NON-FDA APPROVED USES
- Treatment of PCP in combination with primaquine
- Treatment of CNS toxoplasmosis in combination with pyrimethamine and leucovorin
- CA-MRSA soft tissue infections.
- CA-MRSA pneumonia (may be considered in combination with vancomycin to decrease toxin production in severe cases)
- Acute bacterial sinusitis
Pfizer and other generic manufacturers
300mg; 600mg; 900mg
$5.06 ; $9.16; $13.28
Cleocin pediatric solution
$61.10 (100 mL)
Cleocin vaginal suppository
1% (30g; 60g)
$62.76 .60; $113.03
1% ( 60ml)
*Prices represent cost per unit specified, are representative of "Average Wholesale Price" (AWP).
^Dosage is indicated in mg unless otherwise noted.
USUAL ADULT DOSING
- Soft tissue infection: 300-450 mg PO q6h or 600 mg IV q8h x 14 d then reassess.
- Pelvic inflammatory disease: 900 mg IV q8h (in combination with gentamicin) x 14d.
- Osteomyelitis: 600mg IV q8h x 6-8 wks then reassess.
- Acute bacterial sinusitis: 300mg PO q6h x 2-3 wks.
- Bacterial vaginosis: 100 mg vaginal suppository qhs x 3-7 d.
- Acne: 1-2 topical applications daily.
- Actinomycosis: 600mg IV q 8h x 2-6wks, then clindamycin 300mg PO q6h x 6-12mos.
- PCP: clindamycin 600mg IV q6h-q8h or 300mg-450mg PO q6h-8h + primaquine 15-30mg (base) PO once daily +/- prednisone (recommended for PaO2< 70) x 21 days.
- CNS toxoplasmosis: clindamycin 600mg IV q6h or clindamycin 450mg-600mg PO q6h + pyrimethamine 200mg PO loading dose, then 50-75mg PO q24hd + leucovorin 10-20mg q24hd until immune reconstitution (CD4 >200 on stable HAART for 6-12 mos).
- Cleocin caps should be taken with a full glass of water to avoid esophageal irritation.
USUAL PEDIATRIC DOSING
- 5 to 7.5 mg/kg/dose IV infusion by syringe pump over 30 minutes, or PO.
Antibiotic Dosing Chart:
Renal function and drug elimination are most strongly correlated with Postmenstrual Age (PMA; equivalent to Gestational Age plus Postnatal Age). PMA is the primary determinant of dosing interval, with Postnatal Age as the secondary qualifier.
Dosing Interval Chart
0 to 28
30 to 36
0 to 14
37 to 44
0 to 7
PEDIATRIC RENAL DOSING
OTHER PEDIATRIC INFORMATION
Increase dosing interval should be considered in patients with significant liver dysfunction.
DOSING FOR GLOMERULAR FILTRATION OF 50-80
DOSING FOR GLOMERULAR FILTRATION OF 10-50
DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN
DOSING IN HEMODIALYSIS
DOSING IN PERITONEAL DIALYSIS
DOSING IN HEMOFILTRATION
ADVERSE DRUG REACTIONS
- Diarrhea (not due to C. difficile in 10-30%)
- GI intolerance: nausea, vomiting and anorexia
- Generalized morbilliform rash
- C. difficile colitis in 6% of pts
- Stevens-Johnson syndrome
- Allergic-type reactions (including bronchial asthma) in pts who have aspirin hyper-sensitivity (from tartrazine found in the 75 and 150 mg caps)
- Erythromycin: in vitro antagonism. Clinical significance unclear. Avoid co-administration.
- Kaolin-pectin: decreases clindamycin absorption.
- Loperamide and diphenoxylate/atropine: may increase risk of diarrhea and C. difficile-associated colitis. Avoid use with clindamycin.
- Nondepolarizing muscle relaxant (pancuronium, tubocurarine): lincosamides may enhances the action of nondepolarizing muscle relaxants. Use with caution in pts receiving such agents.
Active against most gram-positive cocci except Enterococcus and nosocomially-acquired MRSA. Active against most community-acquired MRSA (if CA-MRSA is resistant to erythromycin, D-test should performed to confirm clindamycin sensitivity). Increasing resistance seen with B. fragilis.
Spectrum of Activity
Aerobic gram-positive bacilli
Bacillus spp (not anthracis or cereus)
Aerobic gram-positive cocci
Staphylococcus aureus (methicillin-sensitive)
Streptococcus (Group G)
Streptococcus (Group C)
Streptococcus agalactiae (Group B)
Streptococcus pneumoniae (PCN intermediate sensitive; MIC 0.1-1.0 mcg/ml)
Streptococcus pneumoniae (PCN sensitive, MIC < 0.1 mcg/ml)
Streptococcus pyogenes (Group A)
Streptococcus intermedius group (S. anginosus, S intermedius, S. constellatus)
Anaerobic gram-positive bacilli
Anaerobic gram-positive cocci
Aerobic gram-negative bacilli
Capnocytophaga canimorous (DF-2)
Capnocytophaga ochracea (DF-1)
Anaerobic gram-negative bacilli
Prevotella bivia (Bacteroides)
- MIC breakpoint of 0.5 mcg/mL for Staphylococci.
Inhibits protein synthesis by binding to 50S ribosomal subunits, interfering with transpeptidation and early chain termination.
Metabolism and Excretion
Metabolized to sulfoxide and N-dimethyl metabolites. Only 10% is excreted in urine within 24hrs. Majority excreted as inactive metabolite in feces and bile.
Cmax, Cmin, and AUC
Cmax 10 mcg/ml after 600 mg IV and 2.5 mcg/ml after 150 mg IV and po dose administration, respectively.
Distributed to many body tissues and fluids including ascites fluid, pleural fluid, synovial fluid, bone, bile and saliva. Poor CNS penetration.
DOSING FOR DECREASED HEPATIC FUNCTION
Dose reduction recommended for severe hepatic failure.
Category B-In a surveillance study of Michigan Medicaid recipients, 647 exposures to clindamycin during the 1st trimester resulted in 4.8% birth defects. These data do not support an association between clindamycin and congenital effects.
BREAST FEEDING COMPATIBILITY
Excreted into breast milk. The American Academy of Pediatrics considers clindamycin to be compatible with breast feeding.
Oral and parenteral lincomycins have good activity vs. anaerobes; increasing resistance with B. fragilis makes metronidazole a more reliable agent for intrabdominal infections. On a per pt basis, clindamycin is the antimicrobial most likely to cause C. difficile colitis, but many more pts get diarrhea (antibiotic-related) without C. difficile colitis. Prescribe with caution in individuals with h/o colitis. Four times a day dosing may limit patient adherence. A first-line oral treatment option for CA-MRSA soft tissue infection due to good tissue penetration (and a theoretical benefit of toxin inhibition), but should not be used with bacteremia.
- Gall SA et al: Intravenous metronidazole or clindamycin with tobramycin for therapy of pelvic infections. Obstet Gynecol 57:51, 1981 [PMID:7005778]
Comment: Clindamycin is equivalent to metronidazole in the treatment of pelvic infection.
- Safrin S et al: Comparison of three regimens for treatment of mild to moderate Pneumocystis carinii pneumonia in patients with AIDS. A double-blind, randomized, trial of oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, and clindamycin-primaquine. ACTG 108 Study Group. Ann Intern Med 124:792, 1996 [PMID:8610948]
Comment: Clindamycin-primaquine is an acceptable alternative to TMP-SMX , or dapsone-trimethoprim in the management of mild or moderately severe PCP.
- Smego RA et al: A meta-analysis of salvage therapy for Pneumocystis carinii pneumonia. Arch Intern Med 161:1529, 2001 [PMID:11427101]
Comment: Meta-analysis suggests clindamycin + primaquine is the most effective alternative in pts unresponsive to conventional PCP treatment.
- Katlama C et al: Pyrimethamine-clindamycin vs. pyrimethamine-sulfadiazine as acute and long-term therapy for toxoplasmic encephalitis in patients with AIDS. Clin Infect Dis 22:268, 1996 [PMID:8838183]
Comment: Pyrimethamine-clindamycin is less effective than sulfadiazine-pyrimethamine but can be used as an alternative treatment regimen in sulfa allergic pts.
- Snydman DR et al: National survey on the susceptibility of Bacteroides Fragilis Group: report and analysis of trends for 1997-2000. Clin Infect Dis 35:S126, 2002 [PMID:12173121]
Comment: Report of 2,673 strains of the Bacteroides fragilisgroup species for 1997-2000. Rates of resistance to clindamycin have remained high for several yrs (16%). The revised IDSA guidelines for intra-abdominal sepsis do not include clindamycin.
- Stevens DL et al: The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis. J Infect Dis 158:23, 1988 [PMID:3292661]
Comment: PCN works by inhibiting bacterial replication, but clindamycin shuts down production of toxins and its activity is independent of inoculum size. Clindamycin or clindamycin + PNC are advocated for devastating streptococcal soft tissue infections including necrotizing fasciitis, myositis and TSS (NEJM 334: 240, 1996).