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Greener Prescribing: A Quasi-Experimental Study of the Environmental Impact of Metronidazole Dosing Interval
Majd Alsoubani1,2, Maureen Campion1, Somya Swarup3
1Division of Geographic Medicine and Infectious Diseases, Department of Medicine, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA.
Abstract:
Background: Antimicrobial administration is a major contributor to healthcare-associated waste. We evaluated the environmental impact of changing the default metronidazole dosing frequency from three-times-daily (TID) to twice-daily (BID) administration in a three-hospital system. Methods: We conducted a quasi-experimental uncontrolled interrupted time-series study across an integrated health system. Inpatient oral and intravenous metronidazole utilization was assessed from January 2023 through December 2024, before and after a change in the default metronidazole dosing on 1 February 2024. Overall utilization was measured as days of therapy (DOT)/1000 days present (DP), and frequency-specific utilization was standardized as dispensed doses/1000 DP. Plastic waste was estimated using EcoRxChoice, and modeled disposal-related carbon dioxide-equivalent (CO2e) emissions reflected facility-specific incineration and transportation processes. Results: Overall metronidazole utilization remained similar (36.4 pre-intervention vs. 37.2 DOT/1000 DP post-intervention). After implementation TID utilization decreased relative to baseline (-4.41 dispensed doses/1000 DP per month; 95% CI, -6.02 to -2.80 p < 0.001), whereas twice-daily utilization increased (+1.32 dispensed doses/1000 DP per month; 95% CI, 0.37 to 2.27 p = 0.007). Mean modeled plastic waste decreased from approximately 200 to 164 kg/month. Over the 11-month post-intervention period, the monthly trend decreased by 14.63 kg/month relative to the pre-intervention trend (95% CI, -21.42 to -7.83; p < 0.001) and modeled disposal-related 351.3 kg of CO2e. Conclusions: Optimizing antibiotic dosing frequency is a simple, scalable antimicrobial stewardship strategy that was associated with reductions in modeled metronidazole plastic waste and modeled disposal-related emissions while leveraging the established clinical non-inferiority of twice-daily metronidazole dosing.
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