Metronidazole Hydrochloride and High Cholesterol (Hyperlipoproteinemia, Hypertriglyceridemia, Sitosterolemia)

• Generic Name: metronidazole
• Dosage Forms: n.a.
• Other Brand Names: Flagyl, MetroGel, FIRST Metronidazole, Flagyl 375

Adjunct for treatment of bone and joint infections caused by Bacteroides, including the B. fragilis group (B. fragilis, B. distasonis, B. ovatus, B. thetaiotaomicron, B. vulgatus).

Treatment of endocarditis caused by Bacteroides (including the B. fragilis group).

Treatment of gynecologic infections (including endometritis, endomyometritis, tubo-ovarian abscess, postsurgical vaginal cuff infection) caused by Bacteroides (including the B. fragilis group), Clostridium, Peptococcus niger, or Peptostreptococcus.

Treatment of acute pelvic inflammatory disease (PID); used in conjunction with other anti-infectives. Metronidazole is included in PID regimens to provide coverage against anaerobes.

When a parenteral regimen is indicated for PID, an initial regimen of IV cefoxitin and IV or oral doxycycline is recommended followed by oral doxycycline; if tubo-ovarian abscess is present, some experts recommend that the oral follow-up regimen include metronidazole (or clindamycin) in addition to doxycycline.

When an oral regimen is indicated for PID, an single IM dose of ceftriaxone, cefoxitin (with oral probenecid), or cefotaxime is recommended in conjunction with oral doxycycline (with or without oral metronidazole). Alternatively, if a parenteral cephalosporin is not feasible and the community prevalence and individual risk for gonorrhea is low, a regimen of oral levofloxacin or oral ofloxacin (with or without oral metronidazole) may be considered.

Treatment of intra-abdominal infections (including peritonitis, intra-abdominal abscess, liver abscess) caused by susceptible Bacteroides (including the B. fragilis group), Clostrium, Eubacterium, P. niger, or Peptostreptococcus.

Treatment of CNS infections (including meningitis, brain abscess) caused by Bacteroides (including the B. fragilis group).

Treatment of respiratory tract infections (including pneumonia) caused by Bacteroides (including the B. fragilis group).

Treatment of septicemia caused by Bacteroides (including the B. fragilis group) or Clostridium.

Treatment of skin and skin structure infections caused by Bacteroides (including the B. fragilis group), Clostridium, Fusobacterium, P. niger, or Peptostreptococcus.

Treatment of acute intestinal amebiasis and amebic liver abscess caused by Entamoeba histolytica. Oral metronidazole or oral tinidazole followed by a luminal amebicide (iodoquinol, paromomycin) is the regimen of choice for mild to moderate or severe intestinal disease and for amebic hepatic abscess.

Treatment of bacterial vaginosis (formerly called Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis) in pregnant or nonpregnant women.

CDC recommends treatment of bacterial vaginosis in all symptomatic women (including pregnant women). In addition, asymptomatic pregnant women at high risk for complications of pregnancy should be screened (preferably at the first prenatal visit) and treatment initiated if needed.

Treatment recommendations for bacterial vaginosis in HIV-infected women are the same as those for women without HIV infection.

Regimens of choice in nonpregnant women are a 7-day regimen of oral metronidazole, a 5-day regimen of intravaginal metronidazole gel, or a 7-day regimen of intravaginal clindamycin cream; alternative regimens are a 7-day regimen of oral clindamycin or 3-day regimen of intravaginal clindamycin suppositories. The preferred regimens for pregnant women are a 7-day regimen of oral metronidazole or a 7-day regimen of oral clindamycin.

Regardless of regimen used, relapse or recurrence is common; an alternative regimen (e.g., topical therapy when oral therapy was used initially) may be used in such situations.

Routine treatment of asymptomatic male sexual contacts of women who have relapsing or recurrent bacterial vaginosis not recommended.

Alternative to tetracycline for treatment of balantidiasis caused by Balantidium coli.

Treatment of infections caused by Blastocystis hominis. May be effective, but metronidazole resistance may be common.

Clinical importance of B. hominis as a cause of GI pathology is controversial; unclear when treatment is indicated. Some clinicians suggest treatment be reserved for certain individuals (e.g., immunocompromised patients) when symptoms persist and no other pathogen or process is found to explain their GI symptoms.

Treatment of Clostridium difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis, C. difficile diarrhea, C. difficile colitis, and pseudomembranous colitis).

Drugs of choice are metronidazole and vancomycin; metronidazole generally preferred and vancomycin reserved for those with severe or potentially life-threatening colitis, patients in whom metronidazole-resistant C. difficile is suspected, patients in whom metronidazole is contraindicated or not tolerated, or those who do not respond to metronidazole.

Mangement of Crohn’s disease as an adjunct to conventional therapies.

Has been used with or without ciprofloxacin; for induction of remission of mildly to moderately active Crohn’s disease.

Has been used for refractory perianal Crohn’s disease.

Treatment of infections caused by Dientamoeba fragilis. Drugs of choice are iodoquinol, paromomycin, tetracycline, or metronidazole.

Treatment of dracunculiasis caused by Dracunculus medinensis (guinea worm disease).

Treatment of choice is slow extraction of worm combined with wound care. Metronidazole is not curative, but decreases inflammation and facilitates worm removal.

Treatment of giardiasis. Drugs of choice are metronidazole, tinidazole, or nitazoxanide; alternatives are paromomycin, furazolidone (no longer commercially available in the US), or quinacrine (not commercially available in the US).

Treatment of asymptomatic carriers of giardiasis. Treatment of such carriers not generally recommended, except possibly in patients with hypogammaglobulinemia or cystic fibrosis or in an attempt to prevent household transmission of the disease from toddlers to pregnant women.

Treatment of Helicobacter pylori infection and duodenal ulcer disease (active or a history of duodenal ulcer); eradication of H. pylori has been shown to reduce the risk of duodenal ulcer recurrence.

Used in a multiple-drug regimen that includes metronidazole, tetracycline, and bismuth subsalicylate and a histamine H2-receptor antagonist. If initial 14-day regimen does not eradicate H. pylori, a retreatment regimen that does not include metronidazole should be used.

Treatment of recurrent and persistent urethritis in patients with nongonococcal urethritis who have already been treated with a recommended regimen (i.e., azithromycin, doxycycline, erythromycin, ofloxacin or levofloxacin).

Oral metronidazole or oral tinidazole used in conjunction with oral azithromycin (if azithromycin was not used in the initial regimen) is the regimen recommended by CDC for recurrent and persistent urethritis in patients who were compliant with their initial regimen and have not been re-exposed.

Treatment of inflammatory lesions (papules and pustules) and erythema associated with rosacea (acne rosacea). Topical metronidazole may be preferred to oral metronidazole.

Adjunct in treatment of tetanus caused by C. tetani.

Treatment of symptomatic and asymptomatic trichomoniasis when Trichomonas vaginalis has been demonstrated by an appropriate diagnostic procedure (e.g., wet smear and/or culture, OSOM Trichomonas Rapid Test, Affirm VP III).

Drug of choice is metronidazole or tinidazole. Goal of treatment is to provide symptomatic relief, achieve microbiologic cure, and reduce transmission; to achieve this goal, both the index patient and sexual (particularly steady) partner(s) should be treated.

If treatment failure occurs with initial metronidazole treatment and reinfection is excluded, alternative regimens using metronidazole or tinidazole can be used. If retreatment is ineffective, consultation with an expert (available through CDC) is recommended.

Perioperative prophylaxis to reduce the incidence of postoperative anaerobic bacterial infections in patients undergoing colorectal surgery. Preferred regimens are IV cefoxitin alone; IV cefazolin and IV metronidazole; oral erythromycin and oral neomycin; or oral metronidazole and oral neomycin.

Perioperative prophylaxis in patients undergoing appendectomy; used in conjunction with cefazolin. Preferred regimens for appendectomy (nonperforated) are IV cefoxitin alone or IV cefazolin and IV metronidazole.

Empiric anti-infective prophylaxis in sexual assault victims; used in conjunction with IM ceftriaxone and oral azithromycin or doxycycline.