Metronidazole

Metronidazole [1-(2-hydroxyethyl)-2-methyl-5-nitroimidazole], a nitroimidazole antimicrobial, was introduced in 1960 and quickly became the treatment of choice for Trichomonas vaginalis.¹ Initially, metronidazole was regarded as an antiprotozoal agent, proving to be an effective treatment for such infections as trichomoniasis, amebiasis, and giardiasis. The antibacterial activity of metronidazole versus obligate anaerobes was not widely recognized until the 1970s.^2,³ Since then, metronidazole has been used extensively for anaerobic infections such as Clostridium difficile infection (CDI) and those involving Bacteroides spp.

Because metronidazole has been in use for more than 40 years, a plethora of information exists regarding basic knowledge about this antimicrobial, including the mechanism of action, spectrum of activity, pharmacokinetics, adverse drug effects, and clinical uses. The newest addition to the nitroimidazole antimicrobial class is tinidazole, which was approved by the U.S. Food and Drug Administration (FDA) in 2004.⁴ However, this agent is not widely used for infections of a nonparasitic nature, so much of the discussion in the chapter is focused on metronidazole.

Mechanism of Action

Metronidazole possesses bactericidal activity against obligate anaerobes, although the mechanism of action has not yet been thoroughly elucidated. Metronidazole is a prodrug, requiring intracellular nitroreduction to become active; thus metronidazole in the unchanged form is not pharmacologically active.¹ During the process of reduction, cytotoxic intermediates are formed, and these intermediates are thought to be responsible for killing the cells. The reduction process depends on ongoing energy metabolism but not on ongoing cell multiplication, which translates into activity against both dividing and nondividing cells.^1,⁴

Spectrum of Activity and Clinical Uses

Anaerobic bacteria of the Bacteroides fragilis group are known to be the most clinically important anaerobic pathogens, owing to their multidrug-resistant nature and the frequency with which they are involved in infectious diseases including polymicrobial infections such as intraabdominal infections, obstetric-gynecologic infections, and diabetic foot infections.^5,⁶ Nosocomial diarrhea and/or pseudomembranous colitis associated with antibiotic use are frequently caused by Clostridium difficile, another clinically important anaerobe.⁷ Metronidazole is highly effective against both of these medically relevant anaerobes (Table 125-1). Although metronidazole possesses significant antimicrobial activity against several obligate anaerobes, it is not considered to be clinically active versus aerobic bacteria.¹ Tinidazole has similar spectrum of activity to metronidazole against most anaerobic bacteria, including B. fragilis and microaerophilic bacteria such as Helicobacter pylori and Campylobacter spp., but is only currently approved for the treatment of trichomoniasis, giardiasis, amebiasis, and amebic liver abscess. Other uses outside of these indications are considered experimental.⁸

TABLE 125-1 Metronidazole Minimal Inhibitory Concentration and Percent Susceptibility for Various Anaerobes

Anaerobe (No. of Isolates Tested)	MIC90 (mg/L)	% Susceptible
Clostridium difficile (186)	2	100
Peptostreptococcus (49)	2	94
Bacteroides fragilis group* (401)	1	100
Prevotella spp. (65)	2	100
Fusobacterium spp. (22)	2	100
Porphyromonas spp. (19)	2	100

MIC90, minimum inhibitory concentration that inhibits 90% of organisms.

* Includes Bacteroides fragilis, B. distasonis, B. thetaiotaomicron, B. ovatus, B. vulgatus, B. uniformis.

Adapted and modified from Drummond LJ, McCoubrey J, Smith DG et al. Changes in sensitivity patterns to selected antibiotics in Clostridium difficile in geriatric in-patients over an 18-month period. J Med Microbiol 2003;52:259-63; and from Aldridge KE, Ashcraft D, Cambre K et al. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother 2001;45:1238-43.

Clinically, metronidazole has been used successfully to treat anaerobic bacteremia, endocarditis, meningitis, brain abscesses, intraabdominal infections, and mixed aerobic-anaerobic infections, although the addition of an antibiotic effective against aerobic bacteria is necessary for the latter.^2,⁹^–¹¹ Additionally, although without formal FDA approval, metronidazole remains the drug of choice for mild and moderate CDI due to historical and epidemic BI/NAP1/027 strains, owing to excellent oral bioavailability, low potential for selecting for vancomycin-resistant Enterococcus (VRE), lack of detectable resistance among BI/NAP/027 strains, and low cost.¹² However, in patients with severe CDI, treatment with metronidazole resulted in a less than optimal response compared to oral vancomycin therapy.¹³ Consequently, vancomycin is the preferred agent for severe CDI.¹²

Pharmacokinetics

Given orally, metronidazole is almost completely absorbed, with a bioavailability of greater than 90%.¹⁴ In patients with CDI, absorption of oral metronidazole is reduced due to increased bowel emptying causing fecal concentrations to be high, coupled with secretion from plasma into the colon.¹⁵ However, levels decrease rapidly after treatment of CDI is initiated, from 9.3 mg/g in watery stools to 1.2 mg/g in formed stools to an undetectable level once diarrhea has resolved.¹⁵ Intravenous metronidazole is able to maintain high fecal levels in patients with CDI with toxic megacolon or ileus; otherwise, oral metronidazole is recommended.^12,¹⁵ Metronidazole is a relatively small molecular entity (molecular weight = 171.16 D) with low protein binding (<20%) and is widely distributed throughout the body.¹ The steady-state volume of distribution in adults is 0.51 to 1.1 L/kg.¹³ The elimination half-life of metronidazole is 6 to 8 hours for patients with normal liver function.^1,¹⁴ Metronidazole undergoes metabolism in the liver to form five known metabolites, two of which are 1-(2-hydroxyethyl)-2-hydroxymethyl-5-nitroimidazole (the hydroxy metabolite) and 2-methyl-nitroimidazole-1-acetic acid (the acid metabolite). The hydroxy metabolite exhibits 30% to 65% of the anaerobic activity of the parent compound.¹⁴

Adverse Reactions

The most common side effects of metronidazole treatment (at standard doses) are gastrointestinal disturbances including mild nausea, a bad/metallic taste in the mouth, and furring of the tongue. More rare adverse reactions to metronidazole include vaginal and/or urethral burning, dark/discolored urine, and neurologic toxicity such as headache, ataxia, vertigo, somnolence, depression, and peripheral neuropathy.¹ Metronidazole is recognized for causing a disulfiram-like reaction with the concurrent ingestion of alcohol. However, a study conducted by Visapää and coworkers found no evidence of disulfiram-like properties of metronidazole when it was given concomitantly with ethanol,¹⁶ and this reaction has also been disputed by others.¹⁷

Pharmacodynamics

The standard dosing regimen for metronidazole (500-1000 mg q 6-8h) was determined long before pharmacodynamics emerged as a science. Metronidazole exhibits concentration-dependent bactericidal activity along with a significant post-antibiotic effect (>3 h).^14,¹⁸^–²⁰ These factors, in combination with a long half-life and a favorable safety profile, provide a wide corridor to manipulate the metronidazole dose and dosage interval. Much more convenient regimens of larger doses (e.g., 1000-1500 mg) given every 12 hours or once daily are plausible because of the pharmacokinetic and pharmacodynamic (PK/PD) characteristics of this antibiotic.^18,¹⁹ PK analyses show that similar and adequate drug exposure is achievable with metronidazole doses of 500 mg every 8 hours, 1000 mg daily, or 1500 mg daily.^19,²¹ Therefore, from a convenience and cost standpoint, once-daily doses of metronidazole may be adequate when the organism minimum inhibitory concentration (MIC) is less than 2 mg/L.^19,²¹ Knowledge of pharmacodynamic parameters and utilization of such parameters to appropriately dose patients is of utmost importance in the current era of antimicrobial resistance.

Resistance

With more than 40 years of clinical use, worldwide resistance of anaerobes to metronidazole is estimated to be less than 5%.²² A recent multicenter study conducted in the United States reported the first confirmed metronidazole-resistant B. fragilis isolate (MIC = 64 mg/mL) in 2002.²³ Following this report, additional data collected revealed two more isolates that were metronidazole resistant, one of which was also a B. fragilis isolate.²² This report is the first to document metronidazole resistance among Bacteroides spp. and, although negligible, still raises concern, since susceptibility testing is not typically performed on anaerobic cultures. The concern with increasing resistance is not limited to metronidazole alone but includes agents such as ampicillin/sulbactam, clindamycin, and moxifloxacin. Susceptibility of carbapenems, cefoxitin, and piperacillin/tazobactam appears stable.²²

Four genes (chromosomally borne nimB and plasmid-borne nimA, nimC, and nimD) of Bacteroides spp. are commonly associated with metronidazole resistance.^1,¹¹ The suggested mechanism of resistance mediated by these genes is the conversion of the nitro group of metronidazole to an amino group, foregoing the formation of the toxic nitroradicals.¹¹ Evidence of gene transfer has also been found within different Bacteroides spp. and between Bacteroides and Prevotella.¹¹

Diniz and associates exposed B. fragilis group species to 4 mg/L of metronidazole and found that exposure to low levels of metronidazole increased both the virulence and the viability of the isolates.⁶ Another factor to consider is the supposed protective effect of Enterococcus faecalis on B. fragilis when exposed to metronidazole.²⁴ The investigators found that E. faecalis was able to negate the bactericidal effect of metronidazole on B. fragilis. However, a more recent study could not confirm these findings.²⁵

Using a resistance breakpoint of 32 mg/L or higher for metronidazole, Peláez and coworkers, when studying 415 C. difficile isolates, found that 6.3% of the isolates were resistant.²⁶ Another study evaluated the susceptibility patterns of 186 C. difficile isolates from a geriatric population.⁷ Contrary to the findings of Peláez and associates, no resistance to metronidazole was documented.

Susceptibility testing of anaerobes is usually either not performed or not used to make clinical decisions because of several limiting factors: the slow growth of anaerobes, convolution of the testing method, questions surrounding the appropriate testing media, involvement of multiple organisms in anaerobic infections, and the generally held belief that susceptibility patterns of anaerobes have not changed over the years and remain forseeable.²⁷ Studies have proven the value and importance of susceptibility testing, showing that appropriate initial therapy is critical to a positive patient outcome²⁸ and that in vitro susceptibility results reliably predict the clinical outcome of patients.²⁷ Therefore, clinicians must realize that susceptibility testing of anaerobes is necessary and that the susceptibility patterns have changed over the years.

Other Agents Effective Against Obligate Anaerobes

Several classes of antimicrobials, including some broad-spectrum penicillins, clindamycin, carbapenems, β-lactam/β-lactamase inhibitor combinations, certain cephalosporins, certain quinolones, and glycylcyclines, exhibit activity versus certain anaerobic bacteria.¹¹ Metronidazole, carbapenems, and piperacillin/tazobactam have proven to be the most reliable agents, whereas clindamycin, moxifloxacin, piperacillin alone, and cephalosporins such as cefotetan and cefoxitin have exhibited significantly decreased susceptibility rates.^5,^11,²² In vitro studies of select compounds (Tables 125-2 and 125-3) from the representative class of antibacterials with anaerobic activity showed better than 15% resistance to B. fragilis group in the United States as well as in other parts of the world.¹¹ The species that are worrisome include Bacteroides ovatus versus carbapenems, Bacteroides vulgatus versus piperacillin/tazobactam, Bacteroides distasonis versus ampicillin/sulbactam and cefoxitin, and Bacteroides ovatus, Bacteroides uniformis, and Bacteroides vulgatus versus moxifloxacin and clindamycin.²² The newest glycylcycline, tigecycline, has extensive activity against anaerobes, with resistance rates that compare to those of the β-lactam class.²⁹ The clinical utility of these agents for intraabdominal infections is extensively reviewed in the intraabdominal guidelines by the Infectious Diseases Society of America (IDSA) and the Surgical Infection Society.³⁰ β-Lactams such as piperacillin/tazobactam and carbapenem monotherapy are reserved for complicated cases of intraabdominal infection, whereas metronidazole is the anaerobic agent of choice for combination therapy with agents devoid of clinically significant anaerobic activity.³⁰

TABLE 125-2 Antibacterial Activity of Various Antibiotic Agents Against Several Anaerobes

Anaerobe and Antimicrobial Agent (No. of Isolates Tested)	MIC90 (mg/L)	% Susceptible
*Prevotella spp.*^a^,^b
Penicillin G (65)	16	17
Piperacillin/tazobactam (65)	≤0.06	100
Ampicillin/sulbactam (65)	4	100
Cefoxitin (65)	4	100
Doripenem (35)	0.5	100
Ertapenem (35)	0.25	100
Imipenem (65)	0.06	100
Meropenem (65)	0.12	100
Ciprofloxacin (65)	16	35
Clindamycin (65)	4	89.2
*Fusobacterium spp.*^a^,^b
Penicillin G (22)	0.5	91
Piperacillin/tazobactam (22)	0.12	100
Ampicillin/sulbactam (22)	0.25	100
Cefoxitin (22)	0.5	100
Doripenem (15)	1	100
Ertapenem (15)	1	93
Imipenem (15)	0.12	100
Meropenem (15)	0.5	95
Ciprofloxacin (22)	2	96
Clindamycin (22)	0.12	91
*Porphyromonas spp.*^a^,^b
Penicillin G (19)	4	79
Piperacillin/tazobactam (19)	1	100
Ampicillin/sulbactam (19)	1	100
Cefoxitin (19)	4	95
Doripenem (20)	0.5	100
Ertapenem (20)	0.5	95
Imipenem (20)	0.12	100
Meropenem (20)	0. 5	95
Ciprofloxacin (19)	4	90
Clindamycin (19)	8	90
*Peptostreptococcus*^a^,^c
Penicillin G (49)	0.5	94
Piperacillin/tazobactam (10)	0.5	100
Ampicillin/sulbactam (10)	2	100
Cefoxitin (10)	1	100
Doripenem (10)	0.125	100
Ertapenem (10)	0.125	100
Imipenem (10)	0.25	100
Meropenem (10)	0.125	100
Moxifloxacin (10)	32	60
Clindamycin (10)	32	80

MIC90, minimum inhibitory concentration that inhibits 90% of organisms.

Adapted and modified from ^aAldridge KE, Ashcraft D, Cambre K et al. Multicenter survey of the changing in vitro antimicrobial susceptibilities of clinical isolates of Bacteroides fragilis group, Prevotella, Fusobacterium, Porphyromonas, and Peptostreptococcus species. Antimicrob Agents Chemother 2001;45:1238-43; and from ^bWexler HM, Engel AE, Glass D, Li C. In vitro activities of doripenem and comparator agents against 364 anaerobic clinical isolates. Antimicrob Agents Chemother 2005;49:4413-7; and from ^cSnydman DR, Jacobus NV, McDermott LA. In vitro activities of doripenem, a new broad-spectrum carbapenem, against recently collected clinical anaerobic isolates, with emphasis on the Bacteroides fragilis group. Antimicrob Agents Chemother 2008;52:4492-6.

TABLE 125-3 Antibacterial Activity of Various Antibiotic Agents Against B. fragilis Group Isolates

Antibiotic Agent (No. of Isolates Tested)	MIC90 (mg/L)	% Susceptible^a
Penicillin G (160)^a	128	0
Piperacillin (384)^a	128	77
Ticarcillin (137)^a	128	63
Piperacillin/tazobactam (142)^a	8	99.3
Ticarcillin/clavulanate (191)^a	8	96
Ampicillin/sulbactam (382)^a	8	93
Cefoxitin (515)^a	32	84
Cefotetan (473)^a	64	64
Imipenem (378)^a	1	99.5
Meropenem (127)^a	0.5	98
Ertapenem (92)^a	2	94
Doripenem (1351)^b	0.5	98.7
Clindamycin (1351)^b	>128	64
Moxifloxacin (1351)^b	32	59.2
Tigecycline (1351)^b	8	95.3

MIC90, minimum inhibitory concentration that inhibits 90% of organisms.

^a Isolates categorized according to CLSI breakpoints. Nonsusceptible isolates include both intermediate and resistant isolates.

Adapted and modified from Alridge KE, Ashcraft D, O’Brien M et al. Bacteremia due to Bacteroides fragilis group: distribution of species, β-lactamase production, and antimicrobial susceptibility patterns. Antimicrob Agents Chemother 2003;47:148-53; and from ^bSnydman DR, Jacobus NV, McDermott LA et al. Lessons learned from the anaerobe survey: historical perspective and review of the most recent data (2005-2007). Clin Infect Dis 2010;50:S26-33.

Beta-Lactam Antibiotics

Some β-lactam antibiotics, including some broad-spectrum penicillins (piperacillin, ticarcillin), β-lactam/β-lactamase inhibitors (piperacillin/tazobactam, ticarcillin/clavulanate, ampicillin/sulbactam, amoxicillin/clavulanate), certain cephalosporins (e.g., cefoxitin, cefotetan), and carbapenems (imipenem, meropenem, ertapenem, doripenem), possess activity versus various anaerobic bacteria.^5,^11,²² Because β-lactams are generally regarded as concentration-independent or time-dependent antibiotics, the free drug concentration must remain above the MIC (%fT>MIC) for a certain proportion of the dosing interval. Although several investigators have demonstrated antibacterial activity of β-lactams with percent time free drug fraction is above MIC being as little as 40% of the dosing interval,¹⁸ the pharmacodynamic characteristics of β-lactam antibiotics against anaerobic bacteria have not been well characterized. However, owing to the existing knowledge of β-lactam pharmacodynamics, once-daily regimens are unlikely to be effective. However, when comparing the β-lactams, some agents do have more convenient regimens than others because of differences in their pharmacokinetics (e.g., ertapenem 1000 mg q 24 h versus cefoxitin 1000 mg q 6 to 8 h).

Several β-lactam antibiotics have circumvented much of the resistance among anaerobes, maintaining relatively high susceptibility rates. Aldridge and associates showed that the susceptibility of Prevotella spp., Fusobacterium spp., Porphyromonas spp., and Peptostreptococcus was the highest and the most consistent for piperacillin-tazobactam, imipenem, and meropenem (see Table 125-2).³¹ In vitro data for doripenem, the newest addition to the carbapenem class, show that its activity mirrors that of meropenem in terms of gram-negative activity, and that of imipenem with respect to gram-positive activity (see Tables 125-2 and 125-3).³²

Resistance of B. fragilis group isolates to β-lactams can be caused by β-lactamase production, alteration in penicillin-binding proteins, changes in outer membrane permeability, and efflux.¹¹ Aldridge and associates found the order of activity of cephalosporins-cephamycins against B. fragilis group species to be cefoxitin > ceftizoxime > cefotetan = cefotaxime = cefmetazole > ceftriaxone, whereas no isolates were susceptible to penicillin G.⁵ Piperacillin and ticarcillin alone exhibited 77% and 63% susceptibility, respectively, whereas piperacillin-tazobactam and ticarcillin-clavulanate showed 99.3% and 96% susceptibility, respectively. Ampicillin-sulbactam, another β-lactam/β-lactamase inhibitor combination, exhibited 93% susceptibility. All carbapenems had favorable activity (see Table 125-3).^5,³² In the study by Snydman et al., a resistance rate of 1.5% was documented for doripenem versus B. fragilis, but no resistance was documented for other Bacteroides spp. or gram-positive anaerobes, including Clostridium spp.³² These rates were not significantly different compared to the other carbapenem agents. In general, the carbapenem agents maintained excellent activity against the tested clinical anaerobes. In the same study, the susceptibility pattern to piperacillin/tazobactam remained stable, with resistance rates similar to those of carbapenems (0.9%-2.3%); however, this was not the case for ampicillin/sulbactam, which showed an increasing resistance trend, particularly to B. distasonis at 20.6%.²²