Brand names: Cleocin HCL, Cleocin Pediatric, Cleocin Phosphate
Drug class: Lincomycins

Medically reviewed by Drugs.com on Apr 10, 2024. Written by ASHP.

Introduction

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

Uses for Clindamycin

Acute Otitis Media (AOM)

Alternative for treatment of AOM^{† [off-label]}.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^{† [off-label]} 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^{† [off-label]} (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^{† [off-label]}, including infections caused by Actinomyces israelii.^{197 292}

Anthrax

Alternative for treatment of anthrax^{† [off-label]}.^{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 microti^{101 105 134 292 329} 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. microti^{134 329} 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 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.)

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

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 dermatitis^{121 126} 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}

Drug Interactions

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

Clindamycin 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

Parenteral

Solution CompatibilityHID

Drug Compatibility

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 influenzae^{140 141} 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

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

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

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

Frequently asked questions

• What are the best antibiotics for a tooth infection?
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• Is clindamycin a strong antibiotic?
• Can I take clindamycin if I am allergic to penicillin?
• Is clindamycin a penicillin?
• Why can't you lay down after taking clindamycin?
• Can clindamycin be used to treat chlamydia?

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