Metronidazole-associated neurologic events: a nested-case control study

Background — Case reports have described instances of peripheral and central nervous system toxicity during treatment with metronidazole, however, no large-scale studies have examined this association.

Methods — We conducted a population-based nested case control study of adults aged 66 years or older living in Ontario, Canada between April 1, 2003 to March 31, 2017. Cases were individuals who attended hospital for any of cerebellar dysfunction, encephalopathy or peripheral neuropathy within 100 days of a prescription for either metronidazole or clindamycin. We matched each case patient with up to 10 event-free control subjects who also received metronidazole or clindamycin. We used conditional logistic regression to test the association between metronidazole exposure and neurologic events, with clindamycin as the reference exposure.

Results — We identified 1,212 cases with recent use of either metronidazole or clindamycin and 12,098 controls. Neurologic adverse events were associated with an increased odds of metronidazole exposure compared to clindamycin (OR: 1.72; 95% CI: 1.53-1.94), which persisted after accounting for patient demographics, comorbidities and other medication exposures (aOR: 1.43; 95% CI: 1.26 to 1.63). We found a consistent association limited to either central (aOR: 1.46; 95% CI: 1.27 to 1.68) or peripheral (aOR: 1.34; 95% CI: 1.02 to 1.76) nervous system events. Among metronidazole recipients, the overall incidence of neurologic events at 100 days was approximately 0.25%.

Conclusions — Metronidazole is associated with an increased risk of adverse peripheral and central nervous system events relative to clindamycin. Clinicians and patients should be aware of these rare, but potentially serious adverse events.