Choudhari OK, et al., Journal of Ideas in Health 2020;3(Special 1):196-197 © The Author(s). 2020 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e ISSN: 2645-9248 Journal homepage: www.jidhealth.com Open Access Cotrimoxazole as adjuvant therapy in critical ill COVID-19 patients Omkar Kalidasrao Choudhari1*, Sonam Spalgis2, Umesh Chandra Ojha3 Dear Editor, The ongoing pandemic of COVID-19 has forced us to consider using available drugs in the shortfall of vaccines and established treatment. Cotrimoxazole is one of the oldest drugs presently used in the prevention and treatment of opportunistic infections in the human immune deficiency virus (HIV) etc. It is a combination of two drugs Trimethoprim and Sulfamethoxazole. Cotrimoxazole is a potent broad-spectrum antibiotic with antifungal, antiprotozoal, activity. The rationale behind the use of Cotrimoxazole is its anti-inflammatory and immunomodulatory action. The mortality among the COVID- 19 patients is mainly due to the acute respiratory distress syndrome or pulmonary embolism and respiratory failure mediated by cytokine storm due to unopposed multiplication of cascade of inflammatory mediators [1]. The immunomodulatory and anti-inflammatory activity of the Cotrimoxazole is seen in many studies [2.3]. The ARROW trial showed lower concentrations of plasma pro-inflammatory markers like C reactive protein (CRP), Interleukin 6 in continuous Cotrimoxazole prophylaxis, suggesting its role as anti- inflammatory and immunomodulation [3]. The role of Interleukin 6 (IL6) and Tumour necrosis factor-alpha (TNF α) in the pathogenesis of COVID-19 mortality is well documented [4]. The role of Cotrimoxazole in the suppression of TNF α is also well documented [5]. Lymphopenia is associated with adverse outcomes in COVID-19. Cotrimoxazole has shown an increase in lymphocyte count in a short and long therapy duration, but these study findings are not consistent with few other studies; however, no significant impact of Cotrimoxazole was seen on immune activation of CD8 T cells [6-8]. Hence it should be reserved only for critically ill patients. Oxidative stress has an important aspect of the cytokine storm, which is also reduced by Cotrimoxazole [9]. Various side effects are mentioned in the literature. This cost-effective old drug is well tolerated among the population with the concomitant use of folic acid; moreover, it also looks after the secondary infections [7]. To conclude, Cotrimoxazole can be used as critically ill COVID-19 patients. Abbreviations COVID-19: Coronavirus Disease-19; HIV: Human Immune Deficiency Virus; CRP: C Reactive Protein; TNF: Tumour Necrosis Factor; TNF α: Tumour Necrosis Factor-Alpha; IL6: Interleukin 6 Declarations Acknowledgment None Funding The author received no financial support for the research, authorship, and/or publication of this article. Availability of data and materials Data will be available by emailing omkarchoudhari@yahoo.com Authors’ contributions Omkar Kalidasrao Choudhari (OKC) is the principal investigator of this manuscript (Letter). OKC, SS and UCO are equally participated in the the study concept, design, writing, reviewing, editing, and approving the manuscript in its final form. All authors read and approved the final manuscript. Ethics approval and consent to participate I conducted the research following the Declaration of Helsinki; however, Letter Article needs no ethics committee approval. Consent for publication Not applicable Competing interest The author declare that he has no competing interests. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. Author Details 1Post graduate Resident, Department of Clinical Biochemistry Vardhman Mahavir Medical College (VMMC) & Safdarjung Hospital New Delhi. 2Department of Respiratory Medicine, Vallabhbhai Patel ___________________________________________________ omkarchoudhari@yahoo.com 1Post graduate Resident, Department of Clinical Biochemistry Vardhman Mahavir Medical College (VMMC) & Safdarjung Hospital New Delhi Keywords: Cotrimoxazole, pandemic, COVID 19 http://www.jidhealth.com/ Choudhari OK, et al., Journal of Ideas in Health 2020;3(Special1):196-197 197 Chest Institute, New Delhi. 3Institute of Occupational Health and Environmental Research, Basaidarapur, New Delhi & Department of Respiratory Medicine, ESIC PGIMSR, New Delhi. Article Info Received: 13 August 2020 Accepted: 27 August 2020 Published: 25 September 2020 References 1. Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. 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