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Improving malodour management in advanced cancer: a 10-year retrospective study of topical, oral and maintenance metronidazole
  1. Reena George1,
  2. Thotampuri Shanthi Prasoona1,
  3. Ramu Kandasamy1,
  4. Renitha Cherian1,
  5. Thangarathi Celine1,
  6. Jenifer Jeba1,
  7. Shakila Murali1 and
  8. David Mathew2
  1. 1Palliative Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
  2. 2Nuclear Medicine Department, Christian Medical College, Vellore, Tamil Nadu, India
  1. Correspondence to Reena George, Palliative Care Unit, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu 632004, India; reena.vellore{at}


Objectives To explore the relative effectiveness of topical or oral metronidazole used for malodour in necrotic cancers and to propose a protocol for metronidazole usage in managing malodour.

Methods A retrospective case note review of the management of malodour over 10 years comparing outcomes with topical, intermittent and maintenance oral metronidazole.

Results Among 179 patients treated for malodour, the commonest primaries were cervical (45%), and head and neck cancers (40%). Outcomes were poor during the period when only topical or intermittent oral metronidazole was used. Topical use gradually decreased (97% vs 55%) and the proportion of patients receiving maintenance oral metronidazole increased (0% in 2003–2004 vs 93% in 2011). Concurrently, there was reduction in documented malodour (12.5% of visits per patient in 2003–2004 vs 1.5% in 2011, p<0.01).

Conclusions Our data support formulary guidelines recommending maintenance metronidazole for recurrent malodour. Dimethyl trisulfide, a product of anaerobic necrosis causes malodour and can attract maggot-producing flies to decaying tissues. Therefore, to reduce anaerobic malodour in vulnerable settings, we propose a ladder for metronidazole titration. High-risk patients should start with 400 mg thrice daily ×7 days and continue 200 mg once daily. The SNIFFF severity (Smell-Nil, Faint, Foul or Forbidding) can guide follow-up dosage: 200 mg once daily to continue for nil or faint smell; breakthrough courses of 400 mg thrice daily ×1 week for foul smell and 2 weeks for forbidding smell, followed by 200 mg once daily.

The effectiveness and limitations of maintenance metronidazole and the SNIFFF ladder should be prospectively evaluated.

  • metronidazole
  • malodour
  • fungating wounds
  • maggots
  • cervical cancer

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  • Contributors RG designed the study, interpreted data, drafted the SNIFFF protocol and wrote the paper. TSP and RK interpreted and managed data and helped write the paper. RK screened for cases, extracted data, coordinated data management, data presentation and patient follow-up. RMC and TC interpreted and managed data and assisted with data acquisition. RG, TSP, RMC, TC, JJS, SM and DM contributed to the evolution of clinical protocols over the decade. All authors critically reviewed and approved the manuscript.

  • Competing interests None declared.

  • Ethics approval The study received ethical approval from the Institutional Review Board, Christian Medical College, Vellore, India.

  • Provenance and peer review Not commissioned; externally peer reviewed.