The determination of antibiotic levels in body fluids is of great importance in the field of personalized medicine and therapeutic drug monitoring. We report on the determination of sulfamethoxazole (SMX), an antibacterial drug of the sulfanilamide class, in spiked human urine. The protocol is based on the combination of surface-enhanced Raman spectroscopy (SERS) and liquid-liquid extraction (LLE-SERS analysis). First, the urine was diluted to reduce its buffer properties and the influence of the intrinsic urine components on the background SERS signal. Second, the acidification of the diluted urine and SMX extracts was performed to facilitate SMX extraction by chloroform and suppress the background signal, respectively. Finally, the SMX determination process was performed using hydroxylamine-stabilized silver nanoparticles as the SERS substrate. The efficiency and reliability of the LLE-SERS analysis were studied using spiked urine samples obtained from healthy volunteers with an SMX content within the therapeutically relevant concentration range (10e200 mg mL_1). Additionally, the verification of the analysis protocol was done using spiked urine samples obtained from oncology patients. The results of the verification demonstrate the applicability of the analysis for quantitative therapeutic drug monitoring due to the (i) strong suppression of the background SERS signal, which occurs as the result of LLE, dilution, and pH adjusting, (ii) satisfactory limit of detection of 1.7 mgmL_1, and (iii) simple, relatively fast (~30 min), and cost-effective sample pretreatment.