METRONIDAZOLE

(me-troe-ni'da-zole)
Flagyl, Flagyl ER, Flagyl IV RTU, Flagyl 375, Metizol, Metric 21, Metro I.V.,
MetroGel, MetroGel Vaginal, MetroLotion, Noritate, Protostat
Classifications: antiinfective; antitrichomonal; amebicide; antibiotic
Pregnancy Category: B

Availability
250 mg, 500 mg tablets; 375 mg capsules; 750 mg sustained release tablets; 500 mg vials;
0.75% lotion; 1% cream; 0.75% gel

Actions
Synthetic compound with direct trichomonacidal and amebicidal activity as well as
antibacterial activity against anaerobic bacteria and some gram-negative bacteria.

Therapeutic Effects
Effective against Trichomonas vaginalis, Entamoeba histolytica, and Giardia lamblia.
Exhibits antibacterial activity against obligate anaerobic bacteria, gram-negative
anaerobic bacilli, and Clostridia. Microaerophilic Streptococci and most aerobic bacteria
are resistant.

Uses
Asymptomatic and symptomatic trichomoniasis in females and males; acute intestinal
amebiasis and amebic liver abscess; preoperative prophylaxis in colorectal surgery,
elective hysterectomy or vaginal repair, and emergency appendectomy. IV metronidazole
is used for the treatment of serious infections caused by susceptible anaerobic bacteria in
intraabdominal infections, skin infections, gynecologic infections, septicemia, and for
both pre- and postoperative prophylaxis, bacterial vaginosis. Topical: Rosacea.

Unlabeled Uses
Treatment of pseudomembranous colitis, Crohn's disease, H. pylori eradication.

Contraindications
Blood dyscrasias; active CNS disease; first trimester of pregnancy (category B), lactation.
Cautious Use
Coexistent candidiasis; second and third trimesters of pregnancy (category B);
alcoholism; liver disease.

Route & Dosage

Trichomoniasis, Giardiasis, Gardnerella

Adult: PO 2 g once or 250 mg t.i.d.; 375 mg b.i.d. or 500 mg b.i.d. for 7 d Vaginal
Apply once or twice daily times 5 d
Child: PO 15 mg/kg/d in 3 divided doses for 7–10 d
Infant: PO 10–30 mg/kg/d for 5–8 d

Amebiasis
Adult: PO 500–750 mg t.i.d.
Child: PO 35–50 mg/kg/d in 3 divided doses

Anaerobic Infections
Adult: PO 7.5 mg/kg q6h (max: 4 g/d) IV Loading Dose 15 mg/kg IV Maintenance
Dose 7.5 mg/kg q6h (max: 4 g/d)
Child: PO/IV 30 mg/kg/d divided q6h (max: 4 g/d)
Neonate: PO/IV 7.5–15 mg/kg/d divided q12–48h

Pseudomembranous Colitis
Adult: PO 250–500 mg t.i.d. IV 250–500 mg t.i.d. or q.i.d.
Child: PO 30 mg/kg/d divided q6h times 7 d

Bacterial Vaginosis
Adult: PO (Flagyl ER) 750 mg q.d. times 7 d

Rosacea
Adult: Topical apply thin film to affected area b.i.d.

Administration
Oral
 Crush tablets before ingestion if patient cannot swallow whole.
 Ensure that Flagyl ER (extend-release form) is not chewed or crushed. It must be
swallowed whole. Give on an empty stomach, 1 h before or 2 h after meals.
 Give immediately before, with, or immediately after meals or with food or milk to
reduce GI distress.
 Give lower than normal doses in presence of liver disease.

Intravenous
  Note: Verify correct IV concentration and rate of infusion for administration to
neonates, infants, or children with physician.

PREPARE: Intermittent: Sequence for preparing solution (important) consists of (1)

reconstitution with 4.4 mL sterile water or NS, (2) dilution in IV solution to yield 8
mg/mL in NS, D5W, or RL, (3) pH neutralization with approximately 5 mEq sodium
bicarbonate injection for each 500 mg of Flagyl I.V. used. Avoid use of aluminum-
containing equipment when manipulating IV product (including syringes equipped with
aluminum needles or hubs). Note: Flagyl IV RTU does not require mixing, diluting, or
neutralizing. Each container contains 14 mEq of sodium.  

ADMINISTER: Intermittent: Give IV solution slowly at a rate of one dose per hour.  

INCOMPATIBILITIES Solution/additive: tpn, amoxicillin/clavulanate, aztreonam,

dopamine, meropenem. Y-site: Amphotericin B cholesteryl complex, aztreonam,
filgrastim, meropenem, warfarin.

 Note: Precipitation occurs if neutralized solution is refrigerated. Use diluted and

neutralized solution within 24 h of preparation.
 Store at 15°–30° C (59°–86° F); protect from light. Reconstituted Flagyl I.V. is
chemically stable for 96 h when stored below 30° C (86° F) in room light. Diluted
and neutralized IV solutions containing Flagyl I.V. should be used within 24 h of
mixing.

Adverse Effects ( 1%)

Body as a Whole: hypersensitivity (rash, urticaria, pruritus, flushing), fever, fleeting joint
pains, overgrowth of Candida. CNS: Vertigo, headache, ataxia, confusion, irritability,
depression, restlessness, weakness, fatigue, drowsiness, insomnia, paresthesias, sensory
neuropathy (rare). GI: Nausea, vomiting, anorexia, epigastric distress, abdominal cramps,
diarrhea, constipation, dry mouth, metallic or bitter taste, proctitis. Urogenital: Polyuria,
dysuria, pyuria, incontinence, cystitis, decreased libido, dyspareunia, dryness of vagina
and vulva, sense of pelvic pressure. Special Senses: Nasal congestion. CV: ECG changes
(flattening of T wave).

Diagnostic Test Interference

Metronidazole may interfere with certain chemical analyses for AST, resulting in
decreased values.

Interactions
Drug: oral anticoagulants potentiate hypoprothrombinemia; alcohol may elicit disulfiram
reaction; oral solutions of citalopram, ritonavir; lopinavir/ritonavir, and IV
formulations of sulfamethoxazole; trimethoprim, SMX-TMP, nitroglycerin may elicit
disulfiram reaction due to the alcohol content of the dosage form; disulfiram causes
acute psychosis; phenobarbital increases metronidazole metabolism; may increase
lithium levels; fluorouracil, azathioprine may cause transient neutropenia.

Pharmacokinetics
Absorption: 80% of dose absorbed from GI tract. Peak: 1–3 h. Distribution: Widely
distributed to most body tissues, including CSF, bone, cerebral and hepatic abscesses;
crosses placenta; distributed in breast milk. Metabolism: 30%–60% metabolized in liver.
Elimination: 77% excreted in urine; 14% excreted in feces within 24 h. Half-Life: 6–8 h.

NURSING IMPLICATIONS
Assessment & Drug Effects

 Discontinue therapy immediately if symptoms of CNS toxicity (see Appendix F)

develop. Monitor especially for seizures and peripheral neuropathy (e.g.,
numbness and paresthesia of extremities).
 Lab tests: Obtain total and differential WBC counts before, during, and after
therapy, especially if a second course is necessary.
 Monitor for S&S of sodium retention, especially in patients on corticosteroid
therapy or with a history of CHF.
 Monitor patients on lithium for elevated lithium levels.
 Report appearance of candidiasis or its becoming more prominent with therapy to
physician promptly.
 Repeat feces examinations, usually up to 3 mo, to ensure that amebae have been
eliminated.

Patient & Family Education

 Adhere closely to the established regimen without schedule interruption or

changing the dose.
 Refrain from intercourse during therapy for trichomoniasis unless male partner
wears a condom to prevent reinfection.
 Have sexual partners receive concurrent treatment. Asymptomatic trichomoniasis
in the male is a frequent source of reinfection of the female.
 Do not drink alcohol during therapy; may induce a disulfiram-type reaction (see
Appendix F). Avoid alcohol or alcohol-containing medications for at least 48 h
after treatment is completed.
 Urine may appear dark or reddish brown (especially with higher than
recommended doses). This appears to have no clinical significance.
  Report symptoms of candidal overgrowth: Furry tongue, color changes of tongue,
glossitis, stomatitis; vaginitis, curd-like, milky vaginal discharge; proctitis.
Treatment with a candidacidal agent may be indicated.
 Do not breast feed while taking this drug.

Common adverse effects in italic, life-threatening effects underlined: generic names in

bold; classifications in SMALL CAPS; Canadian drug name; Prototype drug

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