Objectives: Increasing antimicrobial resistance has renewed interest in older, less used antimicrobials. Cotrimoxazole shows promise; however, hyperkalaemia and acute kidney injury (AKI) are potential complications. Identifying risk factors for and quantification of these events is required for safe use. This study aimed to evaluate predictors of cotrimoxazole-associated AKI and hyperkalaemia in a clinical setting. Methods: Patients prescribed cotrimoxazole were identified using electronic healthcare records over 3 years (1 April 2016 to 31 March 2019. Individual risk factors were recognized. Serum creatinine and potassium trends were analysed over the subsequent 21 days. AKI and patients with hyperkalaemia were classified using Kidney Disease Improving Global Outcomes (KDIGO) and laboratory criteria. Univariate and multiple logistic regression analyses were performed. Results: Among 214 patients prescribed cotrimoxazole, 42 (19.6%, 95% confidence interval (CI) 14.6e25.7) met AKI criteria and 33 (15.4%, 95% CI 11.0e21.1) developed hyperkalaemia. Low baseline estimated glomerular filtration rate (<60 mL/min/1.73 m 2 , odds ratio (OR) 7.78, 95% CI 3.57e16.13, p < 0.0001) and cardiac disorders (OR 2.40, 95% CI 1.17e4.82, p 0.011) predicted AKI, while low baseline estimated glomerular filtration rate (<60 mL/min/1.73 m 2 , OR 6.80, 95% CI 3.09e15.06, p < 0.0001) and higher baseline serum potassium (p 0.001) predicted hyperkalaemia. Low-dose cotrimoxazole (<1920 mg/d) was associated with lower AKI and hyperkalaemia risk (p 0.007 and 0.019 respectively). Early (within the first 2e4 days of therapy) serum creatinine changes predicted AKI (OR 3.65, 95% CI 1.73e7.41, p 0.001), and early serum potassium changes predicted hyperkalaemia (>0.6 mmol/L, OR 2.47, 95% CI 1.14e5.27, p 0.0236). Conclusions: Cotrimoxazole-associated AKI and hyperkalaemia is frequent and dose dependent. Renal function, serum potassium and preexisting cardiac disorders should be evaluated before prescribing cotrimoxazole. Serum creatinine and potassium monitoring within first 2 to 4 days of treatment to identify susceptible patients is recommended, and the lowest effective dose ought to be prescribed.

The ongoing COVID‐19 pandemic has severely disrupted both healthcare and clinical teaching across the world. Although lockdown restrictions are now easing in many places, allowing medical students to return to their clinical teaching posts, there is still anxiety towards learning in such an unusual setting. As a final year medical student, I became intrigued when reading Sewell et al’s article on identifying cognitive overload among learners[1] and wondered how these results can be translated to help students during the COVID‐19 pandemic.

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Background: Increasing antimicrobial resistance has renewed interest in older, infrequently used antimicrobials. Cotrimoxazole shows future promise; however, acute kidney injury (AKI) and hyperkalaemia are potential complications. Recognising risk factors for cotrimoxazole-associated AKI and hyperkalaemia, and quantifying the impact, are required for safe use against future antimicrobial resistance. Method: A single-centre retrospective observational study using electronic-healthcare records of patients prescribed cotrimoxazole was conducted. Patient risk factors were identified, and serum creatinine and potassium levels were analysed over the subsequent 21-days from prescription. Univariate and multiple logistic regression analyses were performed. The project was registered locally with the clinical governance team as service evaluation [Ref: CSS033]. Results: Of 214 patients, 42 (20%) developed AKI and 33 (15.4%) developed hyperkalaemia. Low baseline eGFR (<60mls/min/1,73m2, OR = 7.78, 95%CI 3.57-16.13, p<0.0001) and pre-existing cardiac disorders (OR = 2.40, 95%CI 1.17-4.82, p=0.011) significantly predicted AKI. Early serum creatinine increases within 2-4 days of therapy predicted future AKI (OR = 3.65, 95%CI 1.73-7.41, p = 0.001). A low baseline eGFR also significantly predicted future hyperkalaemia (<60mls/min/1.73m2, OR = 6.80, 95%CI 3.09-15.06, p<0.0001). Low-dose cotrimoxazole (<1920mg/day) was associated with lower AKI and hyperkalaemia risk (p = 0.007 and 0.019, respectively). Conclusions: Cotrimoxazole-associated AKI and hyperkalaemia is frequent and dose-dependant. Renal function and pre-existing cardiac disorders should be carefully evaluated before prescribing cotrimoxazole. Serum creatinine should be monitored in the first 2-4 days of treatment to identify susceptible patients, and low-doses considered if AKI or hyperkalaemia is suspected.