Co-trimoxazole and sudden death in patients receiving inhibitors of renin-angiotensin system: population based study

BMJ. 2014 Oct 30;349:g6196. doi: 10.1136/bmj.g6196.


Objective: To determine whether the prescription of co-trimoxazole with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker is associated with sudden death.

Design: Population based nested case-control study.

Setting: Ontario, Canada, from 1 April 1994 to 1 January 2012.

Participants: Ontario residents aged 66 years or older treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker. Cases were those who died suddenly shortly after receiving an outpatient prescription for one of co-trimoxazole, amoxicillin, ciprofloxacin, norfloxacin, or nitrofurantoin. Each case was matched with up to four controls on age, sex, chronic kidney disease, and diabetes.

Main outcome measure: Odds ratio for the association between sudden death and exposure to each antibiotic relative to amoxicillin, after adjustment for predictors of sudden death according to a disease risk index.

Results: Of 39,879 sudden deaths, 1027 occurred within seven days of exposure to an antibiotic and were matched to 3733 controls. Relative to amoxicillin, co-trimoxazole was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76). The risk was marginally higher at 14 days (adjusted odds ratio 1.54, 1.29 to 1.84). This corresponds to approximately three sudden deaths within 14 days per 1000 co-trimoxazole prescriptions. Ciprofloxacin (a known cause of QT interval prolongation) was also associated with an increased risk of sudden death (adjusted odds ratio 1.29, 1.03 to 1.62), but no such risk was observed with nitrofurantoin or norfloxacin.

Conclusions: In older patients receiving angiotensin converting enzyme inhibitors or angiotensin receptor blockers, co-trimoxazole is associated with an increased risk of sudden death. Unrecognized severe hyperkalemia may underlie this finding. When appropriate, alternative antibiotics should be considered in such patients.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Angiotensin Receptor Antagonists / therapeutic use*
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use*
  • Anti-Infective Agents, Urinary / adverse effects*
  • Case-Control Studies
  • Death, Sudden / epidemiology*
  • Drug Interactions
  • Drug Therapy, Combination / adverse effects
  • Female
  • Humans
  • Hyperkalemia / chemically induced
  • Hyperkalemia / mortality
  • Male
  • Odds Ratio
  • Ontario / epidemiology
  • Risk Factors
  • Trimethoprim, Sulfamethoxazole Drug Combination / adverse effects*


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Anti-Infective Agents, Urinary
  • Trimethoprim, Sulfamethoxazole Drug Combination