Sulfonamides have a glorious history. In 1935, they were the first class of true
antimicrobial agents with life-saving potency. Today, 66 years later, increased bacterial resistance to
sulfonamides and to
trimethoprim (
TMP), a synthetic
antimicrobial agent that is 30 years younger than
sulfonamides, has limited their use to only a few indications. In the treatment and prophylaxis of patients with
urinary tract infections,
trimethoprim-sulfamethoxazole (
TMP-SMZ) or
TMP alone is still considered the first-line
drug of choice, although increased bacterial resistance to these agents has been linked with treatment failure.
TMP-SMZ has a possible role as a second- or third-line treatment for patients who have
respiratory tract infections. In the developing world, where this inexpensive
drug is widely used as first-line treatment, bacterial resistance has caused problems, especially with regard to the treatment of patients with severe
respiratory tract infections. Use of
TMP-SMZ as prophylaxis for
Pneumocystis carinii infection has rapidly increased the multidrug resistance of bacterial pathogens found in human immunodeficiency virus-infected patients. Today, detailed and reliable knowledge on the resistance of bacterial pathogens to both
TMP-SMZ and
TMP is an essential requirement for the safe and effective use of these drugs in all clinical settings.