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Description

Background

Recent publications describe severe disease in pediatric patients with TMP-SMX associated respiratory failure progressing to extracorporeal membrane oxygenation (ECMO), lung transplantation and/or death. ECMO characteristics in this patient population remain poorly defined.

Methods

This is a retrospective observational report from our institutional referral Redcap database reviewing ECMO characteristics for pediatric patients (age ≤ 18 years old) patients. This includes presumed TMPSMX associated severe respiratory failure, following 6 or more days of TMP-SMX exposure and lack of other diagnostic explanation.

Results

To date, at our institution we have identified 32 total adult and pediatric with clinical criteria for TMP-SMX severe respiratory failure. Twenty-three were pediatric patients. Of 23 cases, 15 of 23 (65%) required ECMO and 4 (17%) required lung transplantation. In ECMO patients, 9 (60%) were female and mean age was 14 (range 1-18). Eleven of 15 (73%) ECMO patients survived. Most patients on ECMO were supported by VV (10/15; 67%), 2/15 (13%) by VA, and 3/15 (20%) were subsequently converted from VV to VA. Overall median ECMO time was 56 days (9-190). The median ECMO time in non-transplanted survivors (N = 8), transplanted survivors (N = 3), and in non-survivors (N= 4), was 46 (IQR: 31-72), 40 (range: 29-57), and 111 (IQR: 108-114) days respectively.

Discussion

This is the only known clinical description of pediatric patients with TMP-SMX respiratory failure requiring ECMO. TMP-SMX associated respiratory failure carries high mortality and substantial risk for ECMO. Suspected cases should be admitted to an ECMO center. In this small cohort, non-transplanted survivors required nearly 6 weeks of ECMO support. It could be reasonable to delay transplantation decision when possible and evaluate for lung recovery.

Publication Date

2-2026

When and Where Presented

Presented at the 42nd Annual Children's National Symposium: ECMO and the Advanced Therapies for Cardiovascular and Respiratory Failure; Keystone, Colorado; February 22-25, 2026

ECMO is Often Required in Pediatric Trimethoprim-sulfamethoxazole (TMP-SMX) Associated Severe Respiratory Failure

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