ﺑﺎﺯﮔﺸﺖ ﺑﻪ ﺻﻔﺤﻪ ﻗﺒﻠﯽ
خرید پکیج
تعداد ایتم قابل مشاهده باقیمانده : 4 مورد

Metronidazole (systemic): Drug information

Metronidazole (systemic): Drug information
(For additional information see "Metronidazole (systemic): Patient drug information" and see "Metronidazole (systemic): Pediatric drug information")

For abbreviations and symbols that may be used in Lexicomp (show table)
ALERT: US Boxed Warning
Carcinogenic:

Metronidazole has been shown to be carcinogenic in mice and rats. Unnecessary use of the drug should be avoided. Its use should be reserved for the conditions for which this drug is indicated.

Brand Names: US
  • Flagyl
Brand Names: Canada
  • APO-MetroNIDAZOLE;
  • Auro-MetroNIDAZOLE;
  • Flagyl;
  • NOVO-Nidazol [DSC];
  • PMS-MetroNIDAZOLE
Pharmacologic Category
  • Amebicide;
  • Antibiotic, Miscellaneous;
  • Antiprotozoal, Nitroimidazole
Dosing: Adult

Amebiasis, intestinal (acute dysentery) or extraintestinal (liver abscess): Oral: 500 to 750 mg every 8 hours for 7 to 10 days followed by an intraluminal agent (eg, paromomycin) (Drugs for Parasitic Infections 2013; Leder 2018a; Leder 2018b).

Bacterial vaginosis: Oral: 500 mg twice daily for 7 days (CDC [Workowski 2015]; SOGC [Yudin 2017]).

Balantidiasis (alternative agent) (off-label use): Oral: 750 mg 3 times daily for 5 days (CDC 2013; Drugs for Parasitic Infections 2013; Weller 2021).

Bite wound infection, prophylaxis or treatment, animal or human bite (alternative agent) (off-label use): Oral, IV: 500 mg every 8 hours (Baddour 2021a; Baddour 2021b; IDSA [Stevens 2014]). Duration is 3 to 5 days for prophylaxis; duration of treatment for established infection is typically 5 to 14 days and varies based on clinical response and patient-specific factors (Baddour 2021a; Baddour 2021b). Note: For animal bites, use in combination with an appropriate agent for Pasteurella multocida. For human bites, use in combination with an appropriate agent for Eikenella corrodens (IDSA [Stevens 2014]).

Clostridioides difficile infection, treatment (off-label use):

Note: Criteria for disease severity is based on expert opinion and should not replace clinical judgment (ACG [Kelly 2021]; IDSA/SHEA [McDonald 2018]).

Nonsevere (ie, WBC ≤15,000 cells/mm3 and serum creatinine <1.5 mg/dL), initial episode (alternative agent if oral vancomycin or fidaxomicin unavailable or contraindicated): Oral: 500 mg 3 times daily for 10 days; may be extended up to 14 days if patient has improved but has not had symptom resolution (IDSA/SHEA [McDonald 2018]).

Fulminant infection (ie, ileus, megacolon, and/or hypotension/shock): IV: 500 mg every 8 hours in combination with oral and/or rectal vancomycin for 10 days; may be extended up to 14 days if patient has improved but has not had symptom resolution (ACG [Kelly 2021]; IDSA/SHEA [McDonald 2018]; Surawicz 2013).

Crohn disease, (off-label use):

Management after surgical resection:

Monotherapy: Oral: 20 mg/kg/day (in 3 divided doses) or 1 to 2 g/day in divided doses for 3 months (ACG [Lichtenstein 2018]; Rutgeerts 1995); begin as soon as oral intake is resumed after surgery (Rutgeerts 1995).

Combination therapy: Oral: 250 mg 3 times daily (D’Haens 2008; Lopez-Sanromán 2017) or 1 to 2 g/day in divided doses for 3 months (ACG [Lichtenstein 2018]); begin as soon as oral intake is resumed after surgery and administer in combination with a thiopurine (azathioprine or mercaptopurine) or a TNF-alpha inhibitor (eg, adalimumab) (De Cruz 2015; D’Haens 2008).

Treatment of simple perianal fistulas, adjunctive agent: Oral: 500 mg twice daily for 4 weeks initially; if clinical response (ie, cessation of drainage and closure of fistula), continue at 250 mg 3 times daily for an additional 4 weeks (Bitton 2019) or 10 to 20 mg/kg/day in divided doses for 4 to 8 weeks with or without ciprofloxacin (ACG [Lichtenstein 2018]).

Dientamoeba fragilis infection (off-label use): Oral: 500 to 750 mg 3 times daily for 10 days (CDC 2012; Nagata 2012).

Giardiasis (alternative agent) (off-label use): Oral: 250 mg 3 times daily or 500 mg 2 times daily for 5 to 7 days (Bartelt 2020; Drugs for Parasitic Infections 2013; Ordonez-Mena 2017).

Helicobacter pylori eradication (off-label use):

Clarithromycin triple regimen: Oral: Metronidazole 500 mg 3 times daily in combination with clarithromycin 500 mg twice daily and a standard-dose or double-dose proton pump inhibitor (PPI) twice daily; continue regimen for 14 days. Note: Avoid use of clarithromycin triple therapy in patients with risk factors for macrolide resistance (eg, prior macrolide exposure, local clarithromycin resistance rates ≥15%) (ACG [Chey 2017]; Fallone 2016).

Bismuth quadruple regimen: Oral: Metronidazole 250 mg 4 times daily or 500 mg 3 or 4 times daily in combination with either bismuth subsalicylate 300 to 524 mg or bismuth subcitrate 120 to 300 mg 4 times daily, tetracycline 500 mg 4 times daily, and a standard-dose PPI twice daily; continue regimen for 10 to 14 days (ACG [Chey 2017]; Fallone 2016).

Concomitant regimen: Oral: Metronidazole 500 mg twice daily in combination with clarithromycin 500 mg twice daily, amoxicillin 1 g twice daily, and a standard-dose PPI twice daily; continue regimen for 10 to 14 days (ACG [Chey 2017]; Fallone 2016).

Sequential regimen (alternative regimen): Oral: Amoxicillin 1 g twice daily plus a standard-dose PPI twice daily for 5 to 7 days; then follow with clarithromycin 500 mg twice daily, metronidazole 500 mg twice daily, and a standard-dose PPI twice daily for 5 to 7 days (ACG [Chey 2017]); some experts prefer the 10-day sequential regimen (amoxicillin for 5 days, followed by metronidazole and clarithromycin for 5 days) over the 14-day sequential regimen (amoxicillin for 7 days, followed by metronidazole and clarithromycin for 7 days) due to the lack of data showing superiority of the 14-day regimen over the 10-day regimen in North America (ACG [Chey 2017]; Crowe 2020).

Hybrid regimen (alternative regimen): Oral: Amoxicillin 1 g twice daily plus a standard-dose PPI twice daily for 7 days; then follow with amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, metronidazole 500 mg twice daily, and a standard-dose PPI twice daily for 7 days (ACG [Chey 2017]; Wang 2015).

Intra-abdominal infection:

Note: Empiric oral regimens may be appropriate for patients with mild to moderate infection. Other patients may be switched from IV to oral therapy at the same dose when clinically improved and able to tolerate an oral diet (SIS [Mazuski 2017]; SIS/IDSA [Solomkin 2010]). The addition of metronidazole may not be necessary for uncomplicated biliary infection of mild to moderate severity (SIS/IDSA [Solomkin 2010]; Vollmer 2021).

Oral, IV: 500 mg every 8 hours as part of an appropriate combination regimen. Duration of therapy is 4 to 5 days following adequate source control (Sawyer 2015; SIS [Mazuski 2017]); for diverticulitis or uncomplicated appendicitis managed without intervention, duration is 7 to 10 days (Barshak 2021; Pemberton 2021).

Intracranial abscess (brain abscess, intracranial epidural abscess) : IV: 7.5 mg/kg (usually 500 mg) every 6 to 8 hours for 6 to 8 weeks in combination with other appropriate antimicrobial therapy (Bodilsen 2018; Sexton 2021; Southwick 2020). Note: May switch IV metronidazole to oral metronidazole at the same dose to complete treatment course (Southwick 2020).

Pelvic inflammatory disease:

Mild to moderate pelvic inflammatory disease, outpatient therapy: Oral: 500 mg twice daily for 14 days in combination with a second- or third-generation parenteral cephalosporin and oral doxycycline (CDC [Workowski 2015]; Wiesenfeld 2020).

Pelvic inflammatory disease with tubo-ovarian abscess, initial therapy (alternative regimen): IV: 500 mg every 8 hours as part of an appropriate combination regimen (Beigi 2020).

Pelvic inflammatory disease with tubo-ovarian abscess, oral therapy following clinical improvement on a parenteral regimen: Oral: 500 mg twice daily with doxycycline to complete at least 14 days of therapy (CDC [Workowski 2015]).

Periodontitis, severe (off-label use): Oral: 500 mg every 8 hours in combination with amoxicillin for 7 to 14 days; used in addition to periodontal debridement (Chow 2019; McGowan 2018; Wilder 2020).

Pneumonia, aspiration (alternative agent): Oral, IV: 500 mg 3 times daily in combination with an appropriate beta-lactam (eg, oral amoxicillin, IV penicillin, or an IV third-generation cephalosporin) for 7 days (Bartlett 2018).

Pouchitis (post ileal pouch-anal anastomosis), acute (off-label use):

Initial therapy (alternative agent): Oral: 500 mg every 12 hours for 14 days (Navaneethan 2009; Nguyen 2019; Shen 2020; Wall 2011).

Refractory disease: Oral: 500 mg every 12 hours in combination with ciprofloxacin for 28 days (Benlice 2019; Shen 2020).

Skin and soft tissue infection:

Necrotizing infection (as a component of an appropriate combination regimen) (alternative agent): IV: 500 mg every 6 hours. Continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014]).

Surgical site infection, incisional (eg, intestinal or GU tract; axilla or perineum), warranting anaerobic coverage: IV: 500 mg every 8 hours in combination with other appropriate agents. Duration depends on severity, need for debridement, and clinical response (IDSA [Stevens 2014]).

Surgical prophylaxis:

IV: 500 mg within 60 minutes prior to surgical incision in combination with other antibiotics. Considered a recommended agent for select procedures involving the GI tract, urologic tract, or head and neck (Bratzler 2013).

Oral:

Colorectal surgical prophylaxis (off-label use): 1 g every 3 to 4 hours for 3 doses with additional oral antibiotics, starting after mechanical bowel preparation the evening before a morning surgery and followed by an appropriate IV antibiotic prophylaxis regimen (Bratzler 2013).

Uterine evacuation (induced abortion or pregnancy loss) (alternative agent) (off-label use): 500 mg as a single dose 1 hour prior to uterine aspiration; may be administered up to 12 hours before the procedure (ACOG 2018; Shih 2020). Note: The optimal dosing regimen has not been established; various protocols are in use (Achilles 2011).

Tetanus ( Clostridium tetani infection) (off-label use): Oral, IV: 500 mg every 6 to 8 hours for 7 to 10 days in combination with supportive therapy (Ahmadsyah 1985; Sexton 2020a).

Trichomoniasis (index case and sex partner):

Initial treatment: Oral: 500 mg twice daily for 7 days. Note: Single 2 g dose is no longer preferred due to inferior efficacy (Howe 2017; Kissinger 2010; Kissinger 2018), but it can be used in patients unable to complete multiple dose treatment course (Sobel 2020). Coverage of trichomoniasis, along with other appropriate antimicrobials, is indicated in cases of recurrent or persistent urethritis in men who have sex with women and who live in regions where T. vaginalis is prevalent and for prophylaxis after sexual assault (CDC [Workowski 2015]).

Persistent or recurrent infection (ie, treatment failure of nitroimidazole [eg, metronidazole]): Oral: 500 mg twice daily for 7 days for failure of 2 g single-dose regimen. If this regimen fails, 2 g once daily for 7 days is recommended (CDC [Workowski 2015]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Renal Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Decreased kidney function does not impact serum half-life of metronidazole but is associated with accumulation of the active hydroxyl and almost inactive acetic acid metabolites (Bergan 1986; Houghton 1985; Lamp 1999). Kidney dysfunction may confer a higher risk of CNS side effects, such as neuropathy, encephalopathy, and seizures (Sarna 2013).

Note: Single-dose regimens (eg, 2 g once) do not require dose adjustment (expert opinion).

Altered kidney function:

IV, Oral:

CrCl ≥10 mL/minute: No dosage adjustment necessary (expert opinion; manufacturer's labeling); however, monitor closely for adverse effects due to accumulation of metabolites in patients with more severe impairment (CrCl <30 mL/minute), particularly with prolonged courses of therapy (Bergan 1986).

CrCl <10 mL/minute: No dosage adjustment necessary (expert opinion; manufacturer's labeling); however, monitor closely for adverse effects due to accumulation of metabolites, particularly with prolonged courses of therapy. A dose of 500 mg every 12 hours may be adequate to achieve therapeutic plasma levels for nonsevere non-Clostridioides difficile infections (Somogyi 1984).

Hemodialysis, intermittent (thrice weekly): Dialyzable (42% to 65% metronidazole and hydroxyl and acetic acid metabolites [Lau 1986]):

IV, Oral: Usual dose: 500 mg every 8 to 12 hours (Heintz 2009). Note: Larger doses may be utilized depending on clinical indication, but with close monitoring for adverse effects, particularly if the treatment course is >1 to 2 weeks in duration (expert opinion). On dialysis days, administer after dialysis. If administration cannot be separated from hemodialysis, consider supplemental dose following hemodialysis.

Peritoneal dialysis: Minimally dialyzed (10% removal with single long dwell; manufacturer's labeling):

IV, Oral: No dosage adjustment necessary (Cassey 1983; Guay 1984). Monitor for adverse effects due to metabolite accumulation, particularly if the treatment course is >1 to 2 weeks in duration (expert opinion).

CRRT:

Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Recommendations are based on high-flux dialyzers and effluent flow rates of 20 to 25 mL/kg/hour (or ~1,500 to 3,000 mL/hour) unless otherwise noted. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection). Close monitoring of response and adverse reactions (eg, neurotoxicity) due to metabolite accumulation is important:

IV, Oral: No dosage adjustment necessary (Heintz 2009; expert opinion).

PIRRT (eg, sustained, low-efficiency diafiltration):

Note: Drug clearance is dependent on the effluent flow rate, filter type, and method of renal replacement. Appropriate dosing requires consideration of adequate drug concentrations (eg, site of infection). Close monitoring of response and adverse reactions (eg, neurotoxicity) due to drug accumulation is important:

IV, Oral: No dosage adjustment necessary (expert opinion). On PIRRT days, administer after PIRRT session. If administration cannot be separated from PIRRT, consider supplemental dose following completion of PIRRT session.

Dosing: Hepatic Impairment: Adult

Manufacturer’s labeling:

Mild or moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary; use with caution and monitor for adverse events.

Severe impairment (Child-Pugh class C):

Capsules:

Amebiasis: 375 mg 3 times daily

Trichomoniasis: 375 mg once daily

Tablets, injection: Reduce dose by 50%

Alternative dosing: The pharmacokinetics of a single oral 500 mg dose were not altered in patients with cirrhosis; initial dose reduction is therefore not necessary (Daneshmend 1982). In one study of IV metronidazole, patients with alcoholic liver disease (with or without cirrhosis) demonstrated a prolonged elimination half-life (eg, ~18 hours). The authors recommended the dose be reduced accordingly (clearance was reduced by ~62%) and the frequency may be prolonged (eg, every 12 hours instead of every 6 hours) (Lau 1987). In another single IV dose study using metronidazole metabolism to predict hepatic function, patients classified as Child-Pugh class C demonstrated a half-life of ~21.5 hours (Muscara 1995).

Dosing: Pediatric

(For additional information see "Metronidazole (systemic): Pediatric drug information")

Note: Some clinicians recommend using adjusted body weight in obese children. Dosing weight = IBW + 0.45 (TBW-IBW)

General dosing, susceptible infection (Red Book [AAP 2018]): Infants, Children, and Adolescents:

Oral: 15 to 50 mg/kg/day in divided doses 3 times daily; maximum daily dose: 2,250 mg/day.

IV: 22.5 to 40 mg/kg/day in divided doses 3 or 4 times daily; maximum daily dose: 4,000 mg/day.

Amebiasis: Infants, Children, and Adolescents: Oral: 35 to 50 mg/kg/day in divided doses every 8 hours for 7 to 10 days; maximum dose: 750 mg/dose; for severe infection or extraintestinal disease, IV may be necessary (Bradley 2018; Red Book [AAP 2018]).

Appendicitis, perforated (divided dosing): Children and Adolescents: IV: 10 mg/kg/dose every 8 hours (Emil 2003).

Appendicitis, perforated (once-daily dosing): Limited data available: Children and Adolescents: IV: 30 mg/kg/dose once daily in combination with ceftriaxone; maximum reported daily dose: 1,500 mg/day (Yardeni 2013); however, other pediatric trials did not report a maximum; in adult patients, a maximum daily dose of 1,500 mg/day for once-daily dosing is suggested (IDSA [Solomkin 2010]); in pediatric patients, once-daily metronidazole in combination with ceftriaxone has been shown to have similar efficacy as triple-combination therapy with ampicillin, clindamycin, and gentamicin (Fraser 2010; St Peter 2006; St Peter 2008).

Balantidiasis: Infants, Children, and Adolescents: Oral: 35 to 50 mg/kg/day in divided doses every 8 hours for 5 days; maximum dose: 750 mg/dose (Red Book [AAP 2018]).

Catheter (peritoneal dialysis); exit-site or tunnel infection: Infants, Children, and Adolescents: Oral: 10 mg/kg/dose 3 times daily. Maximum dose: 500 mg/dose (ISPD [Warady 2012]).

Clostridioides difficile infection:

Infants: Mild to moderate infection: Oral, IV: 7.5 mg/kg/dose every 6 hours for 10 days (Red Book [AAP 2018]).

Children and Adolescents:

Non-severe infection, initial or first recurrence: Oral: 7.5 mg/kg/dose 3 to 4 times daily for 10 days; maximum dose: 500 mg/dose (IDSA/SHEA [McDonald 2018]).

Severe/fulminant infection, initial: IV: 10 mg/kg/dose every 8 hours for 10 days; maximum dose: 500 mg/dose; use concomitantly with oral or rectal vancomycin (IDSA/SHEA [McDonald 2018]).

Dientamoeba fragilis: Infants, Children, and Adolescents: Oral: 35 to 50 mg/kg/day in divided doses every 8 hours for 10 days; maximum dose: 750 mg/dose (Red Book [AAP 2018]).

Giardiasis: Infants, Children, and Adolescents: Oral: 5 to 10 mg/kg/dose every 8 hours for 5 to 7 days; maximum dose: 250 mg/dose (Bradley 2018; Gardner 2001; Granados 2012; Ross 2013; Red Book [AAP 2018]).

Helicobacter pylori eradication: Limited data available: Note: Use as part of an appropriate combination regimen; usual duration of therapy is 14 days (NASPGHAN/ESPGHAN [Jones 2017]).

Weight-directed dosing: Children and Adolescents: Oral: 10 to 15 mg/kg/dose twice daily; maximum dose: 500 mg/dose (Bontems 2011; Butenko 2017; Huang 2013; Iwańczak 2016; Koletzko 2011; Kutluk 2016; Schwarzer 2011).

Fixed dosing (NASPGHAN/ESPGHAN [Jones 2017]): Children and Adolescents:

15 to <25 kg: Oral: 250 mg twice daily.

25 to <35 kg: Oral: 500 mg in the morning and 250 mg in the evening or 375 mg twice daily (if using liquid preparation).

≥35 kg: Oral: 500 mg twice daily.

Inflammatory bowel disease:

Crohn disease, perianal disease; induction: Children and Adolescents: Oral: 7.5 mg/kg/dose 3 times daily for 6 weeks with or without ciprofloxacin; maximum dose: 500 mg/dose (Sandhu 2010).

Ulcerative colitis, pouchitis, persistent: Children and Adolescents: Oral: 20 to 30 mg/kg/day in divided doses 3 times daily for 14 days with or without ciprofloxacin or oral budesonide; maximum dose: 500 mg/dose (Turner 2012).

Intra-abdominal infection: Infants, Children, and Adolescents: IV: 30 to 40 mg/kg/day in divided doses 3 times daily as part of combination therapy; maximum dose: 500 mg/dose (IDSA [Solomkin 2010]).

Pelvic inflammatory disease: Adolescents: Oral: 500 mg twice daily for 14 days; give with doxycycline plus a cephalosporin (CDC [Workowski 2015]).

Peritonitis (peritoneal dialysis) (ISPD [Warady 2012]):

Prophylaxis: Gastrointestinal or genitourinary procedures: Infants, Children, and Adolescents: IV: 10 mg/kg once prior to procedure in combination with cefazolin; Maximum dose: 1,000 mg/dose.

Treatment: Infants, Children, and Adolescents: Oral: 10 mg/kg/dose 3 times daily. Maximum daily dose: 1,200 mg/day.

Prophylaxis against sexually transmitted diseases following sexual assault (CDC [Workowski 2015]): Adolescents: Oral: 2,000 mg as a single dose in combination with azithromycin and ceftriaxone.

Surgical prophylaxis: Children and Adolescents: IV: 15 mg/kg as a single dose 30 to 60 minutes prior to procedure; maximum single dose: 500 mg (IDSA/ASHP [Bratzler 2013]).

Surgical prophylaxis, colorectal: Children and Adolescents: Oral: 15 mg/kg/dose every 3 to 4 hours for 3 doses, starting after mechanical bowel preparation the afternoon and evening before the procedure, with or without additional oral antibiotics and with an appropriate IV antibiotic prophylaxis regimen; maximum dose: 1,000 mg/dose (IDSA/ASHP [Bratzler 2013]).

Tetanus (Clostridium tetani infection): Infants, Children, and Adolescents: IV, Oral: 30 mg/kg/day in divided doses 4 times daily for 7 to 10 days; maximum daily dose: 4,000 mg/day (Red Book [AAP 2018]).

Trichomoniasis; treatment: Oral:

Children <45 kg: 45 mg/kg/day in divided doses 3 times daily for 7 days; maximum daily dose: 2,000 mg/day (Red Book [AAP 2018]).

Children ≥45 kg and Adolescents: 500 mg twice daily for 7 days or 2,000 mg as a single dose once (CDC [Workowski 2015]; Red Book [AAP 2018]). Note: 7-day-course has been shown to be more effective in adult women (Howe 2017; Kissinger 2010; Kissinger 2018).

Vaginosis, bacterial: Oral: Children >45 kg and Adolescents: 500 mg twice daily for 7 days (CDC [Workowski 2015]; Red Book [AAP 2018]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Renal Impairment: Pediatric

Infants, Children, and Adolescents:

Manufacturer's labeling:

Mild, moderate, or severe impairment: There are no dosage adjustments provided in the manufacturer's labeling; however, decreased renal function does not alter the single-dose pharmacokinetics.

ESRD requiring dialysis: Metronidazole metabolites may accumulate; monitor for adverse events; accumulated metabolites may be rapidly removed by dialysis.

Intermittent hemodialysis (IHD): If administration cannot be separated from hemodialysis, consider supplemental dose following hemodialysis.

Peritoneal dialysis (PD): No dosage adjustment necessary

Alternate dosing: Others have used the following adjustments (Aronoff 2007). Note: Renally adjusted dose recommendations are based on doses of 15 to 30 mg/kg/day divided every 6 to 8 hours.

GFR ≥10 mL/minute/1.73 m2: No adjustment required

GFR <10 mL/minute/1.73 m2: 4 mg/kg/dose every 6 hours

Intermittent hemodialysis (IHD): Extensively removed by hemodialysis: 4 mg/kg/dose every 6 hours

Peritoneal dialysis (PD): Extensively removed by peritoneal dialysis: 4 mg/kg/dose every 6 hours

Continuous renal replacement therapy (CRRT): No adjustment required

Dosing: Hepatic Impairment: Pediatric

Infants, Children, and Adolescents:

Manufacturer labeling:

Mild or moderate impairment (Child-Pugh class A or B): No dosage adjustment necessary; use with caution and monitor for adverse events.

Severe impairment (Child-Pugh class C): Immediate-release tablets, injection: Reduce dose by 50%.

Alternate dosing: The pharmacokinetics of a single oral 500 mg dose were not altered in patients with cirrhosis; initial dose reduction is therefore not necessary (Daneshmend 1982). In one study of IV metronidazole, adult patients with alcoholic liver disease (with or without cirrhosis) demonstrated a prolonged elimination half-life (eg, ~18 hours). The authors recommended the dose be reduced accordingly (clearance was reduced by ~62%) and the frequency may be prolonged (eg, every 12 hours instead of every 6 hours) (Lau 1987). In another single IV dose study using metronidazole metabolism to predict hepatic function, patients classified as Child-Pugh class C demonstrated a half-life of ~21.5 hours (Muscara 1995).

Dosing: Geriatric

Refer to adult dosing.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral:

Flagyl: 375 mg

Generic: 375 mg

Solution, Intravenous:

Generic: 500 mg (100 mL)

Solution, Intravenous [preservative free]:

Generic: 500 mg (100 mL); 5 mg/mL (100 mL [DSC])

Tablet, Oral:

Flagyl: 250 mg [DSC], 500 mg

Generic: 250 mg, 500 mg

Generic Equivalent Available: US

Yes

Dosage Forms Considerations

Parenteral solution contains 28 mEq of sodium/gram of metronidazole.

First-Metronidazole and MetroNIDAZOLE Benzo+SyrSpend oral suspensions are a compounding kits. Refer to manufacturer’s labeling for compounding instructions.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral:

Flagyl: 500 mg [contains brilliant blue fcf (fd&c blue #1), fd&c yellow #10 (quinoline yellow)]

Generic: 500 mg

Solution, Intravenous:

Flagyl: 5 mg/mL (100 mL)

Generic: 5 mg/mL (100 mL)

Tablet, Oral:

Generic: 250 mg

Administration: Adult

IV: Infuse intravenously over 30 to 60 minutes. Avoid contact of drug solution with equipment containing aluminum.

Oral: Administer with food to minimize stomach upset.

Administration: Pediatric

Oral: May administer with food to minimize GI upset.

Parenteral: IV: Administer undiluted (5 mg/mL) by slow intermittent infusion over 30 to 60 minutes. Avoid contact of drug solution with equipment containing aluminum.

Use: Labeled Indications

Amebiasis: Treatment of acute intestinal amebiasis (amebic dysentery) and extraintestinal amebiasis (liver abscess)

Limitations of use: When used for amebic liver abscess, may be used concurrently with percutaneous needle aspiration when clinically indicated.

Anaerobic bacterial infections (caused by Bacteroides spp. , including the B. fragilis group):

Bacterial septicemia: Treatment of bacterial septicemia (also caused by Clostridium spp.)

Bone and joint infections: Treatment (adjunctive therapy) of bone and joint infections

CNS Infections: Treatment of CNS infections, including meningitis and brain abscess

Endocarditis: Treatment of endocarditis

Gynecologic infections: Treatment of gynecologic infections including endometritis, endomyometritis, tubo-ovarian abscess, and postsurgical vaginal cuff infection (also caused by Clostridium spp., Peptococcus spp., Peptostreptococcus spp., and Fusobacterium spp.)

Intra-abdominal infections: Treatment of intra-abdominal infections, including peritonitis, intra-abdominal abscess, and liver abscess (also caused by Clostridium spp., Eubacterium spp., Peptococcus spp., and Peptostreptococcus spp.)

Lower respiratory tract infections: Treatment of lower respiratory tract infections, including pneumonia, empyema, and lung abscess

Skin and skin structure infections: Treatment of skin and skin structure infections (also caused by Clostridium spp., Peptococcus spp., Peptostreptococcus spp., and Fusobacterium spp.)

Surgical prophylaxis (colorectal surgery): Injection: Preoperative, intraoperative, and postoperative prophylaxis to reduce the incidence of postoperative infection in patients undergoing elective colorectal surgery classified as contaminated or potentially contaminated

Trichomoniasis: Treatment of infections caused by Trichomonas vaginalis, including treatment of asymptomatic sexual partners

Use: Off-Label: Adult

Balantidiasis; Bite wound infection, prophylaxis or treatment (animal or human bite); Clostridioides difficile infection, treatment; Crohn disease; Dientamoeba fragilis infection; Giardiasis; Helicobacter pylori eradication; Periodontitis, severe; Pouchitis (post ileal pouch-anal anastomosis), acute; Surgical prophylaxis, colorectal surgery (oral metronidazole); Surgical prophylaxis, uterine evacuation (induced abortion or pregnancy loss); Tetanus

Medication Safety Issues
Sound-alike/look-alike issues:

MetroNIDAZOLE may be confused with mebendazole, meropenem, metFORMIN, methotrexate, metoclopramide, miconazole

Adverse Reactions (Significant): Considerations
CNS effects

Metronidazole has been associated with a range of CNS effects, which include peripheral neuropathy (Ref), aseptic meningitis (Ref), ataxia (Ref), neurocerebellar toxicity (Ref), confusion or disorientation (Ref), dysarthria (Ref), encephalopathy (Ref), seizures (Ref), optic neuropathy (Ref), and vertigo (Ref). Most reports have occurred in adults; however, there are reports in pediatric patients (Ref). CNS effects are generally reversible within days to weeks of discontinuation of therapy (Ref); however, some cases may not be reversible (Ref). Peripheral neuropathy symptoms may be prolonged after discontinuation.

Mechanism: Unclear; proposed mechanisms include binding to neural RNA inhibiting protein synthesis, modulation of inhibitory neurotransmitters gamma-aminobutyric acid receptors within the cerebellar and vestibular systems, reversible mitochondrial dysfunction, and vasogenic and cytotoxic edema (Ref).

Onset: Varied; median of 28 days was reported in a systematic review of metronidazole-induced encephalopathy (Ref) and a median of 54 days was reported in another systematic review (Ref); however, both reviews reported that some cases took less than a week.

Risk factors:

May include:

• High doses, high cumulative doses, or prolonged or repeated courses (Ref)

Disulfiram-like reaction

Limited cases of disulfiram-like reactions with metronidazole have been reported in the literature in both adults and pediatric patients when used with alcohol (Ref). Of note, literature reviews have noted limited clinical data supporting this reaction and suggest that the risk of such a reaction is unclear (Ref). The proposed mechanism is inhibition of aldehyde dehydrogenase), which results in the accumulation of aldehydes (Ref). In one case report, onset was rapid, occurring after 2 days (Ref). No risk factors have been identified.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

>10%:

Gastrointestinal: Nausea (10% to 12%)

Genitourinary: Vaginitis (15%)

Nervous system: Headache (18%)

1% to 10%:

Dermatologic: Genital pruritus (5%)

Gastrointestinal: Abdominal pain (4%), diarrhea (4%), xerostomia (2%)

Genitourinary: Dysmenorrhea (3%), urinary tract infection (2%), urine abnormality (3%)

Infection: Bacterial infection (7%), candidiasis (3%)

Nervous system: Dizziness (4%), metallic taste (9%)

Respiratory: Flu-like symptoms (6%), pharyngitis (3%), rhinitis (4%), sinusitis (3%), upper respiratory tract infection (4%)

Frequency not defined:

Cardiovascular: Chest pain, facial edema, flattened T-wave on ECG, flushing, palpitations, peripheral edema, syncope, tachycardia

Dermatologic: Erythematous rash, hyperhidrosis, pruritus, Stevens-Johnson syndrome (Mazumdar 2014), toxic epidermal necrolysis, urticaria

Endocrine & metabolic: Decreased libido

Gastrointestinal: Abdominal cramps, anorexia, constipation, decreased appetite, dysgeusia, epigastric discomfort, glossitis, hairy tongue, pancreatitis (rare) (O’Halloran 2010; Yilmaz 2016; Youssef 2019), proctitis, stomatitis, vomiting

Genitourinary: Cystitis, dark urine (rare), dyspareunia, dysuria, urinary incontinence, urine discoloration, vaginal dryness, vulvovaginal candidiasis

Hematologic & oncologic: Agranulocytosis, eosinophilia, leukopenia (Taylor 1965), neutropenia (reversible) (Khan 2008), thrombocytopenia (reversible, rare) (Lew 2017)

Hepatic: Severe hepatotoxicity (Hestin 1994)

Hypersensitivity: Anaphylaxis (Asensio Sánchez 2008)

Immunologic: Drug reaction with eosinophilia and systemic symptoms, serum sickness-like reaction (joint pains) (VanCleave 2016)

Local: Inflammation at injection site (IV), injection site reaction

Nervous system: Aseptic meningitis (Khan 2007), ataxia (Sagvekar 2019), chills, confusion (Kuriyama 2011), depression, disulfiram-like reaction (with alcohol) (Alonzo 2019), drowsiness, dysarthria (Boot 2017), epilepsy, hypoesthesia, insomnia, irritability, malaise, neurocerebellar toxicity (Patel 2008), numbness, paresthesia, peripheral neuropathy (Goolsby 2018), psychosis, seizure (Huang 2012), vertigo (Chen 2013)

Neuromuscular & skeletal: Arthralgia, asthenia, muscle spasm, myalgia

Ophthalmic: Abnormal eye movements (saccadic), nystagmus disorder, optic neuropathy (Chen 2013)

Renal: Polyuria

Respiratory: Dyspnea, nasal congestion

Miscellaneous: Fever

Postmarketing:

Cardiovascular: Prolonged QT interval on ECG (Gnanapandithan 2021; Mojadidi 2016)

Nervous system: Encephalopathy (Roy 2016)

Contraindications

Hypersensitivity to metronidazole, nitroimidazole derivatives, or any component of the formulation; pregnant patients (first trimester) with trichomoniasis; use of disulfiram within the past 2 weeks; use of alcohol or propylene glycol-containing products during therapy or within 3 days of therapy discontinuation

Canadian labeling: Additional contraindications (not in the US labeling): Active neurological disorders; history of blood dyscrasia; hypothyroidism; hypoadrenalism

Warnings/Precautions

Concerns related to adverse effects:

• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.

Disease-related concerns:

• Cockayne syndrome: Severe hepatotoxicity/acute hepatic failure (has been fatal) has been reported with systemic metronidazole in patients with Cockayne syndrome; onset is rapid after initiation of treatment. Use metronidazole only after risk vs benefit assessment and if there are no appropriate alternatives in patients with Cockayne syndrome. Obtain LFTs prior to treatment initiation, within the first 2 to 3 days of initiation, frequently during therapy, and after treatment is complete. Discontinue treatment if elevated LFTs occur and monitor until LFTs return to baseline.

• Hepatic impairment: Use with caution in patients with hepatic impairment due to potential accumulation; dosage adjustment recommended in patients with severe hepatic impairment.

• Renal impairment: Use with caution in patients with renal impairment due to potential accumulation; dosage adjustments may be required.

• Seizure disorder: Use with caution in patients with a history of seizure disorder.

Dosage-form specific issues:

• Injection: Use injection with caution in patients with heart failure, edema, or other sodium-retaining states, including corticosteroid treatment due to high sodium content. In patients receiving continuous nasogastric secretion aspiration, sufficient metronidazole may be removed in the aspirate to cause a reduction in serum levels.

Metabolism/Transport Effects

Substrate of CYP2A6 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential; Inhibits CYP2C9 (weak)

Drug Interactions

Alcohol (Ethyl): MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Alcohol (Ethyl). A disulfiram-like reaction may occur. Risk X: Avoid combination

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

Busulfan: MetroNIDAZOLE (Systemic) may increase the serum concentration of Busulfan. Management: The toxic effects of busulfan may be greatly increased with concomitant use of metronidazole. This combination should probably be avoided when possible. If these agents must be used together, increased monitoring for busulfan toxicity is recommended. Risk D: Consider therapy modification

Carbocisteine: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Carbocisteine. Specifically, metronidazole may enhance adverse effects of alcohol that is present in liquid formulations of carbocisteine-containing products. Risk X: Avoid combination

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

Disulfiram: May enhance the adverse/toxic effect of MetroNIDAZOLE (Systemic). In particular, the risk for CNS toxicities such as psychosis may be increased. Risk X: Avoid combination

Dronabinol: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Dronabinol. Specifically, metronidazole may produce severe intolerance to the alcohol contained in the dronabinol oral solution. Risk X: Avoid combination

Fluorouracil Products: MetroNIDAZOLE (Systemic) may increase the serum concentration of Fluorouracil Products. Risk C: Monitor therapy

Fosphenytoin: May decrease the serum concentration of MetroNIDAZOLE (Systemic). MetroNIDAZOLE (Systemic) may increase the serum concentration of Fosphenytoin. Risk C: Monitor therapy

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

Lithium: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Lithium. MetroNIDAZOLE (Systemic) may increase the serum concentration of Lithium. Risk C: Monitor therapy

Lopinavir: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Lopinavir. Specifically, the combination of metronidazole and lopinavir/ritonavir solution, which contains 42% alcohol, may result in a disulfiram-like reaction. MetroNIDAZOLE (Systemic) may enhance the arrhythmogenic effect of Lopinavir. Management: Avoid the concomitant use of lopinavir/ritonavir and metronidazole if possible. If these agents are used concomitantly, monitor for QTc prolongation/arrhythmia and if the lopinavir/ritonavir solution is used, development of a disulfiram-like reaction. Risk D: Consider therapy modification

Mebendazole: May enhance the adverse/toxic effect of MetroNIDAZOLE (Systemic). Particularly the risk for Stevens-Johnson syndrome or toxic epidermal necrolysis may be increased. Risk X: Avoid combination

Mycophenolate: MetroNIDAZOLE (Systemic) may decrease the serum concentration of Mycophenolate. Specifically, metronidazole may decrease concentrations of the active metabolite of mycophenolate. Risk C: Monitor therapy

PHENobarbital: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of PHENobarbital. A disulfiram-like reaction may occur if combined with phenobarbital dosage forms that contain propylene glycol or alcohol. PHENobarbital may decrease the serum concentration of MetroNIDAZOLE (Systemic). Risk C: Monitor therapy

Phenytoin: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Phenytoin. A disulfiram-like reaction may occur if combined with phenytoin dosage forms that contain propylene glycol. Phenytoin may decrease the serum concentration of MetroNIDAZOLE (Systemic). MetroNIDAZOLE (Systemic) may increase the serum concentration of Phenytoin. Risk C: Monitor therapy

Primidone: May decrease the serum concentration of MetroNIDAZOLE (Systemic). Risk C: Monitor therapy

Products Containing Propylene Glycol: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Products Containing Propylene Glycol. A disulfiram-like reaction may occur. Risk X: Avoid combination

Ritonavir: May enhance the adverse/toxic effect of MetroNIDAZOLE (Systemic). Specifically, the combination of ritonavir oral solution or ritonavir soft gelatin capsule, both of which contain alcohol, and metronidazole may result in a disulfiram-like reaction. Risk X: Avoid combination

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Tipranavir: MetroNIDAZOLE (Systemic) may enhance the adverse/toxic effect of Tipranavir. A disulfiram-like reaction may occur due to the alcohol contained in tipranavir capsules. Risk C: Monitor therapy

TOLBUTamide: CYP2C9 Inhibitors (Weak) may increase the serum concentration of TOLBUTamide. Risk C: Monitor therapy

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification

Vecuronium: MetroNIDAZOLE (Systemic) may enhance the neuromuscular-blocking effect of Vecuronium. Risk C: Monitor therapy

Vitamin K Antagonists (eg, warfarin): MetroNIDAZOLE (Systemic) may increase the serum concentration of Vitamin K Antagonists. Management: Consider alternatives to concomitant therapy with these agents. If concomitant therapy cannot be avoided, consider reducing the dose of the vitamin K antagonist and monitor for increased INR/bleeding. Risk D: Consider therapy modification

Food Interactions

Peak antibiotic serum concentration lowered and delayed, but total drug absorbed not affected.

Pregnancy Considerations

Metronidazole crosses the placenta.

Cleft lip with or without cleft palate has been reported following first trimester exposure to metronidazole; however, most studies have not shown an increased risk of congenital anomalies or other adverse events to the fetus following maternal use during pregnancy. Because metronidazole was carcinogenic in some animal species, concern has been raised whether metronidazole should be used during pregnancy. Available studies have not shown an increased risk of infant cancer following metronidazole exposure during pregnancy; however, the ability to detect a signal for this may have been limited.

Metronidazole pharmacokinetics are similar between pregnant and nonpregnant patients (Amon 1981; Visser 1984; Wang 2011).

Bacterial vaginosis and vaginal trichomoniasis are associated with adverse pregnancy outcomes and metronidazole is recommended for the treatment of symptomatic pregnant patients. The dose of oral metronidazole for the treatment of bacterial vaginosis during pregnancy is the same as the CDC recommended twice daily dose in nonpregnant females. When treating vaginal trichomoniasis, the CDC recommends the single oral dose regimen in pregnancy. Although use of metronidazole for vaginal trichomoniasis during the first trimester is contraindicated by the manufacturer; available guidelines note treatment can be given at any stage of pregnancy (CDC [Workowski 2015]).

Metronidazole may also be used for the treatment of giardiasis in pregnant women (some sources recommend second and third trimester administration only) (Gardner 2001; HHS [OI adult 2020]) and symptomatic amebiasis during pregnancy (HHS [OI adult 2020]; Li 1996). Short courses may be used for the treatment of pouchitis or perianal disease in pregnant women with inflammatory bowel disease (avoid use in the first trimester) (van der Woude 2015).The use of other agents is preferred when treatment is needed during pregnancy for Clostridioides difficile (Surawicz 2013). Consult current recommendations for appropriate use in pregnant women.

Breast-Feeding Considerations

Metronidazole and its active hydroxyl metabolite are present in breast milk at concentrations similar to maternal plasma concentrations.

The relative infant dose (RID) of metronidazole is 13.7% to 22.9% when calculated using the highest average breast milk concentration reported and compared to an oral infant therapeutic dose of 30 to 50 mg/kg/day. In general, breastfeeding is considered acceptable when the RID is <10%; when an RID is >25% breastfeeding should generally be avoided (Anderson 2016; Ito 2000). Using the highest average milk concentration (45.8 mcg/mL), the estimated daily infant dose via breast milk is 6.87 mg/kg/day. This milk concentration was obtained following a single maternal dose of oral metronidazole 2,000 mg; the authors estimated the infant would have been exposed to metronidazole 21.8 mg over the first 24 hours after the dose (Erickson 1981).

The highest average milk concentration occurred 2 to 4 hours after a single oral maternal dose; the half-life in breast milk was ~9 to 10 hours (Erickson 1981). Metronidazole and its active metabolite can be detected in the serum of breastfeeding infants (Gray 1961; Heisterberg 1983; Passmore 1988).

Loose stools, oral and perianal Candida growth, and oral thrush have been reported in breastfeeding infants exposed to metronidazole (Passmore 1988)

The manufacturer warns of the risk of carcinogenicity in patients exposed to metronidazole based on animal studies; theoretically, this risk is also present in breastfeeding infants exposed to metronidazole via breast milk. Therefore, the manufacturer recommends a decision be made whether to discontinue breastfeeding or to discontinue the drug, taking into account the importance of treatment to the mother. Some guidelines note if metronidazole is given, breastfeeding should be withheld for 12 to 24 hours after a single dose (CDC [Workowski 2015]; WHO 2002); alternatively, the mother may pump and discard breast milk for 24 hours after taking the last metronidazole dose. Breastfeeding should be avoided in women requiring treatment with metronidazole for inflammatory bowel disease (van der Woude 2015). Use of other agents is preferred when treating breastfeeding women for Clostridioides difficile infection (Surawicz 2013).

Dietary Considerations

Take with food to minimize stomach upset.

Sodium: Injectable dosage form may contain sodium.

Ethanol: Use of ethanol is contraindicated during therapy and for 3 days after therapy discontinuation.

Monitoring Parameters

Monitor CBC with differential at baseline, during, and after prolonged or repeated courses of therapy. Monitor LFTs in patients with Cockayne syndrome. Closely monitor elderly patients and patients with severe hepatic impairment or ESRD for adverse reactions. Neurologic symptoms; observe patients carefully if neurologic symptoms occur and consider discontinuation of therapy.

Mechanism of Action

After diffusing into the organism, interacts with DNA to cause a loss of helical DNA structure and strand breakage resulting in inhibition of protein synthesis and cell death in susceptible organisms

Pharmacodynamics and Pharmacokinetics

Absorption: Oral: Well absorbed

Distribution: To bile, seminal fluid, bone, liver, and liver abscesses, lung and vaginal secretions; crosses blood-brain barrier; saliva and CSF concentrations similar to those in plasma

Protein binding: <20%

Metabolism: Hepatic (30% to 60%) to several metabolites including an active hydroxyl metabolite which maintains activity ~30% to 65% of the parent compound (Lamp 1999)

Half-life elimination:

Neonates <7 days (Jager-Roman 1982): Within first week of life, more prolonged than with lower GA:

GA 28 to 30 weeks: 75.3 ± 16.9 hours

GA 32 to 35 weeks: 35.4 ± 1.5 hours

GA 36 to 40 weeks: 24.8 ± 1.6 hours

Neonates ≥7 days: ~22.5 hours (Upadhyaya 1988)

Children and Adolescents: 6 to 10 hours (Lamp 1999)

Adults: ~8 hours

Time to peak, serum: Oral: 1 to 2 hours

Excretion: Urine (unchanged drug and metabolites: 60% to 80%; ~20% of total as unchanged drug); feces (6% to 15%)

Pharmacodynamics and Pharmacokinetics: Additional Considerations

Renal function impairment: CrCl ≤65 mL/minute: Half-life: 18 to 32 hours (hydroxy metabolite [active]) (Lamp 1999)

Hepatic function impairment: Half-life: 18.31 hours (mean) in one study (Lau 1987)

According to Child-Pugh classification (Muscara 1995):

Child-Pugh class A: ~10.7 hours

Child-Pugh class B: ~13.5 hours

Child-Pugh class C: ~21.5 hours

Pricing: US

Capsules (Flagyl Oral)

375 mg (per each): $7.31

Capsules (metroNIDAZOLE Oral)

375 mg (per each): $12.29

Solution (metroNIDAZOLE in NaCl Intravenous)

500 mg/100 mL 0.74% (per mL): $0.03 - $0.04

500 mg/100 mL 0.79 (per mL): $0.01 - $0.06

Tablets (metroNIDAZOLE Oral)

250 mg (per each): $0.43 - $0.58

500 mg (per each): $0.73 - $0.84

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Agometrol (TZ);
  • Amevan (EC);
  • Amgyl (LK);
  • Amotrex (BD);
  • Amrizole (BH, EG, QA);
  • Anaemetro (JP);
  • Anaerobex (AT);
  • Anaerobyl (ZW);
  • Anazol (AE, QA);
  • Anerobizol (PH);
  • Antizoal (PH);
  • Ao Ke An (CN);
  • Arilin (DE);
  • Asiazole (TH);
  • Axagyl (PH);
  • Biatron (ID);
  • Camezol (BF, BJ, CI, ET, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM, ZW);
  • Clont (DE);
  • Clovizole (PH);
  • Dazolin (ID);
  • Deflamon (IT);
  • Dequazol Oral (PE);
  • Dirozyl (BD);
  • Dumozol (AE, CY, JO, KW, SA);
  • Dynazole (PH);
  • Efloran (CZ, UA);
  • Elyzol (FI);
  • Endazole (PH);
  • Entazole (EG);
  • Entizol (CZ);
  • Farcozole (EG);
  • Farnat (ID);
  • Fentiazol (PY);
  • Fladex (ID);
  • Flagesol (UY);
  • Flagizole (AE, CY, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Flagyl (AR, AU, BB, BE, BG, BH, BR, CH, CL, CO, CU, CY, EC, EG, ES, FR, GB, GR, HK, ID, IE, IL, IN, IS, JO, KR, KW, LB, LK, LU, MT, NL, NO, NZ, PE, PH, PK, PT, QA, RO, RU, SA, SG, SI, TH, TR, TW, UA, VE, VN, ZW);
  • Flasinyl (KR);
  • Flazol (AE, BH, CY, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE);
  • Flazole (LV);
  • Fogyl (MY);
  • Frotin (HK, MY, TW);
  • Fu Shu Da (CN);
  • Gravagin (UA);
  • Gynoplix (HK);
  • Helmizol (BR);
  • Klont (MT);
  • Metason (LK);
  • Metazol (ZA);
  • Metgyl (MY);
  • Metrazole (PH);
  • Metris (ZW);
  • Metrogyl (AU, ET);
  • Metrolag (AE, BF, BJ, CH, CI, CY, ET, GH, GM, GN, IQ, IR, JO, KE, KW, LB, LR, LY, MA, ML, MR, MU, MW, NE, NG, OM, SA, SC, SD, SL, SN, SY, TN, TW, TZ, UG, YE, ZM, ZW);
  • Metrolex (TH);
  • Metronidazole IV (AU, NZ);
  • Metronide (AU);
  • Metrorex (ET);
  • Metrozin (CO);
  • Molazol (ID);
  • Nalox (AR);
  • Narobic (ZA);
  • Negazole (ET, QA);
  • Nidazole (AE, BH, JO, QA, SA);
  • Nirmet (TH);
  • Normet (ET);
  • Norzol (MT);
  • Novazole (BF, BJ, CI, ET, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM, ZW);
  • Patryl (PH);
  • Progyl (ID);
  • Protozol (BF, BJ, CI, ET, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN, TN, TZ, UG, ZM, ZW);
  • Protozole (PH);
  • Qualigyl (HK);
  • Qugyl (BD);
  • Rodazid (PH);
  • Ronazol (ID);
  • Rozex (AU, NZ);
  • Sharizole (AE, CY, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Sicabact (ET);
  • Supplin (AE, CY, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Trichex (AT);
  • Trizele (KR);
  • Trogiar (ID);
  • Trogyl (ID);
  • Unigo (HK, TH);
  • Vertisal (CR, DO, GT, HN, NI, PA, SV);
  • Zidoval (AU);
  • Zol (PH)


For country abbreviations used in Lexicomp (show table)

REFERENCES

  1. Achilles SL, Reeves MF; Society of Family Planning. Prevention of infection after induced abortion: release date October 2010: SFP guideline 20102. Contraception. 2011;83(4):295-309. doi:10.1016/j.contraception.2010.11.006 [PubMed 21397086]
  2. Agarwal A, Kanekar S, Sabat S, Thamburaj K. Metronidazole-induced cerebellar toxicity. Neurol Int. 2016;8(1):6365. doi:10.4081/ni.2016.6365 [PubMed 27127600]
  3. Ahmadsyah I, Salim A. Treatment of tetanus: an open study to compare the efficacy of procaine penicillin and metronidazole. Br Med J. 1985;291(6496):648-650. [PubMed 3928066]
  4. Allen LV Jr, Erickson MA 3rd. Stability of ketoconazole, metolazone, metronidazole, procainamide hydrochloride, and spironolactone in extemporaneously compounded oral liquids. Am J Health Syst Pharm. 1996;53(17):2073-2078.
  5. Alonzo MM, Lewis TV, Miller JL. Disulfiram-like reaction with metronidazole: an unsuspected culprit. J Pediatr Pharmacol Ther. 2019;24(5):445-449. doi:10.5863/1551-6776-24.5.445 [PubMed 31598109]
  6. Alvarez RS, Richardson DA, Bent AE, Ostergard DR. Central nervous system toxicity related to prolonged metronidazole therapy. Am J Obstet Gynecol. 1983;145(5):640-641. doi:10.1016/0002-9378(83)91214-0 [PubMed 6829642]
  7. American Academy of Pediatrics (AAP). In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018.
  8. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 135: Second-trimester abortion. Obstet Gynecol. 2013;121(6):1394-1406. doi:10.1097/01.AOG.0000431056.79334.cc [PubMed 23812485]
  9. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol. 2018;131(6):e172-e189. doi: 10.1097/AOG.0000000000002670. [PubMed 29794678]
  10. Amon I, Amon K, Franke G, et al. Pharmacokinetics of metronidazole in pregnant women. Chemotherapy. 1981;27(2):73-79. [PubMed 7471904]
  11. Anagyrou K, Petrikkos GL, Suller MT, et al. Pulmonary Balantidium coli infection in a leukemic patient. Am J Hematol. 2003;73(3):180-183. [PubMed 12827655]
  12. Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-52. [PubMed 27060684]
  13. Aronoff GR, Bennett WM, Berns JS, et al. Drug prescribing in renal failure: dosing guidelines for adults and children. 5th ed. Philadelphia, PA: American College of Physicians; 2007.
  14. Asensio Sánchez T, Dávila I, Moreno E, et al. Anaphylaxis due to metronidazole with positive skin prick test. J Investig Allergol Clin Immunol. 2008;18(2):138-139. [PubMed 18447147]
  15. ASHP. Standardize 4 Safety Initiative Compounded Oral Liquid Version 1.01. July 2017. https://www.ashp.org/-/media/assets/pharmacy-practice/s4s/docs/s4s-ashp-oral-compound-liquids.ashx?la=en&hash=4C2E4F370B665C028981B61F6210335AD5D0D1D6.
  16. Baddour LM, Harper M. Animal bites: Evaluation and management. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 27, 2021a.
  17. Baddour LM, Harper M. Human bites: Evaluation and management. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 27, 2021b.
  18. Baddour LM. Soft tissue infections due to human bites. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://uptodate.com. Accessed April 3, 2018a.
  19. Baddour LM. Soft tissue infections due to dog and cat bites. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://uptodate.com. Accessed April 3, 2018b.
  20. Barshak MB. Antimicrobial approach to intra-abdominal infections in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 8, 2021.
  21. Bartelt LA. Giardiasis: treatment and prevention. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 8, 2020.
  22. Bartlett JG. Aspiration pneumonia in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 1, 2018.
  23. Beigi RH. Management and complications of tubo-ovarian abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 8, 2020.
  24. Benlice C, Shen B, Steele SR. Prevention and medical treatment of pouchitis in ulcerative colitis. Curr Drug Targets. 2019;20(13):1399-1408. doi:10.2174/1389450120666190723130137 [PubMed 31333137]
  25. Bergan T, Thorsteinsson SB. Pharmacokinetics of metronidazole and its metabolites in reduced renal function. Chemotherapy. 1986;32(4):305-318. doi:10.1159/000238429 [PubMed 3731917]
  26. Bitton A, Fichera A. Perianal Crohn’s disease. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 29, 2019.
  27. Bodilsen J, Brouwer MC, Nielsen H, Van De Beek D. Anti-infective treatment of brain abscess. Expert Rev Anti Infect Ther. 2018;16(7):565-578. doi: 10.1080/14787210.2018.1489722. [PubMed 29909695]
  28. Bontems P, Kalach N, Oderda G, et al. Sequential therapy versus tailored triple therapies for Helicobacter pylori infection in children. J Pediatr Gastroenterol Nutr. 2011;53(6):646-650. doi:10.1097/MPG.0b013e318229c769 [PubMed 21701406]
  29. Boot EM, Hanny KH, Meijer FJ, van Eijk JJ. Een vrouw met reversibele encefalopathie [A woman with reversible encephalopathy]. Article in Dutch. Ned Tijdschr Geneeskd. 2017;161:D690. [PubMed 28198344]
  30. Bradley JS, Nelson JD, Barnett E, et al. Nelson's Pediatric Antimicrobial Therapy. 23rd ed. American Academy of Pediatrics; 2017
  31. Bradley JS, Nelson JD, Barnett ED, Cantey JB, eds. Nelson's Pediatric Antimicrobial Therapy. 24th ed. American Academy of Pediatrics; 2018.
  32. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists; Infectious Diseases Society of America; Surgical Infection Society; Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. [PubMed 23327981]
  33. Butenko T, Jeverica S, Orel R, Homan M. Antibacterial resistance and the success of tailored triple therapy in Helicobacter pylori strains isolated from Slovenian children. Helicobacter. 2017;22(5):e12400. doi:10.1111/hel.12400 [PubMed 28653787]
  34. Cassey JG, Clark DA, Merrick P, Jones B. Pharmacokinetics of metronidazole in patients undergoing peritoneal dialysis. Antimicrob Agents Chemother. 1983;24(6):950-951. doi:10.1128/aac.24.6.950 [PubMed 6660863]
  35. Caton JG, Armitage G, Berglundh T, et al. A new classification scheme for periodontal and peri-implant diseases and conditions - introduction and key changes from the 1999 classification. J Periodontol. 2018;89(suppl 1):S1-S8. doi: 10.1002/JPER.18-0157. [PubMed 29926946]
  36. Centers for Disease Control and Prevention (CDC). Update to CDC's Sexually transmitted diseases treatment guidelines, 2010: oral cephalosporins no longer a recommended treatment for gonococcal infections. MMWR Morb Mortal Wkly Rep. 2012;61(31):590-594. [PubMed 22874837]
  37. Centers for Disease Control and Prevention (CDC). Parasites – Dientamoeba fragilis: Resources for Health Professionals. http://www.cdc.gov/parasites/dientamoeba/health_professionals/index.html. Updated December 12, 2012. Accessed April 10, 2014.
  38. Centers for Disease Control and Prevention (CDC). Parasites – Balantidiasis: Resources for Health Professionals. https://www.cdc.gov/parasites/balantidium/health_professionals/index.html. Updated January 10, 2013. Accessed July 25, 2018.
  39. Chatzkel JA, Vossough A. Metronidazole-induced cerebellar toxicity. Pediatr Radiol. 2010;40(8):1453. doi:10.1007/s00247-009-1453-9 [PubMed 19915830]
  40. Chen PS, Huang JK, Cheng SJ, Lin HC. Metronidazole-induced vertigo. Kaohsiung J Med Sci. 2013;29(12):695-696. doi:10.1016/j.kjms.2013.08.001 [PubMed 24296060]
  41. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG clinical guideline: treatment of Helicobacter pylori infection [published correction appears in Am J Gastroenterol. 2018;113(7):1102]. Am J Gastroenterol. 2017;112(2):212-239. doi: 10.1038/ajg.2016.563. [PubMed 28071659]
  42. Chey WD, Wong B. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol. 2007;102(8):1808-1825. [PubMed 17608775]
  43. Chow AW. Complications, diagnosis, and treatment of odontogenic infections. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed August 22, 2019.
  44. Cina SJ, Russell RA, Conradi SE. Sudden death due to metronidazole/ethanol interaction. Am J Forensic Med Pathol. 1996;17(4):343-346. doi:10.1097/00000433-199612000-00013 [PubMed 8947362]
  45. Cohen-Wolkowiez M, Ouellet D, Smith PB, et al. Population pharmacokinetics of metronidazole evaluated using scavenged samples from preterm infants. Antimicrob Agents Chemother. 2012;56(4):1828-1837. [PubMed 22252819]
  46. Cohen-Wolkowiez M, Sampson M, Bloom BT, et al. Determining population and developmental pharmacokinetics of metronidazole using plasma and dried blood spot samples from premature infants. Pediatr Infect Dis J. 2013;32(9):956-961. [PubMed 23587979]
  47. Corson AP, Chretien JH. Metronidazole-associated aseptic meningitis. Clin Infect Dis. 1994;19(5):974. doi:10.1093/clinids/19.5.974 [PubMed 7893894]
  48. Crowe SE. Treatment regimens for Helicobacter pylori. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.
  49. D'Haens GR, Vermeire S, Van Assche G, et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn's disease: a controlled randomized trial. Gastroenterology. 2008;135(4):1123-1129. doi: 10.1053/j.gastro.2008.07.010. [PubMed 18727929]
  50. Daneshmend TK, Homeida M, Kaye CM, Elamin AA, Roberts CJ. Disposition of oral metronidazole in hepatic cirrhosis and in hepatosplenic schistosomiasis. Gut. 1982;23(10):807-813. [PubMed 7117899]
  51. De Cruz P, Kamm MA, Hamilton AL, et al. Crohn's disease management after intestinal resection: a randomised trial. Lancet. 2015;385(9976):1406-1417. doi: 10.1016/S0140-6736(14)61908-5. [PubMed 25542620]
  52. Diodato D, Olivieri G, Pro S, et al. Axonal peripheral neuropathy in propionic acidemia: a severe side effect of long-term metronidazole therapy. Neurology. 2018;91(12):565-567. doi:10.1212/WNL.0000000000006209 [PubMed 30120134]
  53. Drugs for Parasitic Infections. Treat Guidel Med Lett. 2013;11(suppl):e1-e31.
  54. Edwards DL, Fink PC, Van Dyke PO. Disulfiram-like reaction associated with intravenous trimethoprim-sulfamethoxazole and metronidazole. Clin Pharm. 1986;5(12):999-1000. [PubMed 3492326]
  55. Eisenberg L, Suchow R, Coles RS, et al. The effects of metronidazole administration on clinical and microbiologic parameters of periodontal disease. Clin Prev Dent. 1991;13(1):28-34. [PubMed 1860284]
  56. Emil S, Laberge JM, Mikhail P, et al. Appendicitis in children: a ten-year update of therapeutic recommendations. J Pediatr Surg. 2003;38(2):236-242. [PubMed 12596112]
  57. Erickson SH, Oppenheim GL, Smith GH. Metronidazole in breast milk. Obstet Gynecol. 1981;57(1):48-50. [PubMed 7454176]
  58. Fallone CA, Chiba N, van Zanten SV, et al. The Toronto consensus for the treatment of Helicobacter pylori infection in adults. Gastroenterology. 2016;151(1):51-69.e14. [PubMed 27102658]
  59. Feuerstein JD, Ho EY, Shmidt E, et al; American Gastroenterological Association Institute Clinical Guidelines Committee. AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn's Disease. Gastroenterology. 2021;160(7):2496-2508. doi:10.1053/j.gastro.2021.04.022 [PubMed 34051983]
  60. Flagyl capsules (metronidazole) [prescribing information]. New York, NY: Pfizer Labs; January 2021.
  61. Flagyl tablets (metronidazole) [prescribing information]. New York, NY: Pfizer Labs; January 2021.
  62. Flagyl ER (metronidazole) [prescribing information]. New York, NY: Pfizer; June 2015.
  63. Flagyl (metronidazole) [product monograph]. Pointe-Claire, Quebec, Canada: Odan Laboratories LTD; January 2018.
  64. Fraser JD, Aguayo P, Leys CM, et al. A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial. J Pediatr Surg. 2010;45(6):1198-1202. [PubMed 20620320]
  65. Gardner TB, Hill DR. Treatment of giardiasis. Clin Microbiol Rev. 2001;14(1):114-128. [PubMed 11148005]
  66. Gnanapandithan K, Karthik N, Gerber J. Methadone, metoclopramide and metronidazole interaction causing Torsades de Pointes. Clin Pract. 2021;11(1):101-105. Published Feb 7, 2021. doi:10.3390/clinpract11010015 [PubMed 33562182]
  67. Goolsby TA, Jakeman B, Gaynes RP. Clinical relevance of metronidazole and peripheral neuropathy: a systematic review of the literature. Int J Antimicrob Agents. 2018;51(3):319-325. doi:10.1016/j.ijantimicag.2017.08.033 [PubMed 28887203]
  68. Granados CE, Reveiz L, Uribe LG, Criollo CP. Drugs for treating giardiasis. Cochrane Database Syst Rev. 2012;12:CD007787. [PubMed 23235648]
  69. Gray MS, Kane PO, Squires S. Further observations on metronidazole (Flagyl). Br J Vener Dis. 1961;37:278-279. doi: 10.1002/14651858.CD007787.pub2. [PubMed 13901320]
  70. Guay DR, Meatherall RC, Baxter H, Jacyk WR, Penner B. Pharmacokinetics of metronidazole in patients undergoing continuous ambulatory peritoneal dialysis. Antimicrob Agents Chemother. 1984;25(3):306-310. doi:10.1128/aac.25.3.306 [PubMed 6721462]
  71. Halloran TJ. Convulsions associated with high cumulative doses of metronidazole. Drug Intell Clin Pharm. 1982;16(5):409. doi:10.1177/106002808201600511 [PubMed 7084034]
  72. Hari A, Srikanth BA, Lakshmi GS. Metronidazole induced cerebellar ataxia. Indian J Pharmacol. 2013;45(3):295-297. doi:10.4103/0253-7613.111903 [PubMed 23833378]
  73. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy. 2009;29(5):562-577. doi:10.1592/phco.29.5.562 [PubMed 19397464]
  74. Heisterberg L, Branebjerg PE. Blood and milk concentrations of metronidazole in mothers and infants. J Perinat Med. 1983; 11(2):114-120. [PubMed 6854509]
  75. Hestin D, Hanesse B, Frimat L, Trechot P, Netter P, Kessler M. Metronidazole-associated hepatotoxicity in a hemodialyzed patient. Nephron. 1994;68(2):286. doi:10.1159/000188282 [PubMed 7830880]
  76. Hobbs K, Stern-Nezer S, Buckwalter MS, Fischbein N, Finley Caulfield A. Metronidazole-induced encephalopathy: not always a reversible situation. Neurocrit Care. 2015;22(3):429-436. doi:10.1007/s12028-014-0102-9 [PubMed 25561434]
  77. Houghton GW, Dennis MJ, Gabriel R. Pharmacokinetics of metronidazole in patients with varying degrees of renal failure. Br J Clin Pharmacol. 1985;19(2):203-209. doi:10.1111/j.1365-2125.1985.tb02632.x [PubMed 3986078]
  78. Howe K, Kissinger PJ. Single-dose compared with multidose metronidazole for the treatment of trichomoniasis in women: a meta-analysis. Sex Transm Dis. 2017;44(1):29-34. doi: 10.1097/OLQ.0000000000000537. [PubMed 27898571]
  79. Huang YT, Chen LA, Cheng SJ. Metronidazole-induced encephalopathy: case report and review literature. Acta Neurol Taiwan. 2012;21(2):74-78. [PubMed 22879116]
  80. Huang J, Zhou L, Geng L, et al. Randomised controlled trial: sequential vs. standard triple therapy for Helicobacter pylori infection in Chinese children-a multicentre, open-labelled study. Aliment Pharmacol Ther. 2013;38(10):1230-1235. doi:10.1111/apt.12516 [PubMed 24117692]
  81. Ingham HR, Slekon JB, Roxby CM. Bacteriological study of otogenic cerebral abscesses: chemotherapeutic role of metronidazole. Br Med J. 1977;2(6093):991-993. [PubMed 922400]
  82. Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126. [PubMed 10891521]
  83. Iwańczak BM, Borys-Iwanicka A, Biernat M, Gościniak G. Assessment of sequential and standard triple therapy in treatment of Helicobacter pylori infection in children dependent on bacteria sensitivity to antibiotics. Adv Clin Exp Med. 2016;25(4):701-708. doi:10.17219/acem/38554 [PubMed 27629844]
  84. Jacobs DO. Clinical practice. Diverticulitis. N Engl J Med. 2007;357(20):2057-2066. [PubMed 18003962]
  85. Jager-Roman E, Doyle PE, Baird-Lambert J, Cvejic M, Buchanan N. Pharmacokinetics and tissue distribution of metronidazole in the new born infant. J Pediatr. 1982;100(4):651-654. [PubMed 7062220]
  86. Jones NL, Koletzko S, Goodman K, et al. Joint ESPGHAN/NASPGHAN Guidelines for the management of Helicobacter pylori in children and adolescents (update 2016). J Pediatr Gastroenterol Nutr. 2017;64(6):991-1003. doi:10.1097/MPG.0000000000001594 [PubMed 28541262]
  87. Kapoor K, Chandra M, Nag D, Paliwal JK, Gupta RC, Saxena RC. Evaluation of metronidazole toxicity: a prospective study. Int J Clin Pharmacol Res. 1999;19(3):83-88. [PubMed 10761537]
  88. Kelly CR, Fischer M, Allegretti JR, et al. ACG clinical guidelines: prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol. 2021;116(6):1124-1147. doi:10.14309/ajg.0000000000001278 [PubMed 34003176]
  89. Khan AY, Golewale MH, Kahn DA. A case of chronic drug-induced neutropenia. J Psychiatr Pract. 2008;14(4):246-250. doi:10.1097/01.pra.0000327316.27023.5d [PubMed 18664895]
  90. Khan S, Sharrack B, Sewell WA. Metronidazole-induced aseptic meningitis during Helicobacter pylori eradication therapy. Ann Intern Med. 2007;146(5):395-396. doi:10.7326/0003-4819-146-5-200703060-00017 [PubMed 17339628]
  91. Kissinger P, Mena L, Levison J, et al. A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women. J Acquir Immune Defic Syndr. 2010;55(5):565-571. doi: 10.1097/QAI.0b013e3181eda955. [PubMed 21423852]
  92. Kissinger P, Muzny CA, Mena LA, et al. Single-dose versus 7-day-dose metronidazole for the treatment of trichomoniasis in women: an open-label, randomised controlled trial. Lancet Infect Dis. 2018. pii: S1473-3099(18)30423-30427. doi: 10.1016/S1473-3099(18)30423-7. [PubMed 30297322]
  93. Kliegman RM, Stanton BMD, St. Geme J, Schor NF, eds. Nelson' s Textbook of Pediatrics. 20th ed. Philadelphia, PA: Saunders Elsevier; 2016.
  94. Koletzko S, Jones NL, Goodman KJ, et al. Evidence-Based Guidelines From ESPGHAN and NASPGHAN for Helicobacter pylori Infection in Children. J Pediatr Gastroenterol Nutr. 2011;53(2):230-243. [PubMed 21558964]
  95. Kuriyama A, Jackson JL, Doi A, Kamiya T. Metronidazole-induced central nervous system toxicity: a systematic review. Clin Neuropharmacol. 2011;34(6):241-247. doi:10.1097/WNF.0b013e3182334b35 [PubMed 21996645]
  96. Kutluk G, Tutar E, Bayrak A, et al. Sequential therapy versus standard triple therapy for Helicobacter pylori eradication in children: any advantage in clarithromycin-resistant strains?. Eur J Gastroenterol Hepatol. 2014;26(11):1202-1208. doi:10.1097/MEG.0000000000000190 [PubMed 25171023]
  97. Lamp KC, Freeman CD, Klutman NE, Lacy MK. Pharmacokinetics and pharmacodynamics of the nitroimidazole antimicrobials. Clin Pharmacokinet. 1999;36(5):353-373. doi:10.2165/00003088-199936050-00004 [PubMed 10384859]
  98. Lau AH, Chang CW, Sabatini S. Hemodialysis clearance of metronidazole and its metabolites. Antimicrob Agents Chemother. 1986;29(2):235-238. doi:10.1128/aac.29.2.235 [PubMed 3717930]
  99. Lau AH, Evans R, Chang CW, Seligsohn R. Pharmacokinetics of metronidazole in patients with alcoholic liver disease. Antimicrob Agents Chemother. 1987;31(11):1662-1664. [PubMed 3435113]
  100. Leder K, Weller PF. Intestinal Entamoeba histolytica amebiasis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 8, 2020.
  101. Leder K, Weller PF. Extraintestinal Entamoeba histolytica amebiasis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed May 8, 2020.
  102. Lew J, Berenberg J. Metronidazole caused profound drug-induced immune thrombocytopenia. Clin Case Rep. 2017;6(1):206-208. doi:10.1002/ccr3.1334 [PubMed 29375866]
  103. Li E, Stanley SL Jr. Protozoa. Amebiasis. Gastroenterol Clin North Am. 1996; 25(3):471-492. [PubMed 8863036]
  104. Lichtenstein GR, Hanauer SB, and Sandborn WJ, “Management of Crohn's Disease in Adults,” Am J Gastroenterol, 2009, 104(2):465-83. [PubMed 19174807]
  105. Lichtenstein GR, Loftus EV, Isaacs KL, Regueiro MD, Gerson LB, Sands BE. ACG clinical guideline: management of Crohn's disease in adults [published correction appears in Am J Gastroenterol. 2018;113(7):1101]. Am J Gastroenterol. 2018;113(4):481-517. doi: 10.1038/ajg.2018.27. [PubMed 29610508]
  106. Lockhart PB, Tampi MP, Abt E, et al. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc. 2019;150(11):906-921.e12. doi:10.1016/j.adaj.2019.08.020 [PubMed 31668170]
  107. Loesche WJ, Schmidt E, Smith BA, et al, "Effects of Metronidazole on Periodontal Treatment Needs," J Periodontol, 1991, 62(4):247-57. [PubMed 2037955]
  108. Loesche WJ, Giordano JR, Hujoel P, et al, "Metronidazole in Periodontitis: Reduced Need for Surgery," J Clin Periodontol, 1992, 19(2):103-12. [PubMed 1602034]
  109. Lopez-Sanromán A, Vera-Mendoza I, Domènech E, et al; Spanish GETECCU group [APPRECIA study]. Adalimumab vs azathioprine in the prevention of postoperative Crohn's disease recurrence. A GETECCU randomised trial. J Crohns Colitis. 2017;11(11):1293-1301. doi: 10.1093/ecco-jcc/jjx051. [PubMed 28402454]
  110. Mahadevan U, Kane S. American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy. Gastroenterology. 2006; 131(1):283-311. [PubMed 16831611]
  111. Mahl TC, Ummadi S. Metronidazole and mental confusion. J Clin Gastroenterol. 2003;36(4):373-374. doi:10.1097/00004836-200304000-00024 [PubMed 12642754]
  112. Mazumdar G, Shome K. Stevens-Johnson syndrome following use of metronidazole in a dental patient. Indian J Pharmacol. 2014;46(1):121-122. doi:10.4103/0253-7613.125193 [PubMed 24550598]
  113. Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society revised guidelines on the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1-76. doi: 10.1089/sur.2016.261. [PubMed 28085573]
  114. McDonald LC, Gerding DN, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clin Infect Dis. 2018;66(7):e1-e48. doi:10.1093/cid/cix1085 [PubMed 29462280]
  115. McGowan K, McGowan T, Ivanovski S. Optimal dose and duration of amoxicillin-plus-metronidazole as an adjunct to non-surgical periodontal therapy: a systematic review and meta-analysis of randomized, placebo-controlled trials. J Clin Periodontol. 2018;45(1):56-67. doi:10.1111/jcpe.12830 [PubMed 29027242]
  116. McGrath NM, Kent-Smith B, Sharp DM. Reversible optic neuropathy due to metronidazole. Clin Exp Ophthalmol. 2007;35(6):585-586. doi:10.1111/j.1442-9071.2007.01537.x [PubMed 17760644]
  117. Mergenhagen KA, Wattengel BA, Skelly MK, Clark CM, Russo TA. Fact versus fiction: a review of the evidence behind alcohol and antibiotic interactions. Antimicrob Agents Chemother. 2020;64(3):e02167-19. doi:10.1128/AAC.02167-19 [PubMed 31871085]
  118. Metronidazole injection [prescribing information]. Bethlehem, PA: Braun Medical Inc.; January 2018.
  119. Metronidazole injection [prescribing information]. Lake Forest, IL: Hospira, Inc.; January 2018.
  120. Metronidazole injection in sodium chloride [prescribing information]. Deerfield, IL: Baxter Healthcare Corporation; December 2017.
  121. Metronidazole tablet [prescribing information]. East Windsor, NJ: Aurobindo Pharma USA, Inc; March 2021.
  122. Moayyedi PM, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG clinical guideline: management of dyspepsia. Am J Gastroenterol. 2017;112(7):988-1013. doi: 10.1038/ajg.2017.154. [PubMed 28631728]
  123. Mojadidi MK, Hovnanians N, Kaufmann MR, Hill JA. An unusual presentation of QT prolongation. Tex Heart Inst J. 2016;43(4):367-368. Published Aug 1, 2016. doi:10.14503/THIJ-16-5931 [PubMed 27547155]
  124. Mottet C, Vader JP, Felley C, et al. Appropriate management of special situations in Crohn's disease (upper gastro-intestinal; extra-intestinal manifestations; drug safety during pregnancy and breastfeeding): results of a multidisciplinary international expert panel-EPACT II. J Crohns Colitis. 2009; 3(4):257-263. [PubMed 21172284]
  125. Muscara MN, Pedrazzoli J Jr, Miranda EL, et al. Plasma hydroxy-metronidazole/metronidazole ratio in patients with liver disease and in healthy volunteers. Br J Clin Pharmacol. 1995;40(5):477-480. [PubMed 8703652]
  126. Nagata N, Marriott D, Harkness J, Ellis JT, Stark D. Current treatment options for Dientamoeba fragilis infections. Int J Parasitol Drugs Drug Resist. 2012;2:204-215. doi: 10.1016/j.ijpddr.2012.08.002. [PubMed 24533282]
  127. Navaneethan U, Shen B. Pros and cons of antibiotic therapy for pouchitis. Expert Rev Gastroenterol Hepatol. 2009;3(5):547-559. doi: 10.1586/egh.09.37. [PubMed 19817675]
  128. Nguyen GC, Loftus EV Jr, Hirano I, Falck-Ytter Y, Singh S, Sultan S; AGA Institute Clinical Guidelines Committee. American Gastroenterological Association Institute guideline on the management of Crohn's disease after surgical resection. Gastroenterology. 2017;152(1):271-275. doi: 10.1053/j.gastro.2016.10.038. [PubMed 27840074]
  129. Nguyen N, Zhang B, Holubar SD, Pardi DS, Singh S. Treatment and prevention of pouchitis after ileal pouch-anal anastomosis for chronic ulcerative colitis. Cochrane Database Syst Rev. 2019;11(11):CD001176. doi:10.1002/14651858.CD001176.pub5 [PubMed 31785173]
  130. O'Halloran E, Hogan A, Mealy K. Metronidazole-induced pancreatitis. HPB Surg. 2010;2010:523468. doi:10.1155/2010/523468 [PubMed 20862338]
  131. Ordonez-Mena JM, McCarthy ND, Fanshawe TR. Comparative efficacy of drugs for treating giardiasis: a systematic update of the literature and network meta-analysis of randomized clinical trials [published online ahead of print November 27, 2017]. J Antimicrob Chemother. doi: 10.1093/jac/dkx430. [PubMed 29186570]
  132. Pais P, Balasubramaniam KR. Metronidazole-peripheral neuropathy. J Assoc Physicians India. 1982;30(12):918-919. [PubMed 6307965]
  133. Passmore CM, McElnay JC, Rainey EA, et al, "Metronidazole Excretion in Human Milk and its Effect on the Suckling Neonate," Br J Clin Pharmacol, 1988, 26(1):45-51. [PubMed 3203060]
  134. Patel K, Green-Hopkins I, Lu S, Tunkel AR. Cerebellar ataxia following prolonged use of metronidazole: case report and literature review. Int J Infect Dis. 2008;12(6):e111-114. doi:10.1016/j.ijid.2008.03.006 [PubMed 18511323]
  135. Pemberton JH. Acute colonic diverticulitis: medical management. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 8, 2021.
  136. Peyrin-Biroulet L, Deltenre P, Ardizzone S, et al. Azathioprine and 6-mercaptopurine for the prevention of postoperative recurrence in Crohn's disease: a meta-analysis. Am J Gastroenterol. 2009;104(8):2089-2096. doi: 10.1038/ajg.2009.301. [PubMed 19568226]
  137. Phyu H, Edmond MB, Kobayashi T. Metronidazole-induced encephalopathy. IDCases. 2019;18:e00639. doi:10.1016/j.idcr.2019.e00639 [PubMed 31692663]
  138. Putnam D, Fraunfelder FT, Dreis M. Metronidazole and optic neuritis. Am J Ophthalmol. 1991;112(6):737. doi:10.1016/s0002-9394(14)77290-3 [PubMed 1957918]
  139. Rabelo CC, Feres M, Gonçalves C, et al. Systemic antibiotics in the treatment of aggressive periodontitis. A systematic review and a Bayesian Network meta-analysis. J Clin Periodontol. 2015;42(7):647-657. doi: 10.1111/jcpe.12427. [PubMed 26087839]
  140. Ross AG, Olds GR, Cripps AW, Farrar JJ, McManus DP. Enteropathogens and chronic illness in returning travelers. N Engl J Med. 2013;368(19):1817-1825. doi:10.1056/NEJMra1207777 [PubMed 23656647]
  141. Roy U, Panwar A, Pandit A, Das SK, Joshi B. Clinical and neuroradiological spectrum of metronidazole induced encephalopathy: our experience and the review of literature. J Clin Diagn Res. 2016;10(6):OE01-OE09. doi:10.7860/JCDR/2016/19032.8054 [PubMed 27504340]
  142. Rufo PA, Denson LA, Sylvester FA, et al. Health supervision in the management of children and adolescents with IBD: NASPGHAN recommendations. J Pediatr Gastroenterol Nutr. 2012;55(1):93-108. [PubMed 22516861]
  143. Rutgeerts P, Hiele M, Geboes K, et al. Controlled trial of metronidazole treatment for prevention of Crohn's recurrence after ileal resection. Gastroenterology. 1995;108(6):1617-1621. [PubMed 7768364]
  144. Sagvekar Y, Shah V, Rohatgi A, et al. Short-course self-medication of metronidazole leading to acute toxic encephalopathy and ataxia. Ann Indian Acad Neurol. 2019;22(4):543-545. doi:10.4103/aian.AIAN_43_19 [PubMed 31736605]
  145. Sandhu BK, Fell JM, Beattie RM, et al. Guidelines for the management of inflammatory bowel disease in children in the United Kingdom. J Pediatr Gastroenterol Nutr. 2010;50(Suppl 1):S1-S13. doi:10.1097/MPG.0b013e3181c92c53 [PubMed 20081543]
  146. Sarna JR, Furtado S, Brownell AK. Neurologic complications of metronidazole. Can J Neurol Sci. 2013;40(6):768-776. doi:10.1017/s0317167100015870 [PubMed 24257215]
  147. Sawyer RG, Claridge JA, Nathens AB, et al; STOP-IT Trial Investigators. Trial of short-course antimicrobial therapy for intraabdominal infection. N Engl J Med. 2015;372(21):1996-2005. doi:10.1056/NEJMoa1411162 [PubMed 25992746]
  148. Schuster FL, Ramirez-Avila L. Current world status of Balantidium coli. Clin Micro Rev. 2008;21(4):626-638. [PubMed 18854484]
  149. Schutze GE, Willoughby RE; Committee on Infectious Diseases, American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics. 2013;131(1):196-200. [PubMed 23277317]
  150. Schwarzer A, Urruzuno P, Iwańczak B, et al. New effective treatment regimen for children infected with a double-resistant Helicobacter pylori strain. J Pediatr Gastroenterol Nutr. 2011;52(4):424-428. doi:10.1097/MPG.0b013e3181fc8c58 [PubMed 21407111]
  151. Sexton DJ, Sampson JH. Tetanus. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 18, 2020a.
  152. Sexton DJ. Intracranial epidural abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 16, 2021.
  153. Shen B. Management of acute and chronic pouchitis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed December 2, 2020.
  154. Shih G, Wallace R. First-trimester pregnancy termination: uterine aspiration. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed December 8, 2020.
  155. Silva-Senem MX, Heller D, Varela VM, Torres MC, Feres-Filho EJ, Colombo AP. Clinical and microbiological effects of systemic antimicrobials combined to an anti-infective mechanical debridement for the management of aggressive periodontitis: a 12-month randomized controlled trial. J Clin Periodontol. 2013;40(3):242-251. [PubMed 23297772]
  156. Sobel JD, Mitchell C. Trichomoniasis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed June 4, 2020.
  157. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infections in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America [published correction appears in Clin Infect Dis. 2010;50(12):1695]. Clin Infect Dis. 2010;50(2):133-164. [PubMed 20034345]
  158. Somogyi AA, Kong CB, Gurr FW, Sabto J, Spicer WJ, McLean AJ. Metronidazole pharmacokinetics in patients with acute renal failure. J Antimicrob Chemother. 1984;13(2):183-189. doi:10.1093/jac/13.2.183 [PubMed 6706889]
  159. Sørensen CG, Karlsson WK, Amin FM, Lindelof M. Metronidazole-induced encephalopathy: a systematic review. J Neurol. 2020;267(1):1-13. doi:10.1007/s00415-018-9147-6 [PubMed 30536109]
  160. Southwick FS. Treatment and prognosis of bacterial brain abscess. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.
  161. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America [published online ahead of print June 18, 2014]. Clin Infect Dis. 2014;59(2):147-159. doi: 10.1093/cid/ciu296. [PubMed 24947530]
  162. St Peter SD, Little DC, Calkins CM, et al. A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr Surg. 2006;41(5):1020-1024. [PubMed 16677904]
  163. St Peter SD, Tsao K, Spilde TL, et al. Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial. J Pediatr Surg. 2008;43(6):981-985. [PubMed 18558169]
  164. Steinhart AH, Feagan BG, Wong CJ, et al. Combined budesonide and antibiotic therapy for active Crohn's disease: a randomized controlled trial. Gastroenterology. 2002;123(1):33-40. [PubMed 12105831]
  165. Surawicz CM, Brandt LJ, Binion DG, et al. Guidelines for diagnosis, treatment, and prevention of Clostridium difficile infections. Am J Gastroenterol. 2013;108(4):478-498. [PubMed 23439232]
  166. Talley NJ, Vakil N. Practice Parameters Committee of the American College of Gastroenterology. Guidelines for the Management of Dyspepsia. Am J Gastroenterol. 2005;100(10):2324-2337. [PubMed 16181387]
  167. Taylor JA. Metronidazole and transient leukopenia. JAMA. 1965;194(12):1331-1332. [PubMed 5898094]
  168. Trotman RL, Williamson JC, Shoemaker DM, Salzer WL. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy. Clin Infect Dis. 2005;41(8):1159-1166. [PubMed 16163635]
  169. Turner D, Levine A, Escher JC, et al. Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines. J Pediatr Gastroenterol Nutr. 2012;55(3):340-361. [PubMed 22773060]
  170. Upadhyaya P, Bhatnagar V, Basu N. Pharmacokinetics of intravenous metronidazole in neonates. J Pediatr Surg. 1988;23(3):263-265. [PubMed 3357144]
  171. US Department of Health and Human Services (HHS) Panel on Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the prevention and treatment of opportunistic infections in adults and adolescents with HIV: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed May 4, 2020.
  172. van der Woude CJ, Ardizzone S, Bengtson MB, et al; European Crohn’s and Colitis Organization. The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. J Crohns Colitis. 2015;9(2):107-124. [PubMed 25602023]
  173. VanCleave HZ, Sanchez AC, Lieberman JA, Ellenburg JT, Mabry WA. Probable metronidazole induced serum sickness-like reaction in a paediatric patient. J Clin Pharm Ther. 2016;41(6):736-738. doi:10.1111/jcpt.12448 [PubMed 27663456]
  174. Varela VM, Heller D, Silva-Senem MX, et al. Systemic Antimicrobials Adjunctive to a Repeated Mechanical and Antiseptic Therapy for Aggressive Periodontitis: A 6-Month Randomized Controlled Trial. J Periodontol. 2011;82(8):1121-1130. [PubMed 21235333]
  175. Visapää JP, Tillonen JS, Kaihovaara PS, Salaspuro MP. Lack of disulfiram-like reaction with metronidazole and ethanol. Ann Pharmacother. 2002;36(6):971-974. doi:10.1345/aph.1A066 [PubMed 12022894]
  176. Visser AA, Hundt HK. The Pharmacokinetics of a Single Intravenous Dose of Metronidazole in Pregnant Patients. J Antimicrob Chemother. 1984;13(3):279-283. [PubMed 6725177]
  177. Vollmer CM, Zakko SF, Afdhal NH. Treatment of acute calculous cholecystitis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed July 6, 2021.
  178. Wall GC, Shirmer LL, Anliker LE, Tigges AE. Pharmacotherapy for acute pouchitis. Ann Pharmacother. 2011;45(9):1127-1137. [PubMed 21775695]
  179. Wang X, Nanovskaya TN, Zhan Y, et al. Pharmacokinetics of Metronidazole in Pregnant Patients With Bacterial Vaginosis. J Matern Fetal Neonatal Med. 2011;24(3):444-448. [PubMed 20608802]
  180. Wang B, Wang YH, Lv ZF, et al. Review: efficacy and safety of hybrid therapy for Helicobacter pylori infection: a systematic review and meta-analysis. Helicobacter. 2015;20(2):79-88. doi: 10.1111/hel.12180. [PubMed 25381839]
  181. Warady BA, Bakkaloglu S, Newland J, et al. Consensus guidelines for the prevention and treatment of catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Perit Dial Int. 2012;32(Suppl 2):S32-S86. [PubMed 22851742]
  182. Wiesenfeld HC, Meyn LA, Darville T, Macio IS, Hillier SL. A randomized controlled trial of ceftriaxone and doxycycline, with or without metronidazole, for the treatment of acute pelvic inflammatory disease. Clin Infect Dis. Published online February 13, 2020. doi:10.1093/cid/ciaa101 [PubMed 32052831]
  183. Weller PF, Leder K. Balantidium coli infection. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed October 12, 2021.
  184. Wilder RS, Moretti AJ. Overview of gingivitis and periodontitis in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed February 11, 2020.
  185. Williams CS, Woodcock KR. Do ethanol and metronidazole interact to produce a disulfiram-like reaction? Ann Pharmacother. 2000;34(2):255-257. doi:10.1345/aph.19118 [PubMed 10676835]
  186. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1-137. [PubMed 26042815]
  187. World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in the Eleventh WHO Model List of Essential Drugs. 2002. Available at http://www.who.int/maternal_child_adolescent/documents/55732/en/ [PubMed 23215911]
  188. Yardeni D, Kawar B, Siplovich L, et al. Single daily dosing of ceftriaxone and metronidazole is as safe and effective as ampicillin, gentamicin and metronidazole for non-operative management of complicated appendicitis in children. Pediat Therapeut. 2013;3:5.
  189. Yilmaz M, Kinikoglu O, Ceyla B, Arslan F, Mert A. Recurrent pancreatitis induced by metronidazole re-exposure and a review of the current literature. Acta Gastroenterol Belg. 2016;79(3):389-390. [PubMed 27821041]
  190. Youssef I, Saeed N, El Abdallah M, Huevelhorst K, Zakharia K. Metronidazole-induced pancreatitis: Is there underrecognition? A case report and systematic review of the literature. Case Rep Gastrointest Med. 2019;2019:4840539. doi:10.1155/2019/4840539 [PubMed 31281684]
  191. Yudin MH, Money DM. No. 211-Screening and management of bacterial vaginosis in pregnancy. J Obstet Gynaecol Can. 2017;39(8):e184-e191. [PubMed 28729110]
Topic 9589 Version 499.0