Observational study of the clinical utility of sulfamethoxazole serum level monitoring in the treatment of brain abscesses due to Nocardia species.

ABSTRACT: Although there is a lack of data in trimethoprim-sulfamethoxazole (TMP-SMX) serum monitoring utility for invasive nocardial infections, therapeutic drug monitoring is widely used to optimize dosing and avoid adverse reactions that may cause treatment interruption.We retrospectively reviewed all adults who received TMP-SMX to treat nocardial brain abscess and had SMX serum level testing from 2010 to 2020.Twenty-two patients received treatment with TMP-SMX for Nocardia species brain abscess and 16 (72.7%) had a reported SMX level, with a median patient age of 65.5 years (interquartile range, IQR 59.5-72.5). Compared to those who did not have a documented SMX serum level, patients with SMX levels had a shorter median course of TMP-SMX treatment (322 days [IQR 188-365] vs. 365 [IQR 224-365]; P = .31) and higher therapeutic induction dose (10 [62.5%] vs. 3 [50%]; P = .92). Similarly, they were more frequently on hemodialysis (3 [13.6%] vs. 1 [4.5%]; P = > .99). The median peak level was 158.5 (IQR 120-218) µg/mL, collected at 2 hours (75%) post-administration in the induction phase (81.3%). Patients with documented SMX levels had fewer reported drug toxicity (5 [31.3%] vs. 4 [66.7%]; P = .1) than those without SMX levels. Among the five patients who reported TMP-SMX-related toxicity, 4 (80%) had an SMX peak level >150 µg/mL. There was no difference in the cure, relapse, and death rates among the two groups.While SMX level was not associated with Nocardia species brain abscess cure rates and mortality, most patients with SMX peak >150 µg/mL experienced drug toxicity.

Pharmacokinetic study of seven bioactive components of Xiaoyan Lidan Formula in cholestatic and control rats using UPLC-MS/MS.

A rapid, sensitive, and reliable ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method has been developed to simultaneously determine the major bioactive components of Xiaoyan Lidan Formula (XYLDF) in rat plasma, using sulfamethoxazole as the internal standard (IS). The seven major bioactive components are andrographolide, dehydroandrographolide, enmein, 1-methoxicabony-ß-carboline, 4,5-dimethoxy-canthin-6-one, 4-methoxy-5-hydroxy-canthin-6-one, and 1-hydroxymethyl-ß-carboline. After pretreating by protein precipitation with methanol, separation was performed on a UPLC C18 column using gradient elution with a mobile phase consisting of acetonitrile and 0.1% formic acid at a flowing rate of 0.7 mL/min. Detection was performed on TSQ Quantum mass spectrometry set at the positive/negative ionization and multiple reaction monitoring (MRM) mode. The intra- and inter-day precision were less than 9.8%, whereas the intra- and inter-day accuracy were within ± 13.4%. The method was validated and applied to compare the pharmacokinetic profiles of the analytes in serum of Alpha-naphthylisothiocyanate (ANIT)-induced cholestasis and control rats after oral administration of XYLDF. The results showed remarkable differences in pharmacokinetic properties of the analytes between cholestatic (model) and control groups, thereby providing essential scientific information for better understanding of mechanism of XYLDF and a reference for its clinical applications.

Quantification of Serum Sulfamethoxazole and Trimethoprim by Ultra-fast Solid-Phase Extraction-Tandem Mass Spectrometry.

BACKGROUND: The combination of trimethoprim (TMP) and sulfamethoxazole (SMX) is used to treat a number of bacterial infections. TMP/SMX concentrations in serum are conventionally monitored using high-performance liquid chromatography (HPLC) or liquid chromatography tandem mass spectrometry. These methods require laborious manual extraction techniques and relatively long sample analysis times, necessitating the development of a simple, high-throughput method. A simple, high-throughput method to measure TMP/SMX using ultra-fast solid-phase extraction (SPE)-tandem mass spectrometry has been developed. METHODS: Calibration standards, quality control materials, and patient samples were precipitated with acetonitrile containing isotopically labeled internal standards. Samples were vortexed, centrifuged for 5 minutes at 2053g, and the resulting supernatant was diluted in aqueous mobile phase and injected onto the C18 SPE cartridge. MS/MS analysis was performed by electrospray ionization in positive ion mode at a rate of <20 seconds per sample. A 5-point linear 1/x calibration curve was used to calculate sample concentrations. RESULTS: The intra-assay precision coefficients of variation were <6% and <7% for SMX and TMP, respectively, and <10% for both interassay precision coefficients of variation. Comparison studies using 50 patient and spiked serum samples showed r values of 0.9890 and 0.9853 and y-intercept values of -1.918 and -1.357, respectively compared with the HPLC reference method. All data points were <±15% of the mean. Linearity [r = 0.9952 (SMX) and 0.9954 (TMP)] was established from 12 to 400 mcg/mL with a detection limit of 0.47 mcg/mL, and 1.2-40 mcg/mL with a detection limit of 0.06 mcg/mL, for SMX and TMP, respectively. For either drug, no significant carryover was observed after samples at the upper limit of quantification. No interference was observed from any of the 77 drugs and respective metabolites tested. CONCLUSIONS: A high-throughput SPE-tandem mass spectrometry method for TMP/SMX quantification was developed. The <20 seconds analysis time is a significant improvement compared with traditional HPLC and liquid chromatography tandem mass spectrometry methods, without sacrificing analytical performance.

Sulfamethoxazole Levels in HIV-Exposed Uninfected Ugandan Children.

Trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis in HIV-uninfected, exposed (HUE) children variably reduces clinical malaria burden despite antifolate resistance, but data regarding achieved serum levels and adherence are lacking. Serum samples from 70 HUE children aged 3-12 months from Rakai, Uganda, enrolled in an observational study were assayed for random SMX levels using a colorimetric assay. Adherence with TMP-SMX prophylaxis data (yes/no) was also collected. Of 148 visits with concurrent SMX levels available, 56% had self-reported adherence with TMP-SMX therapy. Among these 82 visits, mean (standard deviation) level was 19.78 (19.22) µg/mL, but 33% had SMX levels below half maximal inhibitory concentrations (IC50) for Plasmodium falciparum with some, but not all, of the reported antifolate resistance mutations reported in Uganda. With TMP-SMX prophylaxis, suboptimal adherence is concerning. Sulfamethoxazole levels below IC50s required to overcome malaria parasites with multiple antifolate resistance mutations may be significant. Further study of TMP-SMX in this context is needed.

Pharmacokinetics of mefloquine and its effect on sulfamethoxazole and trimethoprim steady-state blood levels in intermittent preventive treatment (IPTp) of pregnant HIV-infected women in Kenya.

BACKGROUND: Intermittent preventive treatment in pregnancy with sulfadoxine/pyrimethamine is contra-indicated in HIV-positive pregnant women receiving sulfamethoxazole/trimethoprim prophylaxis. Since mefloquine is being considered as a replacement for sulfadoxine/pyrimethamine in this vulnerable population, an investigation on the pharmacokinetic interactions of mefloquine, sulfamethoxazole and trimethoprim in pregnant, HIV-infected women was performed. METHODS: A double-blinded, placebo-controlled study was conducted with 124 HIV-infected, pregnant women on a standard regimen of sulfamethoxazole/trimethoprim prophylaxis. Seventy-two subjects received three doses of mefloquine (15 mg/kg) at monthly intervals. Dried blood spots were collected from both placebo and mefloquine arms four to 672 h post-administration and on day 7 following a second monthly dose of mefloquine. A novel high-performance liquid chromatographic method was developed to simultaneously measure mefloquine, sulfamethoxazole and trimethoprim from each blood spot. Non-compartmental methods using a naïve-pooled data approach were used to determine mefloquine pharmacokinetic parameters. RESULTS: Sulfamethoxazole/trimethoprim prophylaxis did not noticeably influence mefloquine pharmacokinetics relative to reported values. The mefloquine half-life, observed clearance (CL/f), and area-under-the-curve (AUC0→∞) were 12.0 days, 0.035 l/h/kg and 431 µg-h/ml, respectively. Although trimethoprim steady-state levels were not significantly different between arms, sulfamethoxazole levels showed a significant 53% decrease after mefloquine administration relative to the placebo group and returning to pre-dose levels at 28 days. CONCLUSIONS: Although a transient decrease in sulfamethoxazole levels was observed, there was no change in hospital admissions due to secondary bacterial infections, implying that mefloquine may have provided antimicrobial protection.

Method validation and determinations of levofloxacin, metronidazole and sulfamethoxazole in an aqueous pharmaceutical, urine and blood plasma samples using quantitative nuclear magnetic resonance spectrometry.

Selective, rapid and accurate quantitative proton nuclear magnetic resonance (qHNMR) method for the determination of levofloxacin, metronidazole benzoate and sulfamethoxazole in aqueous solutions was developed and validated. The method was successfully applied to the determinations of the drugs and their admixtures in pharmaceutical, urine and plasma samples. Maleic acid and sodium malate were used as internal standards. Effect of temperature on spectral measurements was evaluated. Linear dynamic ranges of 0.50-68.00, 0.13-11.30 and 0.24-21.00 mg per 0.60 mL solution were obtained for levofloxacin, metronidazole benzoate and sulfamethoxazole, respectively. Average recovery % in the range of 96.00-104.20 ± (0.17-2.91) was obtained for drugs in pure, pharmaceutical, plasma and urine samples. Inter and intra-day analyses gave average recoveries % in the ranges 96.10-98.40 ± (1.68-2.81) and 96.00-104.20 ± (0.17-2.91), respectively. Instrumental detection limits ≤0.03 mg per 0.6 mL were obtained for the three drugs. Developed method has demonstrated high performance characteristics for analyzing investigated drugs and their admixtures. Student t-test at 95% confidence level revealed insignificant bias between the real and measured contents of investigated drugs in pure, pharmaceutical, urine and plasma samples and its admixtures. Application of the statistical F-test revealed insignificant differences in precisions between the developed method and arbitrary selected reference methods.

[Pharmacokinetics of sulfamethoxazole in healthy Han volunteers living at plain and in native Han and Tibetan healthy volunteers living at high altitude].

The paper is to report the pharmacokinetics of sulfamethoxazole in healthy Han volunteers living at plain (PH) and native Han and Tibetan healthy volunteers living at high altitude (HNH and HNT). After healthy volunteers were administrated orally cotrimoxazole tablets, plasma concentration of sulfamethoxazole and metabolite N4-acetylsulfamethoxazole was determined by RP-HPLC, and plasma concentration-time data were analyzed by DAS 2.0 software to get the related pharmacokinetic parameters. The main pharmacokinetic parameters t(1/2) of sulfamethoxazole in PH, HNH and HNT were, respectively, 9.30 +/- 1.11, 10.99 +/- 1.23 and 10.44 +/- 1.05 h; tmax were 1.4 +/- 0.3, 2.0 +/- 1.1 and 1.8 +/- 0.4 h; Cmax were 94.42 +/- 15.26, 89.33 +/- 7.67 and 87.43 +/- 11.61 micro x mL(-1); AUC(0-t) were 1202.5 +/- 238.3, 1 434.7 +/- 193.9 and 1302.8 +/- 103.0 microg x h x mL(-1); AUC(0-infinity) were 1240.7 +/- 255.3, 1511.5 +/- 211.9 and 1363.9 +/- 116.5 microg x h x mL(-1); CL were 1.01 +/- 0.22, 0.81 +/- 0.12 and 0.89 +/- 0.08 L x h(-1) x kg(-1); V were 13.27 +/- 1.73, 12.81 +/- 2.15 and 13.28 +/- 1.20 L x kg(-1). Sulfamethoxazole pharmacokinetic parameters of HNH and HNT were significantly different from that of PH. The t(1/2) was significantly higher and the CL was significantly lower in HNH and HNT than that in PH, and the AUC(0-infinity) was significantly lower in HNT compared with HNH. This study found significant changes in the disposition of sulfamethoxazole under the special environment of high altitude hypoxia. This finding may provide some references for clinical rational application of sulfamethoxazole in HNH and HNT.

A novel analysis method for diterpenoids in rat plasma by liquid chromatography-electrospray ionization mass spectrometry.

A sensitive, specific, and rapid liquid chromatography-mass spectrometry (LC-MS) method was developed and validated for analysis of lasiodonin, oridonin, ponicidin, and rabdoternin A in rat plasma using sulfamethoxazole as an internal standard (IS). The plasma samples were pretreated and extracted by liquid-liquid extraction. Chromatographic separation was performed on a C(18) column with linear gradient elution using water and methanol, both of which were acidified with 0.1% aqueous formic acid, at a flow rate of 0.8 ml/min. Detection was accomplished by scanning with multiple reaction monitoring (MRM) via an electrospray ionization (ESI) source. Higher sensitivity was achieved by setting three scanning periods in a novel detection mode. The optimized mass transition ion pairs (m/z) for quantitation were 365.3/347.3 for lasiodonin and oridonin, 361.2/343.2 for ponicidin, 363.2/283.1 for rabdoternin A, and 254.1/156.0 for IS. The total run time was 13.50 min between injections. The specificity, linearity, accuracy, precision, recovery, matrix effect, and several stabilities were validated for all analytes in the rat plasma samples. In conclusion, the validation results demonstrate that this method is robust and specific. The proposed method was further applied to investigate the pharmacokinetics of all analytes after a single oral administration of Isodon rubescens extract to rats.

Good outcome with trimethoprim 10 mg/kg/day-sulfamethoxazole 50 mg/kg/day for Pneumocystis jirovecii pneumonia in HIV infected patients.

Pneumocystis jirovecii pneumonia (PCP) in human immunodeficiency virus (HIV)-infected patients is usually treated with trimethoprim (TMP)-sulfamethoxazole (SMX) 1920 mg 3 times daily (approximately equivalent to TMP 15 mg/kg/day-SMX 75 mg/kg/day) for 21 days. Pharmacokinetic data suggest that lower doses would be equally efficacious and might be associated with a lower incidence of adverse effects. We conducted a retrospective review of case notes for the first episode of laboratory-confirmed PCP in HIV-infected patients treated at Auckland City Hospital, from January 1991 through December 2007. Seventy-three of 84 (87%) patients were treated with TMP-SMX 960 mg 4 times daily or 3 times daily (approximately TMP 10 mg/kg/day-SMX 50 mg/kg/day). The overall mortality was 5/73 (7%). The mortality in patients with severe disease (transcutaneous oxygen saturation on admission < or =84%) was 3/16 (19%) and in patients admitted to the intensive care unit was 5/9 (56%). Fifteen of 73 (21%) patients required a change to an alternative treatment regimen because of adverse effects (rash in 10, rash plus fever in 3, neutropenia in 1, fever plus headache in 1). Treatment of PCP in adult HIV-infected patients with TMP-SMX 960 mg QID or TID appears to have comparable efficacy to treatment with higher doses and to be associated with a lower rate of treatment limiting adverse effects.

Straightforward and rapid determination of sulfadoxine and sulfamethoxazole in capillary blood on sampling paper with liquid chromatography and UV detection.

A method for the determination of sulfadoxine and sulfamethoxazole in capillary blood on sampling paper has been developed and validated. The method is straightforward with minimal sample preparation, and is suitable for rural settings. Separation of sulfadoxine, sulfamethoxazole and internal standard was performed using a Purospher STAR RP-18 endcapped LC column (150x4.6mm) with a mobile phase consisting of acetonitrile:sodium acetate buffer pH 5.2, I=0.1 (1:2, v/v). For sulfadoxine, the within-day precision was 5.3% at 15micromol/l and 3.7% at 600micromol/l, while for sulfamethoxazole it was 5.7% at 15micromol/l and 3.8% at 600micromol/l. The lower limit of quantification was determined to 5micromol/l and precision was 5.5% and 5.0% for sulfadoxine and sulfamethoxazole, respectively.

Comparison of the pharmacokinetics of sulfamethoxazole in male chinese volunteers at low altitude and acute exposure to high altitude versus subjects living chronically at high altitude: an open-label, controlled, prospective study.

BACKGROUND: Sulfamethoxazole is an antibacterial sulfonamide used primarily for the treatment of a wide variety of bacterial infections in combination with trimethoprim. Despite being used as prophylactic treatment for respiratory infections associated with high altitude, little information is available on the pharmacokinetic properties of sulfamethoxazole in subjects living at high altitude, especially in a Chinese population. OBJECTIVE: This study was conducted to investigate the pharmacokinetics of sulfamethoxazole in healthy Chinese subjects after acute and chronic exposure to high altitude. METHODS: An open-label, controlled, prospective study was conducted in healthy Chinese male volunteers. Sulfamethoxazole 1200 mg was administered orally to volunteers in 3 groups: those residing at low altitude (approximately 400 m [approximately 1300 ft]); these same volunteers after 16 hours (acute) of exposure to high altitude (approximately 3780 m [approximately 12,400 ft]); and a separate group of volunteers who had been living at high altitude (approximately 3780 m) for >or=1 year (chronic). The phases of the low-altitude and acute-exposure groups were separated by a 1-week washout period. Blood samples were collected from an indwelling venous catheter into heparinized tubes before (baseline) study drug administration and at 0.25, 0.5, 0.75, 1, 1.5, 2, 3, 4, 6, 8, 12, 24, 36, and 48 hours after study drug administration. Sulfamethoxazole in whole blood, plasma, and plasma water, and its metabolite, N(4)-acetyl-sulfamethoxazole, in plasma were determined by HPLC. Tolerability was determined using blood chemistry testing, continuous 12-lead ECG, and blood pressure monitoring. RESULTS: A total of 23 healthy Chinese male volunteers living at low altitude (race, all Han Chinese; mean [SD] age, 20.4 [1.1] years [range, 19-24 years]; weight, 64.2 [5.9] kg [range, 56.0-75.0 kg]; and height, 172.1 [4.9] cm [range, 163.0-180.0 cm]) and 21 healthy Chinese male volunteers living at high altitude (race, all Han Chinese; mean [SD] age, 21.2 [1.3] years [range, 19-24 years]; weight, 62.4 [8.2] kg [range, 50.0-75.0 kg]; and height, 171.4 [5.8] cm [range, 162.0-182.0 cm]) were enrolled in the study; 20 from each group completed the study. Concentration of sulfamethoxazole in plasma water decreased significantly after exposure to high altitude; therefore, the protein binding was significantly higher in the acute- (80.4%) and chronic-exposure (72.5%) groups compared with the low-altitude group (65.7%; both, P < 0.001). The binding of sulfamethoxazole to red blood cells was 6.0%, 6.9%, and 9.3% in the low-altitude, acute-, and chronic-exposure groups, respectively. The chronic-exposure group was 55% higher than the low-altitude group (P < 0.001). The following values were recorded in the low-altitude, acute-, and chronic-exposure groups after administration of sulfamethoxazole, respectively: mean (SD) t((1/2)), 9.30 (1.11), 10.37 (0.88), and 11.15 (1.53) hours; mean residence time (MRT(0-48)), 12.06 (0.94), 13.15 (0.67), and 13.00 (1.01) hours; elimination rate constant (k(e)), 0.076 (0.010), 0.067 (0.006), and 0.063 (0.009) hours(-1); AUC(0-48), 1202.5 (238.3), 1416.3 (202.6), and 1298.5 (256.0) micro/mL/h; and clearance (CL), 1.01 (0.22), 0.83 (0.13), and 0.92 (0.22) L/kg/h. The t((1/2)) was 11.5% and 19.9% higher in the acute- and chronic-exposure groups, respectively, compared with the low-altitude group, and 7.5% higher in the chronic-exposure group than in the acute-exposure group. MRT was 9.0% and 7.8% higher in the acute- (P < 0.05) and chronic-exposure (P < 0.001) groups, respectively, than in the low-altitude group. AUC(0-48) was 17.8% higher and CL was 17.8% lower in the acute-exposure group compared with the low-altitude group (both, P < 0.05). CONCLUSION: This study found significant changes in the disposition of sulfamethoxazole in these healthy male Chinese subjects after either acute or chronic exposure to an altitude of approximately 3780 m in comparison to those residing at an altitude of approximately 400 m.

Importance of pre-analytical factors contributing to measurement uncertainty, when determining sulfadoxine and sulfamethoxazole from capillary blood dried on sampling paper.

A bioanalytical method is developed and validated for determination of sulfadoxine (SD) and sulfamethoxazole (SM) in 100 microL capillary blood dried on sampling paper (Whatman 31ET Chr). SD and SM are extracted with 2000 microL perchloric acid and the liquid phase is loaded onto ENV+ solid-phase extraction columns. SD, SM, and the internal standard are separated on a Purospher STAR RP-18 liquid chromatography column (150 x 4.6 mm) with a mobile phase consisting of acetonitrile-sodium acetate buffer pH 5.2, I = 0.1 (33:67, v/v). Analytes are detected with UV at 256 nm. Lower limit of quantitation is 5 micromol/L, where precisions are 4.2% and 3.9% for SD and SM, respectively. Three brands of sampling papers have been compared with respect to absorption properties, extraction recoveries, and variations. Punching out dried blood spots (DBS) instead of cutting spots into strips prior to extraction has been evaluated by examining precision and accuracy of SD and SM determinations. Importance of uniformity of types of sampling paper, sampling volume and biological matrix, benefit of punching out discs from DBS, and impact on absorption properties of different brands of sampling papers are discussed. Avoiding pre-analytical errors whenever possible results in concentrations determined being more accurate and precise.

Simultaneous determination and validation of antimicrobials in plasma and tissue of actinomycetoma by high-performance liquid chromatography with diode array and fluorescence detection.

A simple, precise, and reliable chromatographic method was developed for the simultaneous determination in plasma and infected tissue of five antimicrobials proposed for the treatment of actinomycotic mycetoma: amoxicillin, trimethoprim, linezolid, sulfamethoxazole and garenoxacin. Separation of the analytes was achieved on an Atlantis dC18 column (150 mm x 4.6 mm, ID 5 microm) with a mobile phase composed of acetonitrile and trifluoroacetic acid (ATF) 0.1% (v/v) using a gradient program. The detection was carried out using a diode array detector at 254 nm and in a fluorescence detector at wavelengths of excitation and emission of 292 nm and 392 nm for linezolid and sulfamethoxazole, and 292 nm and 408 nm for garenoxacin, respectively. The intraday precision was in the range of 0.7-15% of relative standard deviations (%R.S.D.) for plasma and 1-18% for tissue. Linearity range was from 2.4 to 20 microg/ml for amoxicillin, 0.3 to 20 microg/ml for trimethoprim, sulfamethoxazole and linezolid, and 0.3 to 10 microg/ml for garenoxacin. Acetonitrile was used to precipitate proteins from plasma. Recoveries in plasma ranged from 71% to 118% and in infected tissue from 78% to 122%. Limits of detection (LODs) were 1.2 and 0.5 microg/ml for amoxicillin in plasma and tissue, respectively and 0.15 and 1.2 microg/ml in plasma and tissue, respectively for the other antimicrobials. The method can be applied for individual or simultaneous determination of the antimicrobials in plasma and tissue of mouse infected with actinomycetoma.

Micellar electrokinetic chromatography method for the determination of sulfamethoxazole, trimethoprim and their main metabolites in human serum.

A complete analytical procedure, including sample clean-up and a micellar electrokinetic chromatographic method, is presented for the determination of sulfamethoxazole, trimethoprim, and their main metabolites by using 20 mmol L(-1) borate buffer (pH 9.3), 25 mmol L(-1) sodium dodecylsulfate, and 5% v/v acetonitrile as electrolyte. The separation was carried out at 30 kV and 20 degrees C in a fused silica capillary (60.2 cm x 75 microm inner diameter) fitted with a window in the capillary cartridge of 100 x 800 microm. The detector response was linear from the limit of quantification to 3 mg L(-1) for the individual components. The limits of quantification ranged from 0.13 up to 0.24 mg L(-1). The method was applied to human serum, previously spiked at different concentrations of all the analytes, and recoveries between 95% and 108% were obtained.

The effect of clarithromycin, fluconazole, and rifabutin on sulfamethoxazole hydroxylamine formation in individuals with human immunodeficiency virus infection (AACTG 283).

BACKGROUND: Sulfamethoxazole hydroxylamine formation, in combination with long-term oxidative stress, is thought to be the cause of high rates of adverse drug reactions to sulfamethoxazole in human immunodeficiency virus (HIV)-infected subjects. Therefore the goal of this study was to determine the effect of fluconazole, clarithromycin, and rifabutin on sulfamethoxazole hydroxylamine formation in individuals with HIV-1 infection. METHODS: HIV-1-infected subjects (CD4 + count >/=200 cells/mm 3 ) were enrolled in a 2-part (A and B), open-label drug interaction study (Adult AIDS Clinical Trial Group [AACTG] 283). In part A (n = 9), subjects received cotrimoxazole (1 tablet of 800 mg sulfamethoxazole/160 mg trimethoprim daily) alone for 2 weeks and then, in a randomly assigned order, cotrimoxazole plus either fluconazole (200 mg daily), rifabutin (300 mg daily), or fluconazole plus rifabutin, each for a 2-week period. Part B (n = 12) was identical to part A except that clarithromycin (500 mg twice daily) was substituted for rifabutin. RESULTS: In part A, fluconazole decreased the area under the plasma concentration-time curve (AUC), percent of dose excreted in 24-hour urine, and formation clearance (CL f ) of the hydroxylamine by 37%, 53%, and 61%, respectively (paired t test, P < .05). Rifabutin increased the AUC, percent excreted, and CL f of the hydroxylamine by 55%, 45%, and 53%, respectively ( P < .05). Fluconazole plus rifabutin decreased the AUC, percent excreted, and CL f of the hydroxylamine by 21%, 37%, and 46%, respectively ( P < .05). In part B the fluconazole data were similar to those of part A. Overall, clarithromycin had no effect on hydroxylamine production. CONCLUSIONS: If the exposure (AUC) to sulfamethoxazole hydroxylamine is predictive of sulfamethoxazole toxicity, then rifabutin will increase and clarithromycin plus fluconazole or rifabutin plus fluconazole will decrease the rates of adverse reactions to sulfamethoxazole in HIV-infected subjects.

Simultaneous determination of sulfamethoxazole and trimethoprim in human plasma by capillary zone electrophoresis.

A capillary electrophoretic method for the simultaneous determination of sulfamethoxazole and trimethoprim in plasma was developed. Sulfamethoxazole and trimethoprim extracted from human plasma with ethyl acetate were analyzed at 20 kV and 25 degrees C using 15 mm phosphate buffer (pH 6.2) as the electrolyte. The detection was by UV at 220 nm. The run time was 8.0 min and the limit of quantification was 10.00 microg/mL for sulfamethoxazole and 2.00 microg/mL for trimethoprim. The recovery was >99% for both compounds. This method enabled the detection of sulfamethoxazole and trimethoprim in plasma of patients after oral ingestion of their combined formulation. The present simple and rapid method is applicable to drug monitoring in immunocompromised patients who are taking the combined formulation of these compounds for the treatment or prophylaxis of Pneumocystis carinii pneumonia.

[A case of Nocardia farcinica pneumonia treated with sulfamethoxazole-trimethoprim monitoring its serum concentration].

A 75-year-old male suffered from interstitial pneumonia in December 2000 and treated with predonisolone. The treatment was effective, and the dosage of predonisolone had been gradually tapered. In January 2001, when the dosage was 30 mg/day, he complained of cough and yellowish sputum. The chest X-ray and CT revealed bilateral infiltrations with cavities. He was treated with cefozopram and fluconazole. However, there were no improvements. The sputa of the 2nd, 3rd, 6th and 8th hospital days showed the presence of gram-positive branched rods, which were identified as Nocardia farcinica. Therefore, the treatment was changed to sulfamethoxazole-trimethoprim. During the treatment, serum concentration of sulfamethoxazole was repeatedly measured, and kept over 60 microgram/ml. He was swiftly recovered after the start of sulfamethoxazole-trimethoprim. This case was supposed to be the seventh one of N. farcinica pneumonia in Japan, and the measurement of the concentration of sulfamethoxazole was useful to determine its dosage.

Circadian changes in pharmacokinetics of sulfamethoxazole administered orally to rabbits.

Circadian variations of sulfamethoxazole pharmacokinetics were studied after a single oral administration of sulfamethoxazole, 50 mg/kg, to rabbits at 09:00 (a.m.) and 22:00 (p.m.). The profiles of plasma sulfamethoxazole concentration showed from 6 h to 24 h significant statistical difference (p<0.05) between 09:00 and 22:00. The half-life (t(1/2)) was significantly shorter in the morning (11.2 +/- 3.2 h) when compared to the nighttime (15.4 +/- 3.5 h) (p< 0.05). The AUC was significantly decreased in the morning (1325 +/- 264 microg/ml x h) than that in the nighttime (2059 +/- 379 microg/ml x h) (p<0.05). Total body clearance (CLt) was significantly higher when sulfamethoxazole was given in the morning (6.65 +/- 0.23 ml/min) versus in the nighttime (4.28 +/- 0.20 ml/min) (p<0.05).