title: Does trimethoprim-sulfamethoxazole prophylaxis for HIV induce bacterial resistance to other antibiotic classes? Results of a systematic review.
abstract: 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Zimbabwe AIDS Prevention Project, Department of Community Medicine, College of Health Sciences, University of Zimbabwe, Zimbabwe.
authors.forename: Euphemia L
authors.initials: EL
authors.lastname: Sibanda
authors.forename: Ian V D
authors.initials: IV
authors.lastname: Weller
authors.forename: James G
authors.initials: JG
authors.lastname: Hakim
authors.forename: Frances M
authors.initials: FM
authors.lastname: Cowan
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000401:mortality / Q000517:prevention & control*; D000328:Adult; D000900:Anti-Bacterial Agents / Q000494:pharmacology* / Q000627:therapeutic use; D019072:Antibiotic Prophylaxis; D001419:Bacteria / Q000187:drug effects; D001424:Bacterial Infections / Q000401:mortality / Q000517:prevention & control*; D016022:Case-Control Studies; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D024881:Drug Resistance, Bacterial; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000401:mortality; D006801:Humans; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000494:pharmacology / Q000627:therapeutic use*
chemical_list: D000900:Anti-Bacterial Agents; D015662:Trimethoprim, Sulfamethoxazole Drug Combination