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Clindamycin Hydrochloride

Class: Lincomycins
Note: This monograph also contains information on Clindamycin Phosphate
VA Class: AM350
CAS Number: 21462-39-5
Brands: Cleocin HCL, Cleocin Pediatric, Cleocin Phosphate

Medically reviewed on Jul 9, 2018

Warning

    Diarrhea and Colitis
  • Clostridium difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) has been reported with nearly all anti-infectives, including clindamycin, and may range in severity from mild to life-threatening.121 126 139 Anti-infectives alter normal flora of the colon and may permit overgrowth of C. difficile.121 126 139

  • Because clindamycin has been associated with severe colitis (potentially fatal), it should be reserved for treatment of serious infections when less toxic anti-infectives are inappropriate.121 126 139 Do not use for nonbacterial infections.121 126 139 (See Uses.)

  • C. difficile produces toxins A and B which contribute to development of CDAD.121 126 139 Hypertoxin-producing strains cause increased morbidity and mortality since they may be refractory to anti-infectives and may require colectomy.121 126 139 CDAD must be considered in all patients who present with diarrhea following anti-infective use.121 126 139 Careful medical history is necessary since CDAD has been reported to occur 2 months or longer after administration of anti-infectives.121 126 139

  • If CDAD is suspected or confirmed, ongoing anti-infective use not directed against C. difficile may need to be discontinued.121 126 139 Institute appropriate fluid and electrolyte management, protein supplementation, anti-infective treatment of C. difficile, and surgical evaluation as clinically indicated.121 126 139 (See Superinfection/Clostridium difficile-associated Diarrhea and Colitis [CDAD] under Cautions.)

Introduction

Antibacterial; lincosamide antibiotic derived from lincomycin.121 126 139 140 141

Uses for Clindamycin Hydrochloride

Acute Otitis Media (AOM)

Alternative for treatment of AOM.499

When anti-infectives indicated, AAP recommends high-dose amoxicillin or amoxicillin and clavulanate as drugs of first choice for initial treatment of AOM; certain cephalosporins (cefdinir, cefpodoxime, cefuroxime, ceftriaxone) recommended as alternatives for initial treatment in penicillin-allergic patients without a history of severe and/or recent penicillin-allergic reactions.499

AAP states clindamycin (with or without a third generation cephalosporin) is a possible alternative for treatment of AOM in patients who fail to respond to initial treatment with first-line or preferred alternatives.499

May be effective in infections caused by penicillin-resistant Streptococcus pneumoniae; may not be effective against multidrug-resistant S. pneumoniae and usually inactive against Haemophilus influenzae.499 If used for retreatment of AOM, consider concomitant use of an anti-infective active against H. influenzae and Moraxella catarrhalis (e.g., cefdinir, cefixime, cefuroxime).499

Bone and Joint Infections

Treatment of serious bone and joint infections (including acute hematogenous osteomyelitis) caused by susceptible Staphylococcus aureus or anaerobes.139 590

Adjunct in the surgical treatment of chronic bone and joint infections caused by susceptible bacteria.139

Gynecologic Infections

Treatment of serious gynecologic infections (e.g., endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, postsurgical vaginal cuff infection) caused by susceptible anaerobes.121 126 139

Treatment of pelvic inflammatory disease (PID); used in conjunction with other anti-infectives.344 345 When a parenteral regimen is indicated for treatment of PID, IV clindamycin in conjunction with IV or IM gentamicin is one of several recommended regimens.344 345

Intra-abdominal Infections

Treatment of serious intra-abdominal infections (e.g., peritonitis, intra-abdominal abscess) caused by susceptible anaerobes.121 126 139

No longer routinely recommended for treatment of intra-abdominal infections because of increasing incidence of Bacteroides fragilis resistant to clindamycin.708

Pharyngitis and Tonsillitis

Alternative for treatment of pharyngitis and tonsillitis caused by susceptible S. pyogenes (group A β-hemolytic streptococci; GAS)135 149 292 375 580 in patients who cannot receive β-lactam anti-infectives.292 375 580

AAP, IDSA, and AHA recommend a penicillin regimen (10 days of oral penicillin V or oral amoxicillin or single dose of IM penicillin G benzathine) as treatment of choice for S. pyogenes pharyngitis and tonsillitis;292 375 580 other anti-infectives (oral cephalosporins, oral macrolides, oral clindamycin) recommended as alternatives in penicillin-allergic patients.292 375 580

Respiratory Tract Infections

Treatment of serious respiratory tract infections (e.g., pneumonia, empyema, lung abscess) caused by susceptible S. aureus, S. pneumoniae, other streptococci, or anaerobes.121 126 139 512 513 514

IDSA and ATS consider clindamycin an alternative for treatment of community-acquired pneumonia (CAP) caused by S. pneumoniae or S. aureus (methicillin-susceptible strains) in adults.512 IDSA also considers clindamycin an alternative for treatment of CAP caused by S. pneumoniae, S. pyogenes, or S. aureus in pediatric patients.513 For treatment of pneumonia caused by methicillin-resistant S. aureus (MRSA; also known as oxacillin-resistant S. aureus or ORSA), IDSA states clindamycin is one of several options, unless the strain is resistant to clindamycin.513 514

For information on treatment of CAP, consult current IDSA clinical practice guidelines available at [Web].512 513 514

Septicemia

Treatment of serious septicemia caused by S. aureus, streptococci, or anaerobes.121 126 139

Skin and Skin Structure Infections

Treatment of serious skin and skin structure infections caused by susceptible staphylococci, S. pneumoniae, other streptococci, or anaerobes.121 126 139 514 543 One of several preferred drugs for treatment of staphylococcal and streptococcal skin and skin structure infections, including those known or suspected to be caused by susceptible MRSA.514 543

Treatment of clostridial myonecrosis (gas gangrene) caused by Clostridium perfringens or other Clostridium; used in conjunction with or as alternative to penicillin G.197 292

Alternative for treatment of infected human or animal (e.g., dog, cat, reptile) bite wounds; used in conjunction with either an extended-spectrum cephalosporin or co-trimoxazole.292 543 Purulent bite wounds usually are polymicrobial and broad-spectrum anti-infective coverage recommended.292 543 Nonpurulent infected bite wounds usually caused by staphylococci and streptococci, but can be polymicrobial.543

For information on treatment of skin and skin structure infections, consult current IDSA clinical practice guidelines available at [Web].514 543

Actinomycosis

Alternative to penicillin G or ampicillin for treatment of actinomycosis, including infections caused by Actinomyces israelii.197 292

Anthrax

Alternative for treatment of anthrax.116 117 120

Component of multiple-drug parenteral regimens recommended for treatment of inhalational anthrax that occurs as the result of exposure to B. anthracis spores in the context of biologic warfare or bioterrorism.117 119 120 Initiate treatment with IV ciprofloxacin or doxycycline and 1 or 2 other anti-infective agents predicted to be effective (e.g., chloramphenicol, clindamycin, rifampin, vancomycin, clarithromycin, imipenem, penicillin, ampicillin);117 120 if meningitis is established or suspected, use IV ciprofloxacin (rather than doxycycline) and chloramphenicol, rifampin, or penicillin.117

Based on in vitro data, possible alternative for postexposure prophylaxis following a suspected or confirmed exposure to aerosolized anthrax spores (inhalational anthrax) when drugs of choice (ciprofloxacin, doxycycline) not tolerated or cannot be used.118

Babesiosis

Treatment of babesiosis caused by Babesia microti101 105 134 292 329 or other Babesia.134

Regimens of choice for babesiosis are clindamycin in conjunction with quinine or atovaquone in conjunction with azithromycin.111 134 292 329 Clindamycin and quinine regimen generally preferred for severe babesiosis caused by B. microti134 329 and infections caused by M. divergens, B. duncani, B. divergens-like organisms, or B. venatorum.134

Also consider exchange transfusions in severely ill patients with high levels of parasitemia (>10%), significant hemolysis, or compromised renal, hepatic, or pulmonary function.134 292 329

Bacterial Vaginosis

Treatment of bacterial vaginosis (formerly called Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis).180 181 182 194 196 203 344 345

CDC and others recommend treatment of bacterial vaginosis in all symptomatic women (including pregnant women).344 345

Regimens of choice are 7-day regimen of oral metronidazole; 5-day regimen of intravaginal metronidazole gel; or 7-day regimen of intravaginal clindamycin cream.344 345 Alternative regimens are 2- or 5-day regimen of oral tinidazole; 7-day regimen of oral clindamycin; or 3-day regimen of intravaginal clindamycin suppositories.344 345 Preferred regimens for pregnant women are the oral or intravaginal metronidazole or clindamycin regimens.344

Regardless of treatment regimen used, relapse or recurrence is common;188 192 193 194 195 344 345 retreatment with the same or an alternative regimen (e.g., oral therapy when topical was used initially) may be used in such situations.344

Malaria

Treatment of uncomplicated malaria caused by chloroquine-resistant Plasmodium falciparum or when plasmodial species not identified.113 114 115 134 143 144 Used in conjunction with oral quinine; not effective alone.114 143 144

CDC and others state treatments of choice for uncomplicated chloroquine-resistant P. falciparum malaria or when plasmodial species not identified are the fixed combination of atovaquone and proguanil hydrochloride (atovaquone/proguanil); the fixed combination of artemether and lumefantrine (artemether/lumefantrine); or a regimen of oral quinine in conjunction with doxycycline, tetracycline, or clindamycin.134 143 144 When a quinine regimen used, concomitant doxycycline or tetracycline generally preferred over concomitant clindamycin (more efficacy data available regarding regimens that include a tetracycline);143 clindamycin preferred in young children or pregnant women who should not receive tetracyclines.113 115 134 143 144

Treatment of severe malaria caused by P. falciparum; used in conjunction with IV quinidine gluconate initially and then with oral quinine when an oral regimen tolerated.143 144 Severe malaria requires aggressive antimalarial treatment initiated as soon as possible after diagnosis.143 144

Assistance with diagnosis or treatment of malaria is available from CDC Malaria Hotline at 770-488-7788 or 855-856-4713 from 9:00 a.m. to 5:00 p.m. Eastern Standard Time or CDC Emergency Operation Center at 770-488-7100 after hours and on weekends and holidays.143 144

Pneumocystis jirovecii Pneumonia

Treatment of Pneumocystis jirovecii (formerly Pneumocystis carinii) pneumonia (PCP); used in conjunction with primaquine.134 145 146 148 150 152 153 157 158 159 169 170 206 440 Designated an orphan drug by FDA for treatment of PCP associated with acquired immunodeficiency syndrome (AIDS).212

Co-trimoxazole is drug of choice for treatment of mild, moderate, or severe PCP, including PCP in HIV-infected adults, adolescents, and children.134 440 441 Regimen of primaquine and clindamycin is an alternative for treatment of mild, moderate, or severe PCP in HIV-infected adults and adolescents who have had an inadequate response to co-trimoxazole or when co-trimoxazole is contraindicated or not tolerated.440 Although data not available regarding use in children, regimen of primaquine and clindamycin also can be considered an alternative to co-trimoxazole in HIV-infected children based on data in adults.441

Regimen of primaquine and clindamycin not recommended for prevention of initial episodes (primary prophylaxis) or long-term suppressive or chronic maintenance therapy (secondary prophylaxis) of PCP.440 441 Co-trimoxazole is drug of choice for primary and secondary prophylaxis of PCP in HIV-infected adults, adolescents, and children.440 441

Toxoplasmosis

Alternative for treatment of toxoplasmosis caused by Toxoplasma gondii in immunocompromised adults, adolescents, and children (including HIV-infected patients);129 131 132 134 138 164 166 167 172 440 441 used in conjunction with pyrimethamine (and leucovorin).134 440 441 CDC, NIH, IDSA, and AAP recommend pyrimethamine (and leucovorin) used in conjunction with sulfadiazine as regimen of choice for initial treatment of toxoplasmosis in HIV-infected adults and adolescents, treatment of congenital toxoplasmosis, and treatment of acquired CNS, ocular, or systemic toxoplasmosis in HIV-infected children.440 441 Pyrimethamine (and leucovorin) used in conjunction with clindamycin is the preferred alternative in those unable to tolerate sulfadiazine or who fail to respond to initial regimen.440 441

Alternative for long-term suppressive or chronic maintenance therapy (secondary prophylaxis) to prevent relapse of toxoplasmosis in HIV-infected adults, adolescents, and children who have completed treatment for the disease;440 441 used in conjunction with pyrimethamine and leucovorin.440 441 Pyrimethamine (and leucovorin) used in conjunction with sulfadiazine is regimen of choice for secondary prophylaxis. Pyrimethamine (and leucovorin) used in conjunction with clindamycin is one of several alternatives in those who cannot tolerate sulfonamides.440 441

Perioperative Prophylaxis

Alternative for perioperative prophylaxis to reduce the incidence of infections in patients undergoing certain clean, contaminated surgeries when drugs of choice (e.g., cefazolin, cefuroxime, cefoxitin, cefotetan) cannot be used because of hypersensitivity to β-lactam anti-infectives.360 374

Experts state clindamycin or vancomycin is a reasonable alternative for perioperative prophylaxis in patients allergic to β-lactam anti-infectives who are undergoing cardiac surgery (e.g., CABG, valve repairs, cardiac device implantation), neurosurgery (e.g., craniotomy, spinal and CSF-shunting procedures, intrathecal pump placement), orthopedic surgery (e.g., spinal procedures, hip fracture, internal fixation, total joint replacement), non-cardiac thoracic surgery (e.g., lobectomy, pneumonectomy, lung resection, thoracotomy), vascular surgery (e.g., arterial procedures involving a prosthesis, the abdominal aorta, or a groin incision), lower extremity amputation for ischemia, or certain transplant procedures (e.g., heart and/or lung).360 374 Clindamycin also a reasonable alternative for perioperative prophylaxis in such patients undergoing head and neck surgery (e.g., incisions through oral or pharyngeal mucosa).360 374

For procedures that might involve exposure to enteric gram-negative bacteria, experts state that clindamycin or vancomycin used in conjunction with an aminoglycoside (e.g., amikacin, gentamicin, tobramycin), aztreonam, or a fluoroquinolone is a reasonable alternative in patients allergic to β-lactam anti-infectives.360 374 These procedures include certain GI and biliary tract procedures (e.g., esophageal or gastroduodenal procedures, appendectomy for uncomplicated appendicitis, surgery involving unobstructed small intestine, colorectal procedures), gynecologic and obstetric surgery (e.g., cesarean section, hysterectomy), urologic procedures involving an implanted prosthesis, and certain transplant procedures (e.g., liver, pancreas and/or kidney).360 374

Prevention of Bacterial Endocarditis

Alternative to amoxicillin or ampicillin for prevention of α-hemolytic (viridans group) streptococcal bacterial endocarditis in penicillin-allergic patients undergoing certain dental procedures (i.e., procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of oral mucosa) or certain invasive respiratory tract procedures (i.e., procedures involving incision or biopsy of respiratory mucosa) who have certain cardiac conditions that put them at highest risk of adverse outcomes from endocarditis.451

Anti-infective prophylaxis solely for prevention of bacterial endocarditis no longer recommended by AHA for patients undergoing GU or GI procedures.451

Cardiac conditions identified by AHA as associated with highest risk of adverse outcomes from endocarditis: Prosthetic cardiac valves or prosthetic material used for cardiac valve repair, previous infective endocarditis, certain forms of congenital heart disease, and cardiac valvulopathy after cardiac transplantation.451

Consult most recent AHA recommendations for additional information on which cardiac conditions are associated with highest risk of adverse outcomes from endocarditis and specific recommendations regarding use of prophylaxis to prevent endocarditis in these patients.451

Prevention of Perinatal Group B Streptococcal Disease

Alternative to penicillin G or ampicillin for prevention of perinatal group B streptococcal (GBS) disease in penicillin-allergic pregnant women at high risk for anaphylaxis if they receive a β-lactam anti-infective.292 359 362

Intrapartum anti-infective prophylaxis to prevent early-onset neonatal GBS disease is administered to women identified as GBS carriers during routine prenatal GBS screening performed at 35–37 weeks of gestation during the current pregnancy and to women who have GBS bacteriuria during the current pregnancy, a previous infant with invasive GBS disease, unknown GBS status with delivery at <37 weeks of gestation, amniotic membrane rupture for ≥18 hours, or intrapartum temperature of ≥38°C.292 359

Penicillin G is drug of choice and ampicillin is the preferred alternative for anti-infective prophylaxis of GBS.292 359 362 Cefazolin is recommended for GBS prophylaxis in penicillin-allergic women who do not have immediate-type penicillin hypersensitivity; clindamycin or, alternatively, vancomycin is recommended for such prophylaxis in penicillin-allergic women at high risk for anaphylaxis (e.g., history of anaphylaxis, angioedema, respiratory distress, or urticaria after receiving a penicillin or cephalosporin).292 359 362

Consider that S. agalactiae (group B streptococci; GBS) with in vitro resistance to clindamycin has been reported with increasing frequency;359 perform in vitro susceptibility tests of clinical isolates obtained during GBS prenatal screening.359 GBS isolates susceptible to clindamycin but resistant to erythromycin in vitro should be evaluated for inducible clindamycin resistance.359 If GBS isolate is intrinsically resistant to clindamycin, demonstrates inducible resistance to clindamycin, or if susceptibility to clindamycin and erythromycin are unknown, use vancomycin instead of clindamycin for GBS prophylaxis.292 359 362

Consult most recent CDC and AAP guidelines for additional information on prevention of perinatal GBS disease.359 362

Clindamycin Hydrochloride Dosage and Administration

Administration

Administer orally,121 126 IM,139 or by intermittent or continuous IV infusion.139 Do not administer by rapid IV injection.139

In the treatment of serious anaerobic infections, parenteral route usually used initially but may be switched to oral route when warranted by patient’s condition.121 126 In clinically appropriate circumstances, oral route may be used initially.121 126

Clindamycin phosphate ADD-Vantage vials and commercially available premixed solutions of clindamycin phosphate in 5% dextrose should be used only for IV infusion.139

For solution and drug compatibility information, see Compatibility under Stability.

Oral Administration

Clindamycin hydrochloride capsules126 and clindamycin palmitate hydrochloride oral solution121 can be administered without regard to food.

To avoid the possibility of esophageal irritation, administer clindamycin hydrochloride capsules with a full glass of water.126 Swallow capsules whole;126 do not use in pediatric patients unable to swallow capsules.126

Reconstitution

Reconstitute clindamycin palmitate hydrochloride powder (granules) for oral solution by adding 75 mL of water to the 100-mL bottle.121 Add a large portion of the water initially and shake bottle vigorously; add remainder of the water and shake bottle until solution is uniform.121 The resulting oral solution contains 75 mg of clindamycin/5 mL.121

IM Injection

For IM injection, administer clindamycin phosphate solution containing 150 mg of clindamycin per mL undiluted.139

Single IM doses should not exceed 600 mg.139

IV Infusion

Prior to IV infusion, clindamycin phosphate solutions (including solutions provided in ADD-Vantage vials) must be diluted with a compatible IV solution to a concentration ≤18 mg/mL.139

Usually administered by intermittent IV infusion.139 Alternatively, may be given by continuous IV infusion in adults after first dose is given by rapid IV infusion.139 (See Table 1.)

Commercially available premixed solutions of clindamycin phosphate in 5% dextrose are administered only by IV infusion.139 Discard premixed solution if container seal is not intact or leaks are found or if the solution is not clear.139 Do not introduce additives into the container.139 Do not use flexible containers in series connections with other plastic containers; such use could result in air embolism from residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.139

Dilution

Clindamycin phosphate solution containing 150 mg of clindamycin per mL: Dilute appropriate dose in a compatible IV infusion solution and administer using the recommended rate of administration.139 (See Rate of Administration under Dosage and Administration.)

Clindamycin phosphate solution provided in ADD-Vantage vials: Dilute according to directions provided by the manufacturer.139 ADD-Vantage vials are for IV infusion only.139

Clindamycin phosphate pharmacy bulk package: Dilute in a compatible IV infusion solution;139 not intended for direct IV infusion.139 Bulk package is intended for use only under a laminar flow hood.139 Entry into the vial should be made using a sterile transfer set or other sterile dispensing device, and the contents dispensed in aliquots using appropriate technique; multiple entries with a syringe and needle are not recommended because of the increased risk of microbial and particulate contamination.139 After entry into the bulk package vial, use entire contents promptly; discard any unused portion within 24 hours after initial entry.139

Rate of Administration

Give intermittent IV infusions over a period of at least 10–60 minutes and at a rate ≤30 mg/minute.139 Give no more than 1.2 g by IV infusion in a single 1-hour period.139

Dilute 300-mg doses in 50 mL of compatible diluent and infuse over 10 minutes; dilute 600-mg doses in 50 mL of diluent and infuse over 20 minutes; dilute 900-mg doses in 50–100 mL of diluent and infuse over 30 minutes; dilute 1.2-g doses in 100 mL of diluent and infuse over 40 minutes.139

As an alternative to intermittent IV infusions in adults, the drug can be given by continuous IV infusion after an initial dose is given by IV infusion over 30 minutes.139 (See Table 1.)

Table 1. Infusion Rates for Continuous IV Infusion of Clindamycin Phosphate in Adults139

Target Serum Clindamycin Concentrations

Infusion Rate for Initial Dose

Maintenance Infusion Rate

>4 mcg/mL

10 mg/minute for 30 minutes

0.75 mg/minute

>5 mcg/mL

15 mg/minute for 30 minutes

1 mg/minute

>6 mcg/mL

20 mg/minute for 30 minutes

1.25 mg/minute

Dosage

Available as clindamycin hydrochloride,126 clindamycin palmitate hydrochloride,121 and clindamycin phosphate;139 dosage expressed in terms of clindamycin.121 126 139

Pediatric Patients

General Dosage in Neonates
Oral

Oral solution: Manufacturer recommends 8–12 mg/kg daily for serious infections, 13–16 mg/kg daily for severe infections, and 17–25 mg/kg daily for more severe infections.121 Give daily dosage in 3 or 4 equally divided doses.121 In children weighing ≤10 kg, manufacturer recommends a minimum dosage of 37.5 mg 3 times daily.121

Neonates ≤7 days of age: AAP recommends 5 mg/kg every 12 hours in those weighing ≤2 kg or 5 mg/kg every 8 hours in those weighing >2 kg.292

Neonates 8–28 days of age: AAP recommends 5 mg/kg every 8 hours in those weighing ≤2 kg or 5 mg/kg every 6 hours in those weighing >2 kg.292 In extremely low-birthweight neonates (<1 kg), consider 5 mg/kg every 12 hours until 2 weeks of age.292

IV or IM

Neonates <1 month of age: Manufacturer recommends 15–20 mg/kg daily given in 3 or 4 equally divided doses.139 The lower dosage may be adequate for small, premature neonates.139

Neonates ≤7 days of age: AAP recommends 5 mg/kg every 12 hours in those weighing ≤2 kg or 5 mg/kg every 8 hours in those weighing >2 kg.292

Neonates 8–28 days of age: AAP recommends 5 mg/kg every 8 hours in those weighing ≤2 kg or 5 mg/kg every 6 hours in those weighing >2 kg.292 In extremely low-birthweight neonates (<1 kg), consider 5 mg/kg every 12 hours until 2 weeks of age.292

General Dosage in Children 1 Month to 16 Years of Age
Oral

Capsules: Manufacturer recommends 8–16 mg/kg daily given in 3 or 4 equally divided doses for serious infections or 16–20 mg/kg daily given in 3 or 4 equally divided doses for more severe infections.126

Oral solution: Manufacturer recommends 8–12 mg/kg daily for serious infections, 13–16 mg/kg daily for severe infections, or 17–25 mg/kg daily for more severe infections.121 Give daily dosage in 3 or 4 equally divided doses.121 In children weighing ≤10 kg, manufacturer recommends a minimum dosage of 37.5 mg 3 times daily.121

AAP recommends 10–20 mg/kg daily given in 3 or 4 equally divided doses for mild to moderate infections or 30–40 mg/kg daily given in 3 or 4 equally divided doses for severe infections.292

IV or IM

Manufacturer recommends 20–40 mg/kg daily given in 3 or 4 equally divided doses;139 use the higher dosage for more severe infections.139 Alternatively, manufacturer recommends 350 mg/m2 daily for serious infections or 450 mg/m2 daily for more severe infections.139

AAP recommends 20–30 mg/kg daily given in 3 equally divided doses for mild to moderate infections or 40 mg/kg daily given in 3 or 4 equally divided doses for severe infections.292

Acute Otitis Media (AOM)
Oral

Children 6 months through 12 years of age: 30–40 mg/kg daily in 3 divided doses recommended by AAP.499 Use with or without a third generation cephalosporin.499 (See Acute Otitis Media under Uses.)

Pharyngitis and Tonsillitis
Oral

AAP recommends 10 mg/kg 3 times daily (up to 900 mg daily) for 10 days.292

IDSA recommends 7 mg/kg (up to 300 mg) 3 times daily for 10 days.580

AHA recommends 20 mg/kg daily (up to 1.8 g daily) in 3 divided doses given for 10 days.375

Respiratory Tract Infections
Oral

Children >3 months of age: IDSA recommends 30–40 mg/kg daily given in 3 or 4 divided doses.513

IM or IV

Children >3 months of age: IDSA recommends 40 mg/kg daily given in divided doses every 6–8 hours.513 514

Babesiosis
Oral

IDSA recommends 7–10 mg/kg (up to 600 mg) every 6–8 hours for 7–10 days; used in conjunction with oral quinine sulfate (8 mg/kg [up to 650 mg] every 8 hours for 7–10 days).329 Others recommend 20–40 mg/kg (up to 600 mg) daily in 3 or 4 divided doses for 7–10 days; used in conjunction with oral quinine sulfate (24 mg/kg daily in 3 divided doses for 7–10 days).134

IV

IDSA recommends 7–10 mg/kg (up to 600 mg) every 6–8 hours for 7–10 days; used in conjunction with oral quinine sulfate (8 mg/kg [up to 650 mg] every 8 hours for 7–10 days).329 Others recommend 20–40 mg/kg (up to 600 mg) daily in 3 or 4 divided doses for 7–10 days; used in conjunction with oral quinine sulfate (24 mg/kg daily in 3 divided doses for 7–10 days).134

Malaria
Treatment of Uncomplicated Chloroquine-resistant P. falciparum Malaria
Oral

20 mg/kg daily in 3 equally divided doses given for 7 days;134 143 144 used in conjunction with oral quinine sulfate (10 mg/kg 3 times daily given for 7 days if acquired in Southeast Asia or 3 days if acquired elsewhere).134 143 144

Treatment of Severe P. falciparum Malaria
Oral

20 mg/kg daily in 3 equally divided doses given for 7 days;143 144 used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.143 144

IV, then Oral

10-mg/kg IV loading dose followed by 5 mg/kg IV every 8 hours; when oral therapy is tolerated, switch to oral clindamycin 20 mg/kg daily in 3 divided doses and continue for a total duration of 7 days.143 144

Used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.143 144

Pneumocystis jirovecii Pneumonia
Treatment of Mild to Moderate Infections
Oral

Children: 10 mg/kg (up to 300–450 mg) every 6 hours given for 21 days;441 used in conjunction with oral primaquine (0.3 mg/kg once daily [up to 30 mg daily] for 21 days).441

Adolescents: 450 mg every 6 hours or 600 mg every 8 hours given for 21 days;440 used in conjunction with oral primaquine (30 mg once daily for 21 days).440

IV

Children: 10 mg/kg (up to 600 mg) every 6 hours given for 21 days;441 used in conjunction with oral primaquine (0.3 mg/kg once daily [up to 30 mg daily] for 21 days).441

Adolescents: 600 mg every 6 hours or 900 mg every 8 hours given for 21 days;440 used in conjunction with oral primaquine (30 mg once daily for 21 days).440

Toxoplasmosis
Congenital Toxoplasmosis
Oral or IV

5–7.5 mg/kg (up to 600 mg) 4 times daily;441 used in conjunction with oral pyrimethamine (2 mg/kg once daily for 2 days followed by 1 mg/kg once daily) and oral or IM leucovorin (10 mg with each pyrimethamine dose).441

Optimal duration not determined;441 some experts recommend continuing treatment for 12 months.441

Treatment in Infants and Children
Oral or IV

5–7.5 mg/kg (up to 600 mg) 4 times daily;441 used in conjunction with oral pyrimethamine (2 mg/kg once daily for 2 days followed by 1 mg/kg once daily) and oral or IM leucovorin (10 mg with each pyrimethamine dose).441

Continue acute treatment for ≥6 weeks; longer duration may be appropriate if disease is extensive or response incomplete at 6 weeks.441

Treatment in Adolescents
Oral or IV

600 mg every 6 hours;440 used in conjunction with oral pyrimethamine (200-mg loading dose followed by 50 mg once daily in those <60 kg or 75 mg once daily in those ≥60 kg) and oral leucovorin (10–25 mg once daily; may be increased to 50 mg once or twice daily).440

Continue acute treatment for ≥6 weeks; longer duration may be appropriate if disease is extensive or response incomplete at 6 weeks.440

Prevention of Recurrence (Secondary Prophylaxis) in Infants and Children
Oral

7–10 mg/kg 3 times daily; used in conjunction with oral pyrimethamine (1 mg/kg or 15 mg/m2 [up to 25 mg] once daily) and oral leucovorin (5 mg once every 3 days).441

Initiate long-term suppressive therapy or chronic maintenance therapy (secondary prophylaxis) in all patients after completion of acute treatment of toxoplasmosis.441

Safety of discontinuing secondary toxoplasmosis prophylaxis in HIV-infected infants and children receiving potent antiretroviral therapy not extensively studied.441 Consider discontinuing secondary prophylaxis in HIV-infected children 1 to <6 years of age who have completed toxoplasmosis acute treatment, have received >6 months of stable antiretroviral therapy, are asymptomatic with respect to toxoplasmosis, and have CD4+ T-cell percentages that have remained >15% for >6 consecutive months.441 In HIV-infected children ≥6 years of age who have received >6 months of antiretroviral therapy, consider discontinuing secondary prophylaxis if CD4+ T-cell counts have remained >200/mm3 for >6 consecutive months.441 Reinitiate secondary prophylaxis if these parameters not met.441

Prevention of Recurrence (Secondary Prophylaxis) in Adolescents
Oral

Dosage for secondary prophylaxis against toxoplasmosis in adolescents and criteria for initiation or discontinuance of such prophylaxis in this age group are the same as those recommended for adults.440 (See Adult Dosage under Dosage and Administration.)

Perioperative Prophylaxis
IV

10 mg/kg given within 60 minutes prior to incision.360 374 Used with or without another anti-infective.360 374 (See Perioperative Prophylaxis under Uses.)

May give additional intraoperative doses every 6 hours during prolonged procedures;360 postoperative doses generally not recommended.360

Prevention of Bacterial Endocarditis
Patients Undergoing Certain Dental or Respiratory Tract Procedures
Oral

20 mg/kg as a single dose given 30–60 minutes prior to the procedure.451

IM or IV

20 mg/kg as a single dose given 30–60 minutes prior to the procedure.451

Adults

General Adult Dosage
Serious Infections
Oral

150–300 mg every 6 hours.126

IV or IM

600 mg to 1.2 g daily in 2–4 equally divided doses.139

More Severe Infections
Oral

300–450 mg every 6 hours.126

IV or IM

1.2–2.7 g daily in 2–4 equally divided doses.139

For life-threatening infections, IV dosage may be increased up 4.8 g daily.139

Gynecologic Infections
Pelvic Inflammatory Disease
IV, then Oral

Initially, 900 mg IV every 8 hours;344 345 used in conjunction with IV or IM gentamicin.344 345 After clinical improvement occurs, discontinue IV clindamycin and gentamicin and switch to oral clindamycin in a dosage of 450 mg 4 times daily to complete 14 days of therapy.344 Alternatively, oral doxycycline can be used to complete 14 days of therapy.344 345

Pharyngitis and Tonsillitis
Oral

IDSA recommends 7 mg/kg (up to 300 mg) 3 times daily for 10 days.580

AHA recommends 20 mg/kg daily (up to 1.8 g daily) in 3 divided doses given for 10 days.375

Respiratory Tract Infections
Oral

IDSA recommends 600 mg 3 times daily for 7–21 days.514

IV

IDSA recommends 600 mg 3 times daily for 7–21 days.514

Anthrax
Treatment of Inhalational Anthrax
IV

900 mg every 8 hours.119

Used in multiple-drug regimens that initially include IV ciprofloxacin or IV doxycycline and 1 or 2 other anti-infectives predicted to be effective.116 117 119 120

Duration of treatment is 60 days if anthrax occurred as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism.117 120

Babesiosis
Oral

IDSA and others recommend 600 mg every 8 hours given for 7–10 days;134 329 used in conjunction with oral quinine sulfate (650 mg every 6 or 8 hours for 7–10 days).134 329

IV

IDSA and others recommend 300–600 mg every 6 hours given for 7–10 days; used in conjunction with oral quinine sulfate (650 mg every 6 or 8 hours for 7–10 days).134 329

Bacterial Vaginosis
Treatment in Pregnant or Nonpregnant Women
Oral

300 mg twice daily given for 7 days.344 345

Malaria
Treatment of Uncomplicated Chloroquine-resistant P. falciparum Malaria
Oral

20 mg/kg daily in 3 equally divided doses given for 7 days;134 143 144 used in conjunction with oral quinine sulfate (650 mg 3 times daily given for 7 days if acquired in Southeast Asia or 3 days if acquired elsewhere).134 143 144

Treatment of Severe P. falciparum Malaria
Oral

20 mg/kg daily in 3 equally divided doses given for 7 days;134 143 144 used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.134 143 144

IV, then Oral

10-mg/kg IV loading dose followed by 5 mg/kg IV every 8 hours; when oral therapy is tolerated, switch to oral clindamycin 20 mg/kg daily in 3 divided doses and continue for a total duration of 7 days.143 144

Used in conjunction with IV quinidine gluconate (followed by oral quinine sulfate) given for a total duration of 3–7 days.143 144

Pneumocystis jirovecii Pneumonia
Treatment of Mild to Moderate Infections
Oral

450 mg every 6 hours or 600 mg every 8 hours given for 21 days;440 used in conjunction with oral primaquine (30 mg once daily for 21 days).440

IV

600 mg every 6 hours or 900 mg every 8 hours given for 21 days;440 used in conjunction with oral primaquine (30 mg once daily for 21 days).440

Toxoplasmosis
Treatment
Oral or IV

600 mg every 6 hours;440 used in conjunction with oral pyrimethamine (200-mg loading dose followed by 50 mg once daily in those <60 kg or 75 mg once daily in those ≥60 kg) and oral leucovorin (10–25 mg once daily; may be increased to 50 mg once or twice daily).440

Continue acute treatment for ≥6 weeks; longer duration may be appropriate if disease is extensive or response incomplete at 6 weeks.440

Prevention of Recurrence (Secondary Prophylaxis)
Oral

600 mg every 8 hours;440 used in conjunction with oral pyrimethamine (25–50 mg once daily) and oral leucovorin (10–25 mg once daily).440

Initiate long-term suppressive therapy or chronic maintenance therapy (secondary prophylaxis) in all patients after completion of acute treatment of toxoplasmosis.440

Consider discontinuing secondary prophylaxis in HIV-infected adults or adolescents who have successfully completed initial treatment for toxoplasmosis, are asymptomatic with respect to toxoplasmosis, and have CD4+ T-cell counts that have remained >200/mm3 for ≥6 months.440

Reinitiate secondary prophylaxis if CD4+ T-cell count decreases to <200/mm3, regardless of plasma HIV viral load.440

Perioperative Prophylaxis
IV

900 mg given within 60 minutes prior to incision.360 374 Used with or without another anti-infective.360 374 (See Perioperative Prophylaxis under Uses.)

May give additional intraoperative doses every 6 hours during prolonged procedures;360 postoperative doses generally not recommended.360

Prevention of Bacterial Endocarditis
Patients Undergoing Certain Dental or Respiratory Tract Procedures
Oral

600 mg as a single dose given 30–60 minutes prior to the procedure.451

IM or IV

600 mg as a single dose given 30–60 minutes prior to the procedure.451

Prevention of Perinatal Group B Streptococcal Disease
Women at Risk Who Should Not Receive β-lactam Anti-infectives
IV

900 mg every 8 hours; initiate at time of labor or rupture of membranes and continue until delivery.359

Special Populations

Hepatic Impairment

Dosage adjustments not usually necessary.121 126 139 Monitor hepatic function if used in those with severe hepatic disease.121 126 139

Renal Impairment

Dosage adjustments not usually necessary.121 126 139

Geriatric Patients

Dosage adjustments not usually necessary if used in geriatric patients with normal hepatic function and normal (age-adjusted) renal function.121 126 139

Cautions for Clindamycin Hydrochloride

Contraindications

  • Hypersensitivity to clindamycin or lincomycin.121 126 139

Warnings/Precautions

Warnings

Superinfection/Clostridium difficile-associated Diarrhea and Colitis (CDAD)

Possible emergence and overgrowth of nonsusceptible organisms, particularly yeasts.121 126 139 Institute appropriate therapy if superinfection occurs.121 126 139

Treatment with anti-infectives alters normal colon flora and may permit overgrowth of Clostridium difficile.121 126 139 302 303 304 C. difficile infection (CDI) and C. difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) reported with nearly all anti-infectives, including clindamycin, and may range in severity from mild diarrhea to fatal colitis.121 126 139 302 303 304 C. difficile produces toxins A and B which contribute to development of CDAD;121 126 139 302 hypertoxin-producing strains of C. difficile are associated with increased morbidity and mortality since they may be refractory to anti-infectives and colectomy may be required.121 126 139

Consider CDAD if diarrhea develops during or after therapy and manage accordingly.121 126 139 302 303 304 Obtain careful medical history since CDAD may occur as late as ≥2 months after anti-infective therapy discontinued.121 126 139

If CDAD suspected or confirmed, discontinue anti-infectives not directed against C. difficile whenever possible.121 126 139 302 Initiate appropriate supportive therapy (e.g., fluid and electrolyte management, protein supplementation), anti-infective therapy directed against C. difficile (e.g., metronidazole, vancomycin), and surgical evaluation as clinically indicated.121 126 139 302 303 304

Patients with Meningitis

Do not use for treatment of meningitis; clindamycin diffusion into CSF inadequate for treatment of CNS infections.121 126 139

Sensitivity Reactions

Anaphylactic shock and anaphylactoid reactions with hypersensitivity reported.121 126 139

Other severe hypersensitivity reactions, including severe skin reactions such as toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome, reported and have been fatal in some cases.121 126 139 Acute generalized exanthematous pustulosis and erythema multiforme also reported.121 126 139

Generalized mild to moderate morbilliform-like (maculopapular) rash,121 126 139 vesiculobullous rash,121 126 urticaria,121 126 pruritus,121 126 angioedema,121 126 and rare instances of exfoliative dermatitis121 126 reported.

Some commercially available clindamycin capsules (e.g., Cleocin HCl 75- and 150-mg capsules) contain the dye tartrazine (FD&C yellow No. 5), which may cause allergic reactions including bronchial asthma in susceptible individuals.126 Although the incidence of tartrazine sensitivity is low, it frequently occurs in patients sensitive to aspirin.126

Prior to initiation of clindamycin, make careful inquiry regarding prior hypersensitivity to drugs and other allergens.121 126 139 Use with caution in atopic individuals.121 126 139

If anaphylactic or severe hypersensitivity reactions occur, permanently discontinue clindamycin and institute appropriate therapy as necessary.121 126 139

General Precautions

Selection and Use of Anti-infectives

To reduce development of drug-resistant bacteria and maintain effectiveness of clindamycin and other antibacterials, use only for treatment or prevention of infections proven or strongly suspected to be caused by susceptible bacteria.121 126 139

When selecting or modifying anti-infective therapy, use results of culture and in vitro susceptibility testing.121 126 139 In the absence of such data, consider local epidemiology and susceptibility patterns when selecting anti-infectives for empiric therapy.121 126 139

Surgical procedures should be performed in conjunction with clindamycin therapy when indicated.121 126 139

History of GI Disease

Use with caution in patients with a history of GI disease, particularly colitis.100 (See Superinfection/Clostridium difficile-associated Colitis under Cautions.)

Cardiovascular Effects

Rapid IV administration has caused cardiopulmonary arrest and hypotension.139

Laboratory Monitoring

Monitor liver function, renal function, and CBCs periodically during prolonged therapy.121 126 139

Specific Populations

Pregnancy

Reproduction studies in rats and mice have not revealed evidence of teratogenicity.121 126 139

In clinical trials that included pregnant women, systemic clindamycin administered during second and third trimesters was not associated with increased frequency of congenital abnormalities.126 139 No adequate and well-controlled studies to date using clindamycin in pregnant women during first trimester of pregnancy.121 126 139

Use during pregnancy only when clearly needed.121 126 139

Clindamycin phosphate injection contains benzyl alcohol as a preservative; benzyl alcohol can cross the placenta.139 (See Pediatric Use under Cautions.)

Lactation

Distributed into milk;100 121 126 139 potentially can cause adverse effects on GI flora of breast-fed infants.121 126 139

Manufacturer states clindamycin use in the mother is not a reason to discontinue breast-feeding; however, it may be preferable to use an alternate anti-infective.121 126 139

If used in a breast-feeding mother, monitor infant for possible adverse effects on GI flora, including diarrhea and candidiasis (thrush, diaper rash) or, rarely, blood in the stool indicating possible antibiotic-associated colitis.121 126 139

Consider benefits of breast-feeding and importance of clindamycin to the woman; also consider potential adverse effects on breast-fed child from the drug or from the underlying maternal condition.121 126 139

Pediatric Use

Monitor organ system functions when used in pediatric patients (birth to 16 years of age).121 126 139

Each mL of clindamycin phosphate injection contains 9.45 mg of benzyl alcohol.139 Large amounts of benzyl alcohol (i.e., 100–400 mg/kg daily) have been associated with toxicity (potentially fatal “gasping syndrome”) in neonates.106 107 108 109 139 Although amount of benzyl alcohol in recommended IM or IV clindamycin dosages are substantially lower than amounts reported in association with “gasping syndrome,” minimum amount of benzyl alcohol at which toxicity may occur unknown.139 Risk of benzyl alcohol toxicity depends on quantity administered and capacity of liver and kidneys to detoxify the chemical.139 Premature and low-birthweight infants may be more likely to develop toxicity.139

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether they respond differently than younger adults.121 126 139

Clinical experience indicates that C. difficile-associated diarrhea and colitis seen in association with anti-infectives may occur more frequently and be more severe in geriatric patients (>60 years of age).121 126 139 303 Carefully monitor geriatric patients for development of diarrhea (e.g., changes in bowel frequency).121 126 139

Hepatic Impairment

Moderate to severe liver disease may result in prolonged clindamycin half-life, but accumulation may not occur.121 126 139

Periodically monitor liver enzymes in patients with severe hepatic impairment.121 126 139

Common Adverse Effects

GI effects (nausea, vomiting, diarrhea, abdominal pain, tenesmus); rash; local reactions (pain, induration, sterile abscess with IM and thrombophlebitis, erythema, pain and swelling with IV).121 126 139

Interactions for Clindamycin Hydrochloride

Substrate of CYP isoenzyme 3A4 and, to a lesser extent, CYP3A5.121 126 139

Moderate inhibitor of CYP3A4 in vitro; does not inhibit CYP1A2, 2C9, 2C19, 2E1, or 2D6.121 126 139

Drugs Affecting Hepatic Microsomal Enzymes

CYP3A4 or 3A5 inhibitors: Possible increased plasma concentrations of clindamycin.121 126 139 Monitor for adverse effects if used with potent CYP3A4 inhibitor.121 126 139

CYP3A4 or 3A5 inducers: Possible decreased plasma concentrations of clindamycin.121 126 139 Monitor for loss of clindamycin effectiveness if used with potent CYP3A4 inducer.121 126 139

Specific Drugs

Drug

Interaction

Comments

Neuromuscular blocking agents (tubocurarine, pancuronium)

Potential for enhanced neuromuscular blocking action121 126 139 198 199

Use with caution in patients receiving neuromuscular blocking agents;121 126 139 198 199 closely monitor for prolonged neuromuscular blockade199

Rifampin

Possible decreased clindamycin concentrations121 126 139

Monitor for clindamycin effectiveness121 126 139

Clindamycin Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Clindamycin hydrochloride capsules: Approximately 90% of an oral dose rapidly absorbed from GI tract;126 peak serum concentrations attained within 45 minutes.126

Clindamycin palmitate hydrochloride oral solution: Rapidly hydrolyzed in GI tract to active clindamycin.121

Clindamycin phosphate: Following IM or IV administration, rapidly hydrolyzed in plasma to active clindamycin.139

Following IM administration of clindamycin phosphate, peak serum concentrations occur within 3 hours in adults and 1 hour in children.139

Food

Administration of clindamycin hydrochloride capsules126 or clindamycin palmitate hydrochloride oral solution121 with food does not appreciably affect absorption121 or serum concentrations of the drug.126

Distribution

Extent

Widely distributed into body tissues and fluids,121 126 140 including saliva,140 ascites fluid,140 peritoneal fluid,140 pleural fluid,140 synovial fluid,140 bone,121 126 140 and bile.140

Clinically important concentrations not attained in CSF, even in the presence of inflamed meninges.121 126 139 140

Readily crosses the placenta;140 141 cord blood concentrations may be up to 50% of concurrent maternal blood concentrations.140

Distributed into milk.100 121 126 139 140

Plasma Protein Binding

93%.a

Elimination

Metabolism

Partially metabolized to bioactive and inactive metabolites.a

In vitro studies indicate clindamycin is predominantly metabolized by CYP3A4 and, to a lesser extent, by CYP3A5 to the major bioactive metabolite clindamycin sulfoxide and minor metabolite N-desmethylclindamycin.121 126 139

Elimination Route

Excreted in urine, bile, and feces.a

Approximately 10% of an oral dose excreted in urine and 3.6% excreted in feces as active drug and metabolites;121 126 remainder is excreted as inactive metabolites.121 126

Not appreciably removed by hemodialysis or peritoneal dialysis.121 126 139

Half-life

Adults and children: 2–3 hours.121 126 139

Geriatric adults: Approximately 4 hours (range: 3.4–5.1 hours) following oral administration.121 126 139

Neonates: Serum half-life depends on gestational and chronologic age and body weight.102 Reportedly averages 8.7 or 3.6 hours in premature or full-term neonates, respectively, and is about 3 hours in infants 4 weeks to 1 year of age.102

Special Populations

Pharmacokinetics after IV administration in healthy older adults (61–79 years of age) similar to younger adults (18–39 years of age).121 126 139

Serum half-life increased slightly in patients with markedly reduced renal or hepatic function.121 126 139

Stability

Storage

Oral

Capsules

20–25°C.126

For Solution

20–25°C.121 Following reconstitution, stable for 2 weeks at room temperature;121 do not refrigerate because solution will thicken.121

Parenteral

Solution, for IM or IV Use

20–25°C.139

Solution, for IV Infusion only

ADD-Vantage vials: 20–25°C.139

Pharmacy bulk package: 20–25°C.139 Discard unused portions within 24 hours after initial entry into the vial.139

Premixed solutions in 5% dextrose: Room temperature (25°C); avoid temperatures >30°C.139

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Solution CompatibilityHID

Compatible

Amino acids 4.25%, dextrose 25%

Dextrose 2.5% in Ringer’s injection, lactated

Dextrose 5% in Ringer’s injection

Dextrose 5% in sodium chloride 0.45 or 0.9%

Dextrose 5 or 10% in water

Isolyte M or P with dextrose 5%

Normosol R

Ringer’s injection, lactated

Sodium chloride 0.9%

Drug Compatibility
Admixture CompatibilityHID

Compatible

Amikacin sulfate

Ampicillin sodium

Aztreonam

Cefazolin sodium

Cefepime HCl

Cefotaxime sodium

Cefoxitin sodium

Ceftazidime

Cefuroxime sodium

Fluconazole

Gentamicin sulfate

Heparin sodium

Hydrocortisone sodium succinate

Methylprednisolone sodium succinate

Metoclopramide HCl

Potassium chloride

Sodium bicarbonate

Tobramycin sulfate

Verapamil HCl

Incompatible

Aminophylline

Ceftriaxone sodium

Ciprofloxacin

Gentamicin sulfate with cefazolin sodium

Tramadol HCl

Variable

Ranitidine HCl

Y-Site CompatibilityHID

Compatible

Acetaminophen

Acyclovir sodium

Amsacrine

Amifostine

Amiodarone HCl

Amphotericin B cholesteryl sulfate complex

Anakinra

Anidulafungin

Aztreonam

Bivalirudin

Cangrelor tetrasodium

Ceftaroline fosamil

Cisatracurium besylate

Cloxacillin sodium

Cyclophosphamide

Dexmedetomidine HCl

Diltiazem HCl

Docetaxel

Doxorubicin HCl liposome injection

Enalaprilat

Esmolol HCl

Etoposide phosphate

Fenoldopam mesylate

Fludarabine phosphate

Foscarnet sodium

Gemcitabine HCl

Granisetron HCl

Heparin sodium

Hetastarch in lactated electrolyte injection (Hextend)

Hydromorphone HCl

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Labetalol HCl

Levofloxacin

Linezolid

Magnesium sulfate

Melphalan HCl

Meperidine HCl

Midazolam HCl

Milrinone lactate

Morphine sulfate

Multivitamins

Nicardipine HCl

Ondansetron HCl

Pemetrexed disodium

Piperacillin sodium–tazobactam sodium

Propofol

Remifentanil HCl

Sargramostim

Tacrolimus

Teniposide

Theophylline

Thiotepa

Vinorelbine tartrate

Zidovudine

Incompatible

Allopurinol sodium

Azithromycin

Caspofungin acetate

Doxapram HCl

Filgrastim

Fluconazole

Idarubicin HCl

Oritavancin diphosphate

Actions and Spectrum

  • Lincosamide antibiotic;140 141 semisynthetic derivative of lincomycin.121 126 139 140 140 141

  • Usually bacteriostatic in action, but may be bactericidal depending on concentration attained at site of infection and susceptibility of the infecting organism.a

  • Inhibits protein synthesis in susceptible bacteria by binding to 23S RNA of the 50S ribosomal subunits.121 126 139 140

  • Clindamycin palmitate hydrochloride and clindamycin phosphate are inactive until hydrolyzed in vivo to free clindamycin.a

  • Spectrum of activity includes many gram-positive aerobic and anaerobic bacteria and some gram-negative anaerobic bacteria.121 126 139 140 141 Generally inactive against most gram-negative aerobic bacteria.140

  • Gram-positive aerobes: Active in vitro against Staphylococcus aureus (methicillin-susceptible strains),121 126 139 140 141 S. epidermidis (methicillin-susceptible strains),121 126 139 141 Streptococcus pneumoniae (penicillin-susceptible strains),121 126 139 140 141 S. pyogenes (group A β-hemolytic streptococci; GAS),121 126 139 140 141 S. agalactiae (group B streptococci; GBS),121 126 139 S. anginosus,121 126 139 S. mitis,121 126 139 and S. oralis.121 126 139 Not active against Enterococcus faecalis or E. faecium.140

  • Anaerobes: Active in vitro against Actinomyces israelii,121 126 139 140 Clostridium clostridioforme,121 126 139 C. perfringens,121 126 139 Eggerthella lenta (previously known as Eubacterium lentum),121 126 139 Finegoldia anaerobius,121 126 139 Finegoldia magna,121 126 139 Fusobacterium necrophorum,121 126 139 F. nucleatum,121 126 139 Micromonas micros,121 126 139 Mobiluncus,173 176 177 Prevotella (P. disiens, P. intermedia, P. melaninogenica, P. vivia),121 126 139 140 173 Porphyromonas,140 173 and Propionibacterium acnes.121 126 139

  • Active in vitro and in vivo against Gardnerella vaginalis.140 173 178 179 180

  • Has in vitro activity against Toxoplasma gondii in infected human fibroblasts.141 Active against Plasmodium falciparum in vitro.140

  • Generally inactive against gram-negative aerobes, including Enterobacteriaceae,140 141 Pseudomonas,140 Acinetobacter,140 and most strains of Haemophilus influenzae140 141 and Neisseria.140 141

  • Resistance to clindamycin has been induced in vitro in staphylococci and has been reported in clinical isolates of S. aureus, especially methicillin-resistant S. aureus (MRSA; also known as oxacillin-resistant S. aureus or ORSA).141

  • S. agalactiae (group B streptococci; GBS) clinical isolates resistant to clindamycin reported with increasing frequency.140 292 359 GBS isolates that appear susceptible to clindamycin but resistant to erythromycin in vitro may have inducible resistance to clindamycin.359

  • Clinical isolates of Bacteroides fragilis with resistance or reduced susceptibility to clindamycin reported with increasing frequency.140 141

  • Resistance to clindamycin most frequently caused by modification of specific bases of the 23S ribosomal RNA.121 126 139

  • Complete cross-resistance usually occurs between clindamycin and lincomycin.121 126 139 141 Because of overlapping binding sites, partial cross-resistance reported between clindamycin and macrolides (e.g., erythromycin) and streptogramin B.121 126 139 140 141

Advice to Patients

  • Advise patients that antibacterials (including clindamycin) should only be used to treat bacterial infections and not used to treat viral infections (e.g., the common cold).121 126 139

  • Importance of completing full course of therapy, even if feeling better after a few days.121 126 139

  • Advise patients that skipping doses or not completing the full course of therapy may decrease effectiveness and increase the likelihood that bacteria will develop resistance and will not be treatable with clindamycin or other antibacterials in the future.121 126 139

  • Clindamycin hydrochloride capsules and clindamycin palmitate hydrochloride oral solution can be taken without regard to meals.121 126

  • Take clindamycin hydrochloride capsules with a full glass of water to avoid the possibility of esophageal irritation.126

  • Advise patients that diarrhea is a common problem caused by anti-infectives and usually ends when the drug is discontinued.121 126 139 Importance of contacting a clinician if watery and bloody stools (with or without stomach cramps and fever) occur during or as late as 2 months or longer after the last dose.121 126 139

  • Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs, and any concomitant illnesses.121 126 139

  • Importance of women informing clinician if they are or plan to become pregnant or plan to breast-feed.121 126 139

  • Importance of advising patients of other important precautionary information.121 126 139 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Clindamycin Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules

75 mg (of clindamycin)*

Cleocin HCl

Pfizer

Clindamycin Hydrochloride Capsules

150 mg (of clindamycin)*

Cleocin HCl

Pfizer

Clindamycin Hydrochloride Capsules

300 mg (of clindamycin)*

Cleocin HCl

Pfizer

Clindamycin Hydrochloride Capsules

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Clindamycin Palmitate Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

For solution

75 mg (of clindamycin) per 5 mL*

Cleocin Pediatric

Pfizer

Clindamycin Palmitate Hydrochloride for Oral Solution

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Clindamycin Phosphate

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection

150 mg (of clindamycin) per mL*

Cleocin Phosphate

Pfizer

Clindamycin Phosphate Injection

9 g (150 mg/mL) (of clindamycin) pharmacy bulk package

Cleocin Phosphate

Pfizer

Injection, for IV infusion only

150 mg (of clindamycin) per mL (300 mg)*

Cleocin Phosphate ADD-Vantage

Pfizer

Clindamycin Phosphate ADD-Vantage

150 mg (of clindamycin) per mL (600 and 900 mg)*

Cleocin Phosphate ADD-Vantage

Pfizer

Clindamycin Phosphate ADD-Vantage

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Clindamycin Phosphate in Dextrose

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for IV infusion

6 mg (of clindamycin) per mL (300 mg) in 5% Dextrose*

Cleocin Phosphate IV

Pfizer

Clindamycin Phosphate in 5% Dextrose

12 mg (of clindamycin) per mL (600 mg) in 5% Dextrose*

Cleocin Phosphate IV

Pfizer

Clindamycin Phosphate in 5% Dextrose

18 mg (of clindamycin) per mL (900 mg) in 5% Dextrose*

Cleocin Phosphate IV

Pfizer

Clindamycin Phosphate in 5% Dextrose

AHFS DI Essentials™. © Copyright 2018, Selected Revisions July 9, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

100. Steen B, Rane A. Clindamycin passage into human milk. Br J Clin Pharmacol. 1982; 13:661-4. http://www.ncbi.nlm.nih.gov/pubmed/7082533?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=1402074&blobtype=pdf

101. Anon. Clindamycin and quinine treatment for Babesia microti infections. MMWR Morb Mortal Wkly Rep. 1983; 32:65-6,72. http://www.ncbi.nlm.nih.gov/pubmed/6405180?dopt=AbstractPlus

102. Bell MJ, Shackelford P, Smith R et al. Pharmacokinetics of clindamycin phosphate in the first year of life. J Pediatr. 1984; 105:482-6. http://www.ncbi.nlm.nih.gov/pubmed/6470871?dopt=AbstractPlus

103. The United States pharmacopeia, 21st rev, and The national formulary, 16th ed. Rockville, MD: The United States Pharmacopeial Convention, Inc; 1984:224-7,1449,1484.

105. Wittner M, Rowin KS, Tanowitz HB et al. Successful chemotherapy of transfusion babesiosis. Ann Intern Med. 1982; 96:601-4. http://www.ncbi.nlm.nih.gov/pubmed/7200341?dopt=AbstractPlus

106. American Academy of Pediatrics Committee on Fetus and Newborn and Committee on Drugs. Benzyl alcohol: toxic agent in neonatal units. Pediatrics. 1983; 72:356-8. http://www.ncbi.nlm.nih.gov/pubmed/6889041?dopt=AbstractPlus

107. Anon. Benzyl alcohol may be toxic to newborns. FDA Drug Bull. 1982; 12:10-1. http://www.ncbi.nlm.nih.gov/pubmed/7188569?dopt=AbstractPlus

108. Centers for Disease Control. Neonatal deaths associated with use of benzyl alcohol. MMWR Morb Mortal Wkly Rep. 1982; 31:290-1. http://www.ncbi.nlm.nih.gov/pubmed/6810084?dopt=AbstractPlus

109. Gershanik J, Boecler B, Ensley H et al. The gasping syndrome and benzyl alcohol poisoning. N Engl J Med. 1982; 307:1384-8. http://www.ncbi.nlm.nih.gov/pubmed/7133084?dopt=AbstractPlus

110. Carlson P, Kontiainen S, Renkonen OV. Antimicrobial susceptibility of Arcanobacterium haemolyticum. Antimicrob Agents Chemother. 1994; 38:142-3.

111. Krause PJ, Lepore T, Sikand VK et al. Atovaquone and azithromycin for the treatment of babesiosis. N Engl J Med. 2000; 343:1454-8. http://www.ncbi.nlm.nih.gov/pubmed/11078770?dopt=AbstractPlus

113. Pukrittayakamee S, Chantra A, Vanijanonta S et al. Therapeutic responses to quinine and clindamycin in multidrug-resistant falciparum malaria. Antimicrob Agents Chemother. 2000; 44:2395-8. http://www.ncbi.nlm.nih.gov/pubmed/10952585?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=90075&blobtype=pdf

114. Metzger W, Mordmuller B, Graninger W et al. High efficacy of short-term quinine-antibiotic combinations for treating adult malaria patients in an area in which malaria is hyperendemic. Antimicrob Agents Chemother. 1995; 39:245-6. http://www.ncbi.nlm.nih.gov/pubmed/7695315?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=162517&blobtype=pdf

115. McGready R, Cho T, Samuel. Randomized comparison of quinine-clindamycin versus artesunate in the treatment of falciparum malaria in pregnancy. Trans R Soc Trop Med Hyg. 2001; 95:651-6. http://www.ncbi.nlm.nih.gov/pubmed/11816439?dopt=AbstractPlus

116. Centers for Disease Control and Prevention. Update: investigation of bioterrorism-related anthrax and interim guidelines for clinical evaluation of persons with possible anthrax. MMWR Morb Mortal Wkly Rep. 2001; 50:941-8. http://www.ncbi.nlm.nih.gov/pubmed/11708591?dopt=AbstractPlus

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