1. METRONIDAZOLE PROF. DR. MARLINA, MS, Apt.

2. GENERIC NAME: metronidazole DRUG CLASS AND MECHANISM: Metronidazole is an antibiotic effective against anaerobic bacteria and certain parasites.

3. Anaerobic bacteria are single-celled, living organisms that thrive in environments in which there is little oxygen (anaerobic environments) and can cause disease in the abdomen (bacterial peritonitis), liver (liver abscess), and pelvis (abscess of the ovaries and the Fallopian tubes).

4. Giardia lamblia and ameba are intestinal parasites that can cause abdominal pain and diarrhea in infected individuals. Giardia lambliaabdominal paindiarrhea Trichomonas is a vaginal parasite that causes inflammation of the vagina (vaginitis).vaginitis Metronidazole selectively blocks some of the functions within the bacterial cells and the parasites resulting in their death.

5. PREPARATIONS: Tablets: 250 and 500 mg. Tablets, extended release: 750 mg. Capsule: 375 mg. Cream: 0.75% and 1%. Lotion: 0.75%. Gel: 0.75% 1%. Injection: 5 mg/ml

7. STORAGE: Metronidazole should be stored at room temperature and protected from light.

8. PRESCRIBED FOR: Metronidazole is used to treat parasitic infections including : ▫Giardia infections of the small intestine, ▫amebic liver abscess, and amebic dysentery (infection of the colon causing bloody diarrhea), ▫bacterial vaginosis, trichomonas vaginal infections,bacterial vaginosis ▫ and carriers of trichomonas (both sexual partners) who do not have symptoms of infection.

9. Metronidazole is also used alone or in combination with other antibiotics in treating abscesses in the liver, pelvis, abdomen, and brain caused by susceptible anaerobic bacteria.

10. Metronidazole is also used in treating infection of the colon caused by a bacterium called C. difficile. (Many commonly-used antibiotics can alter the type of bacteria that inhabit the colon.C. difficile C. difficile is an anaerobic bacterium that can infect the colon when the normal types of bacteria in the colon are inhibited by common antibiotics. This leads to inflammation of the colon (pseudomembranous colitis) with severe diarrhea and abdominal pain.)colitis

11. Metronidazole also is used in combination with other drugs to treat Helicobacter pylori (H. pylori) that causes stomach or intestinal ulcers.Helicobacter pylori Metronidazole topical gel is used for treating acne rosacea, and the vaginal gel is used for treating bacterial vaginosis. acne rosacea

12. DOSING: Metronidazole may be taken orally with or without food. In the hospital, metronidazole can be administered intravenously to treat serious infections. The liver is primarily responsible for eliminating metronidazole from the body, and doses may need to be reduced in patients with liver disease and abnormal liver function. liver disease

13. Various metronidazole regimens are used. Some examples are listed below. Amebic dysentery: 750 mg orally 3 times daily for 5-10 days Amebic liver abscess: 500-750 mg orally three times daily for 5-10 days Anaerobic infections: 7.5 mg/kg orally every 6 hours not to exceed 4 grams daily

14. Bacterial Vaginosis: 750 mg (extended release tablets) once daily for 7 days. One applicator-full of 0.75% vaginal gel, once or twice daily for 5 days. Clostridium difficile infection: 250-500 mg orally 4 times daily or 500-750 orally 3 times daily Giardia: 250 mg orally three times daily for 5 days

15. Helicobacter pylori: 800-1500 mg orally daily for several days in combination with other drugs.Helicobacter pylori Pelvic inflammatory disease (PID): 500 mg orally twice daily for 14 days in combination with other drugs.Pelvic inflammatory disease Trichomoniasis: 2 g single dose or 1 g twiceTrichomoniasis Rosacea: apply topical gel 0.75-1% once dailyRosacea

16. Why Metronidazole Is Active against both Bacteria and Parasites Metronidazole is one of the rare examples of a drug developed against a parasite which has since gained broad use as an antibacterial agent (24).24 Briefly, at Rhone-Poulenc labs in France, extracts of Streptomyces spp. were screened for activity against Trichomonas vaginalis, a cause of vaginal itching.

17. Azomycin, a nitroimidazole, was identified, and metronidazole, a synthetic derivative, was used to treat chronic trichomonad infections, beginning in 1959 (66).66

18. Metronidazole was shown to be efficacious against Entamoeba histolytica, the cause of amebic dysentery and liver abscess, in 1966 (67).67 Giardia lamblia (also known as G. duodenalis) was treated with metronidazole after this luminal parasite was recognized as a cause of malabsorption and epigastric pain in the 1970s (102).102

19. The antibacterial activity of metronidazole was discovered by accident in 1962 when metronidazole cured a patient of both trichomonad vaginitis and bacterial gingivitis (78).78 However, it was not until the 1970s that metronidazole was popularized for treatment of infections caused by gram-negative anaerobes such as bacteroides or gram-positive anaerobes such as clostridia (24, 48).2448

20. Presently, metronidazole, which is inexpensive, has good tissue penetration, and produces relatively mild side effects, is on the formulary at most hospitals for prophylaxis against anaerobic infection after bowel surgery, for treatment of wound abscess, and for treatment of antibiotic- associated colitis caused by Clostridium difficile (85, 94).8594

21. Metronidazole is an important part of combination therapy against Helicobacter pylori, a major cause of gastritis and a risk factor for stomach cancer (21,57).2157

22. NEW IDEAS ABOUT METRONIDAZOLE- SENSITIVE PARASITES Luminal parasites have two characteristics which distinguish them from other eukaryotes: (i) they live under anaerobic conditions, and (ii) they lack mitochondria and enzymes of oxidative phosphorylation (61).61

23. Indeed, a widely held view is that luminal parasites are “living fossils,” which reflect eukaryotic lifestyles prior to oxygenation of the planet and acquisition of the mitochondrial endosymbiont (2, 9, 68).2968

24. This conclusion is supported by the presence of amebae, giardia, and trichomonads at or near the bases of the eukaryotic phylogenetic trees constructed from small subunit rRNA sequences (82).82

25. Further, these luminal parasites lack centrioles, Golgi with tight lamellae (giardia and amebae), and introns (giardia and trichomonads) (1, 26, 51, 55, 81).126 515581

26. Recent studies of metronidazole-sensitive parasites suggest that these organisms are not living fossils but instead are diverse eukaryotes with novel adaptations to their anaerobic niche.

27. First, amebae and giardia lack fermentation enzymes (lactate dehydrogenase and pyruvate decarboxylase), which are present in yeast and other eukaryotes (60, 90).6090 Second, luminal parasites appear to have acquired by horizontal transfer bacterial genes which encode fermentation enzymes (72, 80).7280 These include an iron-sulfur protein called pyruvate:ferredoxin oxidoreductase (POR), which is involved in metronidazole activation (36, 64, 88).366488 Third, all of these “amitochondriate” parasites have a gene encoding a homologue of the mitochondrial 60-kDa heat shock protein (Hsp60) (11, 15, 32, 34,70, 71).111532 347071

28. The trichomonad mitochondrion has been converted into a fermentation factory called “hydrogenosome” (5, 8, 11-13, 36,40, 62). The mitochondrion-derived organelle of amebae is atrophic, while that of giardia may have been lost (26, 52, 71,84).5811-1336406226527184

29. The goals of this review are to : (i) demonstrate how luminal parasites are similar to and different from each other, (ii) discuss the biochemistry and phylogeny of bacterium-like fermentation enzymes involved in metronidazole activation, (iii) explore the peculiar compartmentalization of these fermentation enzymes, and (iv) discuss mechanisms of metronidazole resistance in these parasites. Readers are referred to recent reviews of the clinical uses of metronidazole and of metronidazole resistance in H. pylori and other anaerobic bacteria (24, 30, 48, 57, 64, 85, 89, 94, 102).2430485764858994102

30. DIVERSE MORPHOLOGY OF METRONIDAZOLE- SENSITIVE ORGANISMS The bacteria and parasites treated with metronidazole, which share an anaerobic niche in the lumen of the bowel or vagina and in tissue abscesses, show little resemblance to each other (61).61 For example, amebae have a large cytosol that is filled with vesicles and vacuoles that resemble those of macrophages (55).55

31. Like macrophages, amebae phagocytose bacteria, including anaerobic bacteria such as Clostridia spp. or facultative anaerobes such asEscherichia coli (59).59 Giardias have two identical nuclei, multiple flagellae, and a sucker disc, which is composed of a set of unique cytoskeletal proteins called “giardins” (1, 26).126

32. Trichomonads alternate between an ameboid form, which phagocytoses bacteria like entamoebae, and a flagellated form, which moves somewhat as do giardias (66).66 In the pouch or rumen of bicloved mammals (e.g., sheep or cows), cellulose is degraded by anaerobic bacteria, as well as anaerobic fungi and ciliates (14).14

33. The rumen fungi (e.g., Neocallimastix,Piromyces, and Orpinomyces) are filamentous and resemble the more familiar hyphal fungi, which are facultative anaerobes, such as Aspergillus and Candida(92).92

34. The rumen ciliates (e.g., Polyplastron andDasytricha), which are covered with cilia, resemble their aerobic counterparts, such as Paramecium and Tetrahymena (20, 33, 65).203365