Co-trimoxazole in Pregnancy

[Yomna88]

HIV positive female, 28 weeks pregnant was prescribed co-trimoxazole as prophylaxis against pneumocystis carnii infection. Is it safe for the female to administer this medication in the first trimester or is it safer in the second and third trimesters?

[admin-james]

Hi, thanks for your post.

Most authorities agree that prophylaxis with cotrimoxaxole is worthwhile in pregnant, HIV+ women. However, there is still some debate about when in the pregnancy the treatment should be started and whether CD4 testing is useful to this decision. The following sources explore the issue in more detail, but the short version is that there is no clear consensus about when in the pregnancy the risk is greatest.

-James Abbey, MD

1: Ford N, Shubber Z, Jao J, Abrams EJ, Frigati L, Mofenson L. Safety of cotrimoxazole in pregnancy: a systematic review and meta-analysis. J Acquir Immune Defic Syndr. 2014 Aug 15;66(5):512-21. Review. PubMed PMID: 24853309; PubMed Central PMCID: PMC4331013.

2: Forna F, McConnell M, Kitabire FN, Homsy J, Brooks JT, Mermin J, Weidle PJ. Systematic review of the safety of trimethoprim-sulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource-limited settings. AIDS Rev. 2006 Jan-Mar;8(1):24-36. Review. PubMed PMID: 16736949.

[Marimar2]

I think it is safe but being diagnosed to HIV AIDS will not give a good health to the baby. Praying for the poor little angel!

[bestellen]

Co-trimoxazole is an antibiotic used to treat and prevent many different bacterial infections. It contains two antibiotics in one pill and there are many brand names including Septrin, Septra, Bactrim, Nucotrim and Cotrim.

It also works against malaria, which is caused by a parasite and several other diseases.

Since the 1990s, in rich countries it has been given to people with HIV as prophylaxis (when a medicine is given to prevent an infection) against PCP (Pneumocystis jiroveci) and toxoplasmosis. In rich settings, people are only given co-trimoxazole prophylaxis if they have low CD4 counts. It is discontinued when their CD4 count recovers to above 200 after starting ARVs.

In many resource limited settings, co-trimoxazole prophylaxis is recommended for everyone with a CD4 count less than 350. It is also used at WHO stage 2, 3 and 4 and in people who are also diagnosed with TB, whatever their CD4 count. These recommendations are strong in settings where bacterial infections and malaria are common among HIV positive people.

Some countries have a CD4 threshold of below 200 co-trimoxazole prophylaxis, particularly if the main reason for using it is to prevent PCP (Pneumocystis jiroveci) and toxoplasmosis. Some countries provide co-trimoxazole prophylaxis for everyone with HIV, particularly where bacterial infections and malaria are very common and there is no access to CD4 testing.

Co-trimoxazole is pregnancy category C. This means that it should be used when the benefit is greater than the risk. This classification is because abnormalities were seen when rats received high doses when the drugs was first being developed. There is no strong evidence to suggest that co-trimoxazole causes serious abnormalities in humans, but it is used with caution in pregnancy in some places.

As the risk of life-threatening infections among pregnant women with low CD4 counts and weak immune systems is greater than that of abnormalities in the unborn child exposed to co-trimoxazole, recommendations for HIV positive pregnant women are the same as for any non-pregnant adult in many countries and by the WHO.

A Zambian study of over 1000 HIV positive women showed significant improvements, for both mothers and infants, when pregnant women received co-trimoxazole. This led to reductions in chorioamnionitis (bacterial infection of the membranes that surround the infant in pregnancy), prematurity and infant mortality. A Malawian study found that it is better malaria prophylaxis than the standard one in HIV positive pregnant women.

Countries have different recommendations for stopping co-trimoxazole when a person’s immune system gets better on ARVs. Most recommend stopping when your CD4 count has recovered to over 350 after taking it for at least 6 months. Others, where bacterial infections and malaria are not common, recommend stopping at 200.

New babies who have been exposed to HIV will also receive co-trimoxazole, starting at 4 to 6 weeks of age until after they are confirmed HIV negative. Co-trimoxazole is recommended for all HIV infected babies less than 12 months old.

Source: World Health Organisation (WHO). Essential prevention and care interventions for adults and adolescents living with HIV in resource poor settings. WHO, 2008.