What is the appropriate Septrin (co‑trimoxazole) dose for an adult with an uncomplicated lower urinary‑tract infection and an estimated glomerular filtration rate of 75 mL/min/1.73 m²?

Septrin Dose for Uncomplicated Lower Urinary Tract Infection

For an adult with uncomplicated lower UTI and eGFR 75 mL/min/1.73 m², prescribe Septrin (co-trimoxazole) 160/800 mg (one double-strength tablet) orally twice daily for 3 days, provided local E. coli resistance is < 20% and the patient has not received this agent in the preceding 3 months. 1, 2

Dosing Regimen

• Women: One double-strength tablet (160 mg trimethoprim/800 mg sulfamethoxazole) twice daily for 3 days achieves 90–100% clinical cure when the organism is susceptible. 1, 2
• Men: The same dose (160/800 mg twice daily) but extended to 7 days is required because short-course therapy is inadequate in males. 1, 2
• No renal dose adjustment is needed at eGFR 75 mL/min/1.73 m²; dose reduction is required only when creatinine clearance falls below 30 mL/min. 3

Critical Prescribing Criteria

• Verify local resistance: Use co-trimoxazole empirically only when local E. coli resistance is < 20%; efficacy plummets to 41–54% when the organism is resistant, compared with 90–100% when susceptible. 1, 2
• Exclude recent exposure: Do not prescribe if the patient received co-trimoxazole in the prior 3–6 months, as recent use independently predicts resistance. 1, 2
• Avoid in late pregnancy: Co-trimoxazole is contraindicated in the last trimester of pregnancy. 1

When Co-Trimoxazole Is Unsuitable

• If local resistance ≥ 20% or data unavailable: Switch to nitrofurantoin 100 mg twice daily for 5 days (93% clinical cure, 88% microbiological eradication) or fosfomycin 3 g single dose (91% clinical cure). 1, 2
• If eGFR < 30 mL/min/1.73 m²: Avoid nitrofurantoin; use fosfomycin or a fluoroquinolone (culture-guided only). 2, 3
• If suspected pyelonephritis (fever > 38°C, flank pain, CVA tenderness): Extend duration to 14 days and obtain urine culture before starting therapy. 1

Indications for Urine Culture

• Do not obtain routine culture for straightforward uncomplicated cystitis in otherwise healthy women. 1, 2
• Obtain culture and susceptibility testing when:
  • Symptoms persist after completing therapy
  • Symptoms recur within 2–4 weeks
  • Fever, flank pain, or systemic signs suggest pyelonephritis
  • Atypical presentation or vaginal discharge is present
  • Patient is pregnant (All five criteria are guideline-mandated.) 1, 2

Management of Treatment Failure

• If symptoms do not resolve by day 3 or recur within 2 weeks: Obtain urine culture immediately and switch to a different antibiotic class for 7 days (not a repeat 3-day course). 1, 2
• Assume the organism is resistant to the initial agent and select an alternative (nitrofurantoin, fosfomycin, or fluoroquinolone based on culture results). 1, 2

Common Pitfalls to Avoid

• Do not use co-trimoxazole without verifying local resistance is < 20%; many regions now exceed this threshold, rendering empiric use inappropriate. 1, 2
• Do not treat asymptomatic bacteriuria in non-pregnant, non-catheterized patients; this promotes resistance without clinical benefit. 1, 2
• Do not prescribe amoxicillin or ampicillin for uncomplicated UTI; worldwide E. coli resistance exceeds 55–67%. 1, 2
• Reserve fluoroquinolones for culture-proven resistant organisms or pyelonephritis; do not use empirically for simple cystitis due to serious adverse effects (tendon rupture, C. difficile infection). 1, 2

Algorithmic Decision Points

1. Check local E. coli co-trimoxazole resistance:

   • If < 20% and no recent exposure → prescribe co-trimoxazole 160/800 mg twice daily for 3 days (women) or 7 days (men). 1, 2

2. If resistance ≥ 20% or unknown:

   • Choose nitrofurantoin 100 mg twice daily for 5 days or fosfomycin 3 g single dose. 1, 2

3. If symptoms persist or recur:

   • Obtain urine culture and switch to a different class for 7 days. 1, 2