- Skin and soft tissue infections caused by streptococci, staphylococci and anaerobes
- Pelvic infections (endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, and postsurgical vaginal cuff infections)
- Intra-abdominal infections such as peritonitis and intra-abdominal abscess caused by anaerobes (note: IDSA no longer recommends clindamycin due to increased B. fragilis resistance rate)
- Streptococcus pneumoniae (empyema, pneumonitis, and lung abscess)
- Septicemia (no longer recommended)
- Acne vulgaris (topical gel)
- Bacterial vaginosis in non-pregnant women (vaginal ovules)
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
- Systemic dosing: note, clindamycin capules should be taken with a full glass of water to avoid esophageal irritation.
- Soft tissue infections: 300-450 mg PO q6h or 600 mg IV q8h x 7-14 d with reassessment.
- Pelvic inflammatory disease: 900 mg IV q8h (in combination with gentamicin), initial regimen in hospital
- Osteomyelitis: 600mg IV q8h/300-450 mg PO four times daily x usually 6-8 wks then reassess.
- Acute bacterial sinusitis: 300 mg PO q6h x 10-14d
- Actinomycosis: 600mg IV q 8h x 2-6wks, then clindamycin 300 mg PO q6h x 6-12mos
- Malaria: potential utility as part of alternative regimen, especially in pregnancy
- PCP: clindamycin 600mg IV q6h-q8h or 300mg-450mg PO q6h-8h + primaquine 15-30 mg (base) PO once daily +/- prednisone (recommended for PaO2< 70%) x 21 days
- CNS toxoplasmosis: clindamycin 600mg IV q6h or clindamycin 450 mg-600 mg PO q6h + pyrimethamine 200mg PO loading dose, then 50-7 5mg PO q24hd + leucovorin 10-20 mg q24hd until immune reconstitution (CD4 >200 on stable HAART for 6-12 mos)
- Topical applications:
- Bacterial vaginosis: 100 mg vaginal suppository qhs x 3-7 d
- Acne: 1-2 topical applications daily
USUAL PEDIATRIC DOSING
- Neonate (Neofax): 5 to 7.5 mg/kg/dose IV or PO
Post-menstrual age (weeks)
Post-natal age (days)
Dosing interval (hours)
≤ 29 weeks
> 28 days
30 to 36 weeks
> 14 days
37 to 44 weeks
> 7 days
≥ 45 weeks
- General Dosing:
- IV: 20-40 mg/kg/day IV divided q6-8h; max 900 mg/dose given IV
- PO: 20-30 mg/kg/day PO divided q6-8h; max 450 mg/dose given PO
- NOTE: guidelines for CAP , MRSA bone/joint & skin and soft tissue infections , and rhinosinusitis  state that PO dose can be as high as 40 mg/kg/day, however, most use a max of 30 mg/kg/day PO for tolerability.
- Malaria: see malaria module for details, usually part of alternative regimen.
- Uncomplicated (PO therapy): 20 mg/kg/day PO divided q8h plus quinine x 7 days
- Severe (IV therapy): loading dose of 10 mg/kg IV x 1, then 15 mg/kg/day IV divided q8h plus IV quinidine gluconate; switch to PO therapy (clindamycin and quinine) when able for total treatment duration of 7 days
- Toxoplasmosis :
- Infants/children: 5 to 7.5 mg/kg/dose IV/PO q6h (max 600 mg/dose IV or PO) with pyrimethamine and leucovorin
- Adolescents: 600 mg IV/PO q6h with pyrimethamine and leucovorin
- Secondary prophylaxis:
- Infants/children: 7 to 10 mg/kg/dose PO q8h with pyrimethamine and leucovorin
- Adolescents: 600 mg PO q8h with pyrimethamine and leucovorin
- PCP :
- Infants/children: 10 mg/kg/dose IV/PO q6h (max 600 mg IV, max 450 mg PO) with primaquine
- Adolescents: 600 mg IV q6h OR 300 mg PO q6h OR 450 mg PO q8h with primaquine
- General Dosing:
Pediatric Dosing Author: Alice Jenh Hsu, Pharm.D. BCPS
PEDIATRIC RENAL DOSING
- No renal dosage adjustment necessary.
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): occurs in 10-30%
- GI intolerance: nausea, vomiting and anorexia
- Generalized morbilliform rash
- C. difficile colitis: ~6%
- Stevens-Johnson syndrome
- Allergic-type reactions (including bronchial asthma): patients who have aspirin hypersensitivity (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.
Aerobic gram-positive bacilli
Bacillus spp (not anthracis or cereus)
Aerobic gram-positive cocci
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)
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 lincomycin with good activity vs. anaerobes; increasing resistance seen with B. fragilis makes metronidazole a more reliable agent for intra-abdominal infections.
- On a per pt basis, clindamycin is the antimicrobial most likely to cause C. difficile colitis, but many more patients 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 with oral regimen.
- 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 as first-line agent alone for bacteremia or endocarditis.
- Note: resistance rates described in dermatological literature for P. acnes are far higher than that described in isolates from sterile sites.
- Boyanova L, Kolarov R, Mitov I: Recent evolution of antibiotic resistance in the anaerobes as compared to previous decades. Anaerobe May 26 [PMID:24875330]
Comment: Though not commonly tested in many laboratories, increasing resistance to many agents seen in anaerobes, especially B. fragilis. Resistance to clindamycin has generally increased over the years.
- Bradley JS et al: The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 53:e25, 2011 [PMID:21880587]
Comment: IDSA/PIDS dosing recommendations for clindamycin for the treatment of CAP in children.
- Brook I, Wexler HM, Goldstein EJ: Antianaerobic antimicrobials: spectrum and susceptibility testing. Clin Microbiol Rev 26:526, 2013 [PMID:23824372]
Comment: Vagaries and nuances of anaerobic testing are well-discussed in this review, along with resistance mechanisms.
- CDC guidelines for the treatment of malaria in the United States. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf. Accessed 07/14/14.
Comment: CDC guideline recommendations for the use of clindamycin in the treatment of malaria.
- Chow AW et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 54:e72, 2012 [PMID:22438350]
Comment: IDSA guideline recommendations for the use of clindamycin for the treatment of rhinosinusitis.
- 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.
- Clindamycin. In: Neofax(R). Truven Health Analytics, Inc. Greenwood Village, CO. http://neofax.micromedexsolutions.com/ . Accessed July 14, 2014.
Comment: Neofax dosing recommendations for clindamycin based on post-menstrual and post-natal age.
- Liu C et al: Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 52:e18, 2011 [PMID:21208910]
Comment: IDSA guideline recommendations for the use of clindamycin in the treatment of MRSA infections.
- 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.
- Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children.Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Department of Health and Human Services. Available athttp://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf. Section accessed 07/14/14.
Comment: DHHS guideline recommendations for the use of clindamycin in the management of PCP and Toxoplasmosis in HIV infected children.
- 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.
- 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).
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