Does trimethoprim-sulfamethoxazole prophylaxis for HIV induce bacterial resistance to other antibiotic classes? Results of a systematic review

Clin Infect Dis. 2011 May;52(9):1184-94. doi: 10.1093/cid/cir067.


Background: Trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis has long been recommended for immunosuppressed HIV-infected adults and children born to HIV-infected women. Despite this, many resource-limited countries have not implemented this recommendation, partly because of fear of widespread antimicrobial resistance not only to TMP-SMX, but also to other antibiotics. We aimed to determine whether TMP-SMX prophylaxis in HIV-infected and/or exposed individuals increases bacterial resistance to antibiotics other than TMP-SMX.

Methods: A literature search was conducted in Medline, Global Health, Embase, Web of Science, ELDIS, and ID21.

Results: A total of 501 studies were identified, and 17 met the inclusion criteria. Only 8 studies were of high quality, of which only 2 had been specifically designed to answer this question. Studies were classified as (1) studies in which all participants were infected and/or colonized and in which rates of bacterial resistance were compared between those taking or not taking TMP-SMX and (2) studies comparing those who had a resistant infection with those who were not infected. Type 1 studies showed weak evidence that TMP-SMX protects against resistance. Type 2 studies provided more convincing evidence that TMP-SMX protects against infection.

Conclusion: There was some evidence that TMP-SMX prophylaxis protects against resistance to other antibiotics. However, more carefully designed studies are needed to answer the question conclusively.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • AIDS-Related Opportunistic Infections / mortality
  • AIDS-Related Opportunistic Infections / prevention & control*
  • Adult
  • Anti-Bacterial Agents / pharmacology*
  • Anti-Bacterial Agents / therapeutic use
  • Antibiotic Prophylaxis*
  • Bacteria / drug effects
  • Bacterial Infections / mortality
  • Bacterial Infections / prevention & control*
  • Case-Control Studies
  • Child
  • Child, Preschool
  • Cohort Studies
  • Cross-Sectional Studies
  • Drug Resistance, Bacterial*
  • Female
  • HIV Infections / complications*
  • HIV Infections / mortality
  • Humans
  • Trimethoprim, Sulfamethoxazole Drug Combination / pharmacology
  • Trimethoprim, Sulfamethoxazole Drug Combination / therapeutic use*


  • Anti-Bacterial Agents
  • Trimethoprim, Sulfamethoxazole Drug Combination