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inherently have a pH of 4.5 (range: 3.2-6.5), so it is unknown
whether injury is due to the osmolarity, pH, or some other
factor.20 Similar to osmolarity, the pH at which clinicians
should be alarmed is also largely unknown; however, it is
generally accepted that alkaline solutions are relatively more
caustic to tissues than acidic fluids.4
It should be noted that only one other case report involving intravenous metronidazole injection infiltration was
identified in the literature via a PubMed and International
Pharmaceutical Abstracts inquiry.11 This case involved a
45-year-old patient who was placed on intravenous metronidazole and intravenous ampicillin therapy for antimicrobial
therapy targeted against abdominal pathogens. This patient
experienced an estimated 50-mL volume of metronidazole
infiltration similar to our described case and subsequently
developed "full blown gangrene" of the dorsal portion of his
right hand and a large portion of 4 out of 5 digits within a
day after the event. All laboratory markers were normal, and
aspirin, pentoxifylline, and nifedipine were employed to
mitigate the extensiveness of gangrene development. The
authors should be commended for publishing the first identified case report involving metronidazole injection infiltration, as it is clear that more case reports and case series
would contribute to the knowledge of metronidazole infiltrations. However, there are several aspects of information
which would be of value for full understanding and evaluation of the reported metronidazole infiltration event. First,
medication factors such as the dose, concentration, and
solution vehicle of metronidazole therapy would give clinicians a sense as to the drug product's osmolarity and potential for extravasation injury from a hyperosmolarity
standpoint. Also, it is unclear whether the medications presented encompass all medications which were administered
via the implied access site. Of course, if the intravenous
access site had been utilized for other medication therapy,
these would need to be considered in terms of potential culprit agents. The authors only comment on the fact that ampicillin and intravenous fluids were administered via an
alternate access site, and it seems probable that a patient
presenting with profound emesis and diarrhea potentially
received other intravenous agents to aid symptom control
during the inpatient admission including at least antiemetics. If by chance, promethazine was administered intravenously during the hospitalization and prior to the
development of gangrene, we would consider this to be the
most likely cause of the outcomes based upon past case
reports.21-23

Conclusion
We describe a case of metronidazole injection infiltration
which did not require pharmacologic or nonpharmacologic interventions and resulted in marked resolution
shortly after the event. This case supplements the current

Hospital Pharmacy 52(8)
literature by contrasting the sole other case report which
resulted in profound necrosis near the intravenous access
site. This case suggests intravenous metronidazole injection infiltrations may not require clinician alarm or treatment if events occur under circumstances similar to that
which is presented.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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