Question

Is it safe to use cotrimoxazole in pregnancy?

18 September 2012. Related: All topics, Opportunistic infections, Pregnancy.

I am HIV-positive and pregnant. I have just started on ARVs but also on co-trimoxazole. Is it safe to use cotrimoxazole in pregnancy?

Answer

Answer: Polly Clayden

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.

http://www.who.int/hiv/pub/prev_care/OMS_EPP_AFF_en.pdf