clindamycin (Cleocin, Cleocin Pediatric, Clindesse, ClindaMax Vaginal)
Classes: Antibiotics, Lincosamide
Dosing and uses of Cleocin, Clindesse (clindamycin)
Adult dosage forms and strengths
capsule
- 75mg
- 150mg
- 300mg
injectable solution
- 150mg/mL
oral solution
- 75mg/5mL
intravenous solution
- 300 mg/50mL (5% dextrose)
- 600 mg/50mL (5% dextrose)
- 900 mg/50mL (5% dextrose)
Serious Infections Caused by Anaerobic Bacteria
150-450 mg PO q6-8hr; not to exceed 1.8 g/day, Or
1.2-2.7 g/day IV/IM divided q6-12hr; not to exceed 4.8 g/day
Amnionitis
450-900 mg IV q8hr
Inhalational & Gastrointestinal Anthrax (Off-label)
900 mg IV q8hr with ciprofloxacin 400 mg PO q12hr or doxycycline 150-300 mg PO q12hr
Bacterial Vaginosis
300 mg PO q12hr for 7 days
Surgical Prophylaxis
900 mg PO/IV 1 hr prior to procedure; may redose q6hr if necessary
Bite Wounds (Human or Animal)
300 mg PO q6hr
Gangrenous Pyomyositis
900 mg IV q8hr with penicillin g
Group B Streptococcus
Neonatal prophylaxis
900 mg IV q8hr until delivery
Orofacial/Parapharyngeal Space Infections
150-450 mg PO q6hr for at least 7 days; not to exceed 1.8 g/day, Or
600-900 mg IV q8hr
Pelvic Inflammatory Disease
900 mg IV q8hr with gentamicin 2 mg/kg; THEN 1.5 mg/kg q8hr; continue after discharge with doxycycline 100 mg PO q12hr to complete 14 days of therapy
Toxic Shock Syndrome
900 mg IV q8hr plus oxacillin or nafcillin (2 g IV q4hr) or vancomycin (30 mg/kg/day IV divided q12hr
Endocarditis Prophylaxis (Off-label)
600 mg PO/IV/IM 30-60 min before procedure
Avoid IM injections in patients receiving anticoagulant therapy; administer PO in these circumstances; in general, administer IV only if patient does not tolerate or is unable to absorp oral medications
Dosing considerations
- Recent AHA guidelines recommend only for high-risk patients undergoing invasive procedures
CNS Toxoplasmosis, With Pyrimethamine or Leucovorin (Off-label)
600 mg IV or PO q6hr for at least 6 weeks
Gardnerella Vaginalis (Off-label)
PO: 300 mg PO q12hr for 7 days
Pneumocystis (Carinii) Jiroveci (Off-label)
30 mg/kg/day divided q6-8hr
300-450 mg PO q6-8hr with primaquine for 21 days
600-900 mg IV q6-8hr with primaquine for 21 days
Sarcoidosis (Orphan)
Orphan indication sponsor
- Autoimmunity Research Foundation; 3423 Hill Canyon Avenue; Thousand Oaks, CA 91360
Administration
PO: May take with food
Pediatric dosage forms and strengths
capsule
- 75mg
- 150mg
- 300mg
injectable solution
- 150mg/mL
oral solution
- 75mg/5mL
intravenous solution
- 300 mg/50mL (5% dextrose)
- 600 mg/50mL (5% dextrose)
- 900 mg/50mL (5% dextrose)
Serious Infections Caused by Anaerobic Bacteria
<7 days
- <2 kg (or >7 days, <1.2 kg): 10 mg/kg/day IV/IM divided q12hr
- >2 kg (or >7 days, 1.2-2 kg): 15 mg/kg/day IV/IM divided q8hr
>7 days
- >2 kg: 20 mg/kg/day IV/IM divided q6hr
<1 month
- 15-20 mg/kg/day divided q6-8hr
>1 month
- Hydrochloride: 8-20 mg/kg/day PO
- Palmitate: 8-25 mg/kg/day divided q6-8hr; 37.5 mg q8hr minimum palmitate dose
Anthrax
15-40 mg/kg/day IV divided q6-8hr
8-25 mg/kg/day PO divided 6-8hr
Endocarditis
Prophylaxis
20 mg/kg PO 30-60 min before procedure, Or
20 mg/kg IV/IM within 30-60 minutes before procedure
Streptococcal Pharyngitis
May consider use in patients allergic to penicillin (IDSA guidelines)
Chronic carrier treatment: 20-30 mg/kg/day PO divided q8hr; not to exceed 300 mg/dose
Acute treatment in penicillin-allergic patients: 7 mg/kg/dose TID for 10 days; not to exceed 300 mg/dose
Orofacial Infections
10-20 mg/kg/day PO divided q6-8hr, Or
15-25 mg/kg/day IV divided q6-8hr
May adjust dose as necessary not to exceed 40 mg/kg/day
Dosing Considerations
IM: No more than 600 mg per injection
Endocarditis: Recent AHA guidelines recommend only for invasive procedures in high-risk patients
Administration
May take with food
Cleocin, Clindesse (clindamycin) adverse (side) effects
Frequency not defined
Abdominal pain
Agranulocytosis
Eosinophilia (transient)
Diarrhea
Fungal overgrowth
Pseudomembranous colitis
Hypersensitivity
Stevens-Johnson syndrome
Rashes
Urticaria
Hypotension
Nausea
Vomiting
Sterile abscess at IM site
Thrombophlebitis
Granulocytopenia
Neutropenia
Thrombocytopenia
Polyarthritis
Renal dysfunction
Postmarketing reports
Metallic taste
Warnings
Black box warnings
Clostridium difficile-associated diarrhea (CDAD) has been reported and may range in severity from mild diarrhea to fatal colitis
C difficile produces toxins A and B, which contribute to CDAD; hypertoxin-producing C difficile strains increase morbidity and mortality (more likely to be refractory to antimicrobial therapy and may require colectomy)
If CDAD suspected or confirmed, ongoing antibiotic use not directed against C difficile may need to be discontinued
Contraindications
Hypersensitivity to clindamycin, lincomycin, or formulation components
Cautions
Endocarditis prophylaxis: Use only for high-risk patients, per recent AHA guidelines
Risk of potentially fatal pseudomembranous colitis, fungal or bacterial superinfection on prolonged use; discontinue therapy if significant abdominal cramps, diarrhea, or passage of blood and mucus occurs
May increase risk of drug-resistant bacteria if prescribed in the absence of proven or strongly suspected bacterial infection
Use caution in hepatic impairment, monitor for hepatic abnormalities; periodic liver enzyme determinations should be made when treating patients with severe liver disease
Not for use in meningitis due to inadequate penetration into CSF
Severe skin reactions including toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome (SJS), some with fatal outcome, reported; permanently discontinue if reactions occur
Parenteral product contains benzyl alcohol, which has been associated with gasping syndrome and death in newborns
Use with caution in patients with history of gastrointestinal disease, especially colitis
Not for administration as a bolus; infuse over 10-60 min
Consider possibility of clostridium difficile in all patients who present with diarrhea following antibiotic use
Serious anaphylactic reactions require immediate emergency treatment with epinephrine; oxygen and intravenous corticosteroids should also be administered as indicated
Prescribe with caution in atopic individuals
Indicated surgical procedures should be performed in conjunction with antibiotic therapy
Clindamycin dosage modification may not be necessary in patients with renal disease
Pregnancy and lactation
Pregnancy category: B
In clinical trials with pregnant women, the systemic administration of clindamycin during the second and third trimesters, has not been associated with an increased frequency of congenital abnormalities
Lactation: Excreted in breast milk; manufacturer suggests discontinue drug or do not nurse (AAP Committee states compatible with nursing)
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of Cleocin, Clindesse (clindamycin)
Mechanism of action
Suppresses protein synthesis by binding to 50S ribosomal subunits; bacteriostatic or bactericidal depending on drug concentration, organism and infection site
Absorption
Bioavailability: Oral (rapid; 90%)
Peak serum time: Within 60 min (PO); 1-3 hr (IM)
Distribution
High concentrations in bone and urine
No significant levels in CSF, even with inflamed meninges
Crosses placenta; enters breast milk
Vd: ~2 L/kg
Metabolism
Hepatic
Elimination
Half-life: 2-3 hr (adults); 8.7 hr (premature neonates); 3.6 hr (full-term neonates); 2 hr (children); 4 hr (elderly)
Excretion: Urine (10%) as active drug; feces (~4%) as active drug
Administration
IV Incompatibilities
Additive: Aminophylline, ceftriaxone, ciprofloxacin, gentamicin/cefazolin, ranitidine(?)
Syringe: Tobramycin
Y-site: Allopurinol, azithromycin, doxapram, filgrastim, fluconazole, idarubicin
Reported to be physically incompatible with aminophylline, ampicillin, barbiturates, Ca-gluconate, magnesium sulfate, and phenytoin; other reports say ampicillin is additive compatible and magnesium sulfate is Y-site compatible
IV Compatibilities
Solution: Compatible with most common diluents
Additive: Amikacin, aztreonam, cefazolin, cefepime, cefoperazone, cefotaxime, cefoxitin, ceftazidime, cefuroxime, cimetidine, fluconazole, gentamicin, heparin, hydrocortisone, kanamycin, methylprednisolone, metoclopramide, metronidazole, netilmicin, ofloxacin, KCl, penicillin G, piperacillin, Na-bicarbonate, tobramycin, verapamil, vitamin B/C
Syringe: Amikacin, aztreonam, caffeine, gentamicin, heparin
Y-site: Amifostine, amiodarone, amphotericin B CholSO4, amsacrine, aztreonam, bivalirudin, cefpirome, cisatracurium, cyclophosphamide, dexmedetomidine, diltiazem, docetaxel, doxorubicin liposomal, enalaprilat, esmolol, etoposide PO4, fenoldopam, fludarabine, foscarnet, gatifloxacin, gemcitabine, granisetron, hetastarch, hydromorphone, heparin, labetalol, levofloxacin, linezolid, meperidine, morphine, midazolam, milrinone, nicardipine, ondansetron, perphenazine, piperacillin/tazobactam, propofol, remifentanil, sargramostim, tacrolimus, teniposide, theophylline, thiotepa, vinorelbine, vitamin B/C, zidovudine
IV Preparation
Dilute 300 and 600 mg in 50 mL of D5W
Dilute 900 mg in 50-100 mL of D5W
Dilute 1200 mg in 100 mL of D5W
IV Administration
Intermittent IV infusion
- Infuse over 10-60 min at a rate not exceeding 30 mg/min
- See manufacturer's PI for rapid and maintenance rates for specific desired serum levels
- 300 mg doses infuse over 10 min
- 600 mg doses infuse over 20 min
- 900 mg doses infuse over 30 min
- 1200 mg doses infuse over 60 min; no more than 1200 mg of drug should be given by IV infusion in 1 hr
Continuous IV infusion
- May give continuous IV infusion instead of intermittent after first dose has been given by rapid IV infusion