson syndrome. Fever, tachycardia, and chills are all indications and
symptoms of superinfection, so keep an eye on the patients. Keep an eye on the liver function tests
and look for signs of hepatitis. Weekly renal function testing should be performed. Examine the
patient's fluid intake, urine output, and urine pH, and immediately report any hematuria, oliguria, or
anuria. Keep an eye on your neurologic condition. Seizures, hallucinations, and depression should all
be reported.
Educating the patients

● Advise patients to take on a regular schedule as prescribed, along with a full glass of water. Tell
him to drink plenty of fluids to minimize crystal formation in urine.

● If suspension is prescribed, make sure the patient has a specially marked measuring spoon or
other device so he can measure doses accurately.

● Instruct the patient to complete the full course of treatment even if he starts to feel better. Teach
patients to recognize and immediately report signs and symptoms of hypersensitivity, especially rash.

● Inform patients that drug can cause blood disorders, GI and liver problems, serious skin reactions,
and other infections. Describe key warning signs and symptoms (easy bruising or bleeding, severe
diarrhea, unusual tiredness, yellowing of skin or eyes, sore throat, rash, cough, mouth sores, fever).
Tell him to report these right away.

● Urge patients to promptly report scant or bloody urine or inability to urinate.

● Tell the patient to contact the prescriber if he develops depression.

● Teach patients effective ways to counteract photosensitivity. Advise him that dong quai and St.
John’s wort increases phototoxicity risk and should be avoided during therapy.

● Advise female patients to inform prescriber if she is pregnant. Tell her not to take drugs near term.

● Caution female patients not to breastfeed, because she could pass drug effects to infants.

● As appropriate, review all other significant and life-threatening adverse reactions and interactions,
especially those related to the drugs, tests, herbs, and behaviors mentioned above.

2. Why was TMP-SMZ prescribed? Explain your answer.

What is UTI?

UTIs can be caused by a variety of pathogens, including bacteria, fungus, and, in some
circumstances, viruses. Bacterial UTIs, on the other hand, are the most prevalent.

If you have a bacterial UTI, the only method to get rid of the bacteria that's causing it is to get rid of
the bacterium that's causing it. Antibiotics have a role in this. They either prevent the germs from
developing or destroy the bacteria directly.
It's important to note that antibiotics are exclusively used to treat UTIs and other bacterial illnesses.
Antibiotics will not assist you if you have a fungal or viral UTI.

Although not all antibiotics are effective in the treatment of urinary tract infections, a number of them
are. The medicines trimethoprim/sulfamethoxazole, nitrofurantoin, and fosfomycin are the most
commonly used to treat a UTI. But in this case, let us explain well on trimethoprim/sulfamethoxazole
medication.

Trimethoprim-sulfamethoxazole (Bactrim) for UTI

Trimethoprim/sulfamethoxazole (generic Bactrim) is an antibiotic combination medication that

contains trimethoprim and sulfamethoxazole. TMP/SMX is another name for it. The potent
combination inhibits two crucial stages necessary for some bacteria to produce the proteins they
require to thrive.

In general, TMP/SMX is effective in the treatment of UTIs. Bactrim isn't as effective as it should be
against UTI-causing bacteria in some regions because germs have become resistant to the medicine,
a situation known as antibiotic resistance.

The dosage for TMP/SMX should be 3 days, take one double-strength tablet (160 mg
trimethoprim/800 mg sulfamethoxazole) twice a day. This is dependent on the severity of the
condition, which is why the medicine is given for 14 days in the case scenario.

On the other hand, rashes or hives, nausea, and vomiting are the most frequent TMP/SMX side
effects. More serious, although extremely rare, possible side effects include Stevens-Johnson
syndrome (SJS) and toxic epidermal necrolysis (TEN).

3. What should the health care provider discuss with the patient in regard to taking the drug
and its possible side effects? What other information should FL receive?

Rashes or hives, nausea, and vomiting are the most frequent TMP/SMX side effects. More serious,
although extremely rare, possible side effects include Stevens-Johnson syndrome (SJS) and toxic
epidermal necrolysis (TEN).

Educating the patients

● Advise patients to take on a regular schedule as prescribed, along with a full glass of water. Tell
him to drink plenty of fluids to minimize crystal formation in urine.
● If suspension is prescribed, make sure the patient has a specially marked measuring spoon or
other device so he can measure doses accurately.

● Instruct the patient to complete the full course of treatment even if he starts to feel better. Teach
patients to recognize and immediately report signs and symptoms of hypersensitivity, especially rash.

● Inform patients that drug can cause blood disorders, GI and liver problems, serious skin reactions,
and other infections. Describe key warning signs and symptoms (easy bruising or bleeding, severe
diarrhea, unusual tiredness, yellowing of skin or eyes, sore throat, rash, cough, mouth sores, fever).
Tell him to report these right away.

● Urge patients to promptly report scant or bloody urine or inability to urinate.

● Tell the patient to contact the prescriber if he develops depression.

● Teach patients effective ways to counteract photosensitivity. Advise him that dong quai and St.
John’s wort increases phototoxicity risk and should be avoided during therapy.

● Advise female patients to inform prescriber if she is pregnant. Tell her not to take drugs near term.

● Caution female patients not to breastfeed, because she could pass drug effects to infants.

● As appropriate, review all other significant and life-threatening adverse reactions and interactions,
especially those related to the drugs, tests, herbs, and behaviors mentioned above.

4. What is the recommended follow-up care for FL?

Co-trimoxazole should be taken exactly as directed. Do not take more or less of it, or take it more
frequently than your doctor has suggested.

During the first several days of co-trimoxazole medication, patients should start to feel better. Call the
doctor if these symptoms do not improve or if they worsen. Before each usage, give the beverage a
good shake to ensure that the drug is uniformly distributed.

Even if patients feel better, keep taking co-trimoxazole until the prescription is finished. Do not s top
taking co-trimoxazole without consulting your doctor first. The illness may not be entirely healed if
patients stop taking co-trimoxazole too soon or skip doses, and the bacteria may grow resistant to
medications.
5. What other drugs might be used instead of TMP-SMZ? Would one urinary antiinfective drug
be more effective than another? Explain your answer.

Nitrofurantoin (Macrobid)

Nitrofurantoin is an antibiotic used to treat urinary tract infections (UTIs) and not much else
because it only acts in urine. Nitrofurantoin prevents bacteria from producing the DNA and proteins
that they require to live. The common dose for Nitrofurantoin is 100 mg twice a day for 5 days.

Nitrofurantoin's side effects include loss of appetite, nausea, and vomiting. Liver conditions include
jaundice (yellowing of the skin and eyes) and hepatitis are more significant possible side effects
(inflammation of the liver).

Fosfomycin

Fosfomycin is an antibiotic that can be used to treat urinary tract infections caused by bacteria that are
resistant to other antibiotics. It works by destroying germs that cause UTIs and preventing bacteria from
adhering to the urinary tract lining.

One dosage of fosfomycin, with 3 grams of fosfomycin powder mixed in water, is the most usual dose. The
most frequent side effects of fosfomycin include nausea, diarrhea, and headaches.

Bactrim, nitrofurantoin, and fosfomycin are effective, but they aren't ideal for everyone. You could, for
example, be allergic to one or more of them. Alternatively, your healthcare professional may have reasons
to recommend a different solution. There are different antibiotics to choose from in certain cases.

Cephalexin, amoxicillin, and cefdinir

Another antibiotic combination medication in the penicillin class is amoxicillin/potassium

clavulanate. Cefdinir and cephalexin are antibiotics that are related to penicillins but are not
penicillins. The cell wall, which ordinarily keeps bacteria physically intact, is destroyed by all three
medicines.

Amoxicillin/clavulanate is commonly given at a dose of 500 mg twice daily for 5 to 7 days, whilst
Cefdinir is given at a dose of 300 mg twice daily for 5 to 7 days, and Cephalexin is given at a dose
of 250 mg to 500 mg every 6 hours for 7 days.

These antibiotics are known to cause diarrhea, nausea, vomiting, and rash. All three have the
potential to produce the serious skin responses SJS and TEN in rare circumstances.
Your healthcare practitioner will not prescribe amoxicillin/clavulanate if you have a penicillin
allergy. They may or may not give cefdinir or cephalexin since there is a tiny (5%) risk that a
person allergic to penicillin will also be allergic to these two antibiotics.

Ciprofloxacin or levofloxacin

Antibiotics like ciprofloxacin and levofloxacin prevent bacteria from replicating their DNA and
reproducing. These antibiotics are somewhat more effective than amoxicillin/potassium
clavulanate, cefdinir, and cephalexin, but they come with a higher risk of major adverse effects.
For small UTIs, most healthcare practitioners will avoid prescribing these antibiotics.

Ciprofloxacin is usually taken twice a day for three days whereas Levofloxacin is taken once a day for
three days both at a dose of 250 mg.

Ciprofloxacin and levofloxacin can have major, debilitating side effects such as tendon rupture and
lengthy nervous system effects. Rashes, diarrhea, nausea, vomiting, and irritability are the most
prevalent adverse effects.

Reference:

Mehnert-Kay, S. A. (2005, August 1). Diagnosis and management of uncomplicated urinary

tract infections. American Family Physician. Retrieved December 4, 2021, from
https://www.aafp.org/afp/2005/0801/p451.html.

WebMD. (n.d.). Sulfamethoxazole-trimethoprim oral: Uses, side effects, interactions,

pictures, warnings & dosing. WebMD. Retrieved December 4, 2021, from
https://www.webmd.com/drugs/2/drug-3409-1071/sulfamethoxazole-trimethoprim-oral/
sulfamethoxazole-trimethoprim-suspension-oral/details.