What is the treatment for Stevens-Johnson Syndrome (SJS) caused by Bactrim (Trimethoprim/Sulfamethoxazole)?

Management of Stevens-Johnson Syndrome Caused by Bactrim (Trimethoprim/Sulfamethoxazole)

The immediate management of Stevens-Johnson Syndrome (SJS) caused by Bactrim requires prompt discontinuation of the culprit drug, transfer to a specialized burn center or ICU for patients with >10% body surface area involvement, and implementation of supportive care measures including wound management, fluid replacement, and monitoring for complications. 1, 2

Initial Management

1. Immediate discontinuation of Bactrim

   • This is the most critical first step to prevent further progression of the disease 2

2. Assess disease severity

   • Calculate SCORTEN within first 24 hours to assess mortality risk 1
   • Determine extent of skin involvement (SJS: <10%, SJS/TEN overlap: 10-30%, TEN: >30%) 3

3. Transfer to appropriate facility

   • Patients with >10% body surface area epidermal detachment should be transferred to a burn center or ICU 2
   • Severe cases with poor prognostic factors require specialized care 2

Wound and Skin Care

• Gently cleanse wounds using warmed sterile saline or dilute chlorhexidine (1/5000) 2
• Apply greasy emollient (50% white soft paraffin with 50% liquid paraffin) over entire epidermis 2
• Leave detached epidermis in situ as a biological dressing 2
• Decompress blisters by piercing and draining fluid 2
• Apply non-adherent dressings (Mepitel™ or Telfa™) to denuded dermis 2
• Handle skin carefully to minimize further epidermal detachment 2

Fluid and Electrolyte Management

• Establish adequate intravenous fluid replacement through non-lesional skin 2
• Monitor fluid balance carefully, with catheterization if clinically indicated 2
• Be cautious of overhydration and resultant hyponatremia 2
• Requirements are lower than those predicted by burn formulas 1

Infection Prevention and Management

• Do not administer prophylactic systemic antibiotics - only treat when clinical signs of infection are present 2
• Monitor closely for signs of sepsis, which may be masked by disease-associated fever 2
• Obtain cultures from lesional skin for bacterial culture 2
• Septicemia is a leading cause of morbidity and mortality in the acute phase 3

Mucosal Care

Ocular Care

• Perform daily ophthalmological review during acute illness 2
• Apply preservative-free lubricants every 2 hours 2
• Perform ocular hygiene daily to remove inflammatory debris 2
• Use topical antibiotics if corneal fluorescein staining or ulceration is present 2

Oral Care

• Clean mouth daily with warm saline mouthwashes 2
• Use benzydamine hydrochloride rinse every 3 hours, particularly before eating 2
• Consider topical anesthetic preparations (viscous lidocaine 2%) for severe pain 2

Urogenital Care

• Examine urogenital tract as part of initial assessment 2
• Apply white soft paraffin to urogenital skin/mucosae every 4 hours 2
• Use silicone dressings on eroded areas to reduce pain and prevent adhesions 2

Pain Management

• Administer adequate background simple analgesia following WHO analgesic ladder principles 2
• For moderate-to-severe pain, use opiate-based regimen with morphine 2
• Consider patient-controlled analgesia (PCA) if appropriate 2
• Monitor level of consciousness, respiratory rate, and oxygen saturation when using opiate infusions 2

Systemic Therapy Options

While supportive care is the mainstay of treatment, several systemic therapies may be considered:

1. Systemic Corticosteroids

   • IV methylprednisolone 0.5-1 mg/kg for moderate cases, 1-2 mg/kg for severe cases 2
   • Convert to oral corticosteroids on response, and wean over at least 4 weeks 2
   • Note: Use with caution as they may increase risk of infection 2

2. Cyclosporine

   • 3-5 mg/kg/day for 10-14 days 4
   • May be used alone or in combination with corticosteroids 4

3. Intravenous Immunoglobulin (IVIG)

   • May be considered in severe or steroid-unresponsive cases 2
   • Evidence for efficacy is mixed 1
   • If used, high-dose regimens (total dose of 3-4 g/kg) appear more effective than low-dose regimens 1

Preventative Measures

• Administer low molecular weight heparin as prophylactic anticoagulation for immobile patients 2
• Consider proton pump inhibitor for patients in whom enteral nutrition cannot be established 2
• Maintain ambient temperature between 25°C and 28°C 2
• Use pressure-relieving mattress to prevent pressure sores 2

Follow-up Care

• Provide written information about drugs to avoid in the future 2
• Encourage wearing a MedicAlert bracelet 2
• Document drug allergy clearly in patient records 2
• Report the episode to pharmacovigilance authorities 2
• Arrange dermatology and ophthalmology follow-up within weeks of discharge 2

Monitoring for Complications

• Respiratory: Monitor for respiratory symptoms and hypoxemia which may indicate pulmonary involvement 1
• Ocular: Long-term sequelae include dry eyes, symblepharon, and visual impairment 3
• Cutaneous: Scarring, pigmentation changes, and nail dystrophy 3
• Urogenital: Strictures and adhesions may develop 3

SJS/TEN caused by Bactrim is a medical emergency with significant mortality risk. Early recognition, prompt discontinuation of the culprit drug, and rapid implementation of appropriate supportive care measures are essential to improve outcomes and reduce mortality.