Sulfamethoxazole-Trimethoprim-Polymyxin Therapy of Serious Multiply Drug-Resistant Serratia Infections

Nonpigmented multiply drug-resistant Serratia marcescens caused an extensive outbreak of infection at the Nashville Veterans Administration Hospital. Isolates were of one serotype resistant to all currently available antimicrobial agents for therapy of systemic infections except for occasional susceptibility to chloramphenicol and kanamycin. Frequently strains were susceptible to nalidixic acid, and all were susceptible to amikacin (BB-K8). Drug-resistant strains caused 130 infections, 12 bacteremias, and 7 infection-associated deaths. Combinations of antimicrobial agents were evaluated for synergism against Serratia strains from infected patients. "Checkerboard" isobolograms indicated in vitro static synergism between sulfamethoxazole, trimethoprim, and polymyxin (STP). Killing curves using clinically achievable concentrations of STP verified the bactericidal effect of STP against these strains. In a daily dosage of 1,600 mg of sulfamethoxazole and 320 mg of trimethoprim orally in combination with 100 to 300 mg of colistimethate parenterally, serum cidal levels at 1:8 or greater were achieved in five of six patients. Clinical improvement or microbiological cure was effected in four of six patients. STP may be potentially useful for selected Serratia infections for which single agents are unavailable or ineffective.