metronidazole

(me troe ni' da zole)

Apo-Metronidazole (CAN), Flagyl, Flagyl 375, Flagyl ER, Flagyl IV, Flagyl IV
RTU, MetroCream (CAN), MetroGel, Metro I.V., Neo-Tric (CAN), NidaGel
(CAN), Noritate, Novonidazol (CAN), PMS-Metronidazole (CAN), Protostat,
Trikacide (CAN)

Pregnancy Category B

Drug classes
Antibiotic
Antibacterial
Amebicide
Antiprotozoal

Therapeutic actions
Bactericidal: Inhibits DNA synthesis in specific (obligate) anaerobes, causing cell death;
antiprotozoal-trichomonacidal, amebicidal: Biochemical mechanism of action is not
known.

Indications
• Acute infection with susceptible anaerobic bacteria
• Acute intestinal amebiasis
• Amebic liver abscess
• Trichomoniasis (acute and partners of patients with acute infection)
• Preoperative, intraoperative, postoperative prophylaxis for patients undergoing
colorectal surgery
• Topical application: Treatment of inflammatory papules, pustules, and erythema
of rosacea
• Unlabeled uses: Prophylaxis for patients undergoing gynecologic, abdominal
surgery; hepatic encephalopathy; Crohn's disease; antibiotic-associated
pseudomembranous colitis; treatment of Gardnerella vaginalis, giardiasis (use
recommended by the CDC)

Contraindications and cautions

• Contraindicated with hypersensitivity to metronidazole; pregnancy (do not use for
trichomoniasis in first trimester).
• Use cautiously with CNS diseases, hepatic disease, candidiasis (moniliasis), blood
dyscrasias, lactation.

Available forms
Tablets—250, 500 mg; ER tablets—750 mg; capsules—375 mg; powder for injection—
500 mg; injection—500 mg/100 mL

Dosages
ADULTS
Oral
• Amebiasis: 750 mg/tid PO for 5–10 days. (In amebic dysentery, combine with
iodoquinol 650 mg PO tid for 20 days.)
• Antibiotic-associated pseudomembranous colitis: 1–2 g/day PO for 7–10 days.
• Gardnerella vaginalis: 500 mg bid PO for 7 days.
• Giardiasis: 250 mg tid PO for 7 days.
• Trichomoniasis: 2 g PO in 1 day (1-day treatment) or 250 mg tid PO for 7 days.
IV
• Anaerobic bacterial infection: 15 mg/kg IV infused over 1 hr; then 7.5 mg/kg
infused over 1 hr q 6 hr for 7–10 days, not to exceed 4 g/day.
• Prophylaxis: 15 mg/kg infused IV over 30–60 min and completed about 1 hr
before surgery. Then 7.5 mg/kg infused over 30–60 min at 6- to 12-hr intervals
after initial dose during the day of surgery only.
Topical (MetroGel)
• Treatment of inflammatory papules, pustules, and erythema of rosacea: Apply and
rub in a thin film twice daily, morning and evening, to entire affected areas after
washing; results should be seen within 3 wk; treatment through 9 wk has been
effective.
PEDIATRIC PATIENTS
• Anaerobic bacterial infection: Not recommended.
• Amebiasis: 35–50 mg/kg/day PO in 3 doses for 10 days.

Pharmacokinetics
Route Onset Peak
Oral Varies 1–2 hr
IV Rapid 1–2 hr
Topical Generally no systemic absorption

Metabolism: Hepatic; T1/2: 6–8 hr

Distribution: Crosses placenta; enters breast milk
Excretion: Urine and feces

IV facts
Preparation: Reconstitute by adding 4.4 mL of sterile water for injection, bacteriostatic
water for injection, 0.9% sodium chloride injection, bacteriostatic 0.9% sodium chloride
injection to the vial and mix thoroughly. Resultant volume is 5 mL with a concentration
of 100 mg/mL. Solution should be clear to pale yellow to yellow-green; do not use if
cloudy or if containing precipitates; use within 24 hr; protect from light. Add
reconstituted solution to glass or plastic container containing 0.9% sodium chloride
injection, 5% dextrose injection or lactated Ringer's; discontinue other solutions while
running metronidazole.
Infusion: Prior to administration, add 5 mEq sodium bicarbonate injection for each
500 mg used (if not using premixed bags); mix thoroughly. Do not refrigerate neutralized
solution. Do not administer solution that has not been neutralized. Infuse over 1 hr.

Adverse effects
 • CNS: Headache, dizziness, ataxia, vertigo, incoordination, insomnia, seizures,
peripheral neuropathy, fatigue
• GI: Unpleasant metallic taste, anorexia, nausea, vomiting, diarrhea, GI upset,
cramps
• GU: Dysuria, incontinence, darkening of the urine
• Local: Thrombophlebitis (IV); redness, burning, dryness, and skin irritation
(topical)
• Other: Severe, disulfiram-like interaction with alcohol, candidiasis
(superinfection)

Interactions
Drug-drug
• Decreased effectiveness with barbiturates
• Disulfiram-like reaction (flushing, tachycardia, nausea, vomiting) with alcohol
• Psychosis if taken with disulfiram
• Increased bleeding tendencies with oral anticoagulants
Drug-lab test
• Falsely low (or zero) values in AST, ALT, LDH, triglycerides, hexokinase glucose
tests

Nursing considerations
Assessment
• History: CNS or hepatic disease; candidiasis (moniliasis); blood dyscrasias;
pregnancy; lactation
• Physical: Reflexes, affect; skin lesions, color (with topical application);
abdominal exam, liver palpation; urinalysis, CBC, liver function tests

Interventions
• Avoid use unless necessary. Metronidazole is carcinogenic in some rodents.
• Administer oral doses with food.
• Apply topically (MetroGel, MetroCream) after cleansing the area. Advise patient
that cosmetics may be used over the area after application.
• Reduce dosage in hepatic disease.

Teaching points
• Take full course of drug therapy; take the drug with food if GI upset occurs.
• Do not drink alcohol (beverages or preparations containing alcohol, cough
syrups); severe reactions may occur.
• Your urine may appear dark; this is expected.
• Refrain from sexual intercourse unless partner wears a condom during treatment
for trichomoniasis.
• Apply the topical preparation by cleansing the area and then rubbing a thin film
into the affected area. Avoid contact with the eyes. Cosmetics may be applied to
the area after application.
 • These side effects may occur: Dry mouth with strange metallic taste (use frequent
mouth care, suck sugarless candy); nausea, vomiting, diarrhea (eat frequent small
meals).
• Report severe GI upset, dizziness, unusual fatigue or weakness, fever, chills.

Adverse effects in Italic are most common; those in Bold are life-threatening.