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 Guide Editors
 Editor In Chief
    Joel E. Gallant, MD, MPH

Pharmacology Editor
    Paul Pham, PharmD, BCPS

Zambia Guideline Team
   Peter Mwaba MMed PhD FRCP
   Alywn Mwinga MMed
   Isaac Zulu MMed MPH
   Velepie Mtonga MMed
   Albert Mwango MBChB
   Jabbin Mulwanda MMed FCS
 

 

 

Drugs>Antimicrobial Agents>
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Clindamycin

Paul A. Pham Pharm.D. and John G. Bartlett M.D.
05-28-2009

Zambia Specific Information

  • Available formulations in Zambia: Capsule: 150 mg. Injection: 150 mg (as phosphate)/ml.
  • Cellulitis in PCN allergic pts: clindamycin 600 mg IV q8h or 300 mg PO q8h
  • PID in PCN allergic pts: Clindamycin 900 mg IV q8h plus gentamicin 5mg/kg/d until clinical improvement, then switch to doxycycline plus metronidazole for 14 days.
  • Diabetic foot ulcer in PCN allergic pts: Clindamycin 600 mg IV q8h plus gentamicin 5 mg/kg/d
  • PCP treatment in SMX/TMP allergic pts: Clindamycin 600 mg q8h plus primaquine 15 mg once-daily x 21 days.
  • Surgical prophylaxis in PCN allergic pts: Clindamycin 300 mg IV x 1 (add gentamicin 3mg/kg for colorectal, biliary, or pelvic surgery).
  • Peritonsillar abscess in PCN allergic pts: clindamycin 600 mg IV q8h or 300 mg PO q8h
  • Falciparum malaria in pregnancy and children <8 years: Clindamycin 5mg/kg tid x 7d PLUS quinine.
Zambia Information Author: Paul A. Pham, Pharm. D.

INDICATIONS

FDA

  • 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)
  • Streptococcus pneumoniae (empyema, pneumonitis, and lung abscess)
  • Septicemia (no longer recommended)
  • 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)
  •  Acne vulgaris (topical gel)
  •  Bacterial vaginosis in non-pregnant women (vaginal ovules)
NON-FDA APPROVED USES

  • PCP in combination with primaquine
  • CNS toxoplasmosis in combination with pyrimethamine and leucovorin
  • Bacterial vaginosis (oral and vaginal ovule)
  • Community acquired MRSA (CA-MRSA) soft tissue infections
  • Osteomyelitis
  • Actinomycosis
  • Acute bacterial sinusitis
  • CA-MRSA pneumonia in combination with vancomycin to reduce toxin production in severe cases.

FORMS

brand 
name
 
generic 
Mfg 
brand 
forms
 
cost* 
Cleocin Clindamycin HClPfizer oral
capsule
150 mg
$1.20
      oral
capsule
300 mg
$3.76
Cleocin phosphate Clindamycin phosphate~PfizerIV
vial
300 mg; 600 mg; 900 mg
$5.06 ; $9.16; $13.28
Cleocin pediatric solutionClindamycin palmitatePfizeroral
solution
75 mg/5 ml
$61.10 (100 mL)
Cleocin vaginal suppositoryClindamycin phosphatePfizervaginal
ovule suppository
100 mg
$23.51
Cleocin T Clindamycin phosphatePfizertopical
gel
1% (30 g; 60 g)
$62.76; $113.03
      topical
lotion
1% (60 ml)
$87.33 (60 mL)
Clindamycin Clindamycin HCL Various generic manufacturersoral
capsule
150 mg
$1.15
      oral
capsule
300 mg
$3.70

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

  • PCP: clindamycin 600 mg IV q 6-8h or 300-450 mg PO q6-8h + primaquine 15-30 mg PO once-daily (base) +/- prednisone (recommended for PO2<70) x 21 days.
  • CNS toxoplasmosis: clindamycin 600 mg IV q6h or clindamycin 450-600 mg PO q6h + pyrimethamine 200 mg PO loading dose, then 50-75 mg PO once-daily + leucovorin 10-20 mg once-daily until immune reconstitution (CD4 >200 on stable HAART for 6-12 mos).
  • Soft tissue (including CA-MRSA) infections: 300-450 mg PO q6h or 600 mg IV q8h x14 d then reassess.
  • Pelvic inflammatory disease: 900 mg IV q8h (in combination with gentamicin) x 14d.
  • Bacterial vaginosis: 100 mg vaginal suppository qhs x 3-7 d
  • Acne: 1-2 applications once-daily
  • Osteomyelitis: 600 mg IV q8h x 6-8 wks then reassess
  • Acute bacterial sinusitis: 300 mg PO q6h x 2-3 wks.
  • Actinomycosis: 600 mg IV q 8h x 2-6 wks, then 300 mg PO q6h x 6-12 mos
  • Capsules should be taken with full glass of water to avoid esophageal irritation

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

Usual dose

DOSING FOR GLOMERULAR FILTRATION OF 10-50

Usual dose

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

Usual dose

DOSING IN HEMODIALYSIS

Usual regimen

DOSING IN PERITONEAL DIALYSIS

Usual regimen

DOSING IN HEMOFILTRATION

Some removal during CAVH

ADVERSE DRUG REACTIONS

COMMON

  • Diarrhea (without C.difficile in 10-30%)
  • GI intolerance: nausea, vomiting, anorexia
OCCASIONAL

  • Generalized morbilliform rash
  • C. difficile colitis in 6% of pts (clindamycin is most common cause on per pt basis);
RARE

  • Stevens-Johnson syndrome
  • Allergic-type reactions (including bronchial asthma) in pts with aspirin hypersensitivity (from tartrazine found in 75 and 150 mg caps)

DRUG INTERACTIONS

  • Nondepolarizing muscle relaxant (pancuronium, tubocurarine): clindamycin may enhance action of nondepolarizing muscle relaxants. Use with caution in pts receiving such agents.
  • Loperamide and diphenoxylate/atropine: may increase risk of diarrhea and C. difficile-associated colitis. Avoid use with clindamycin.
  • Erythromycinin vitro antagonism. Clinical significance unclear. Avoid co-administration.
  • Kaolin-pectin: decreases clindamycin absorption

SPECTRUM

Active against most gram-positive cocci except Enterococcus and nosocomial MRSA. Active against most CA-MRSA. Increasing resistance seen with B. fragilis.

Detailed Spectrum of Activity

PHARMACOLOGY

Pharmacology

COMMENTS

Oral and parenteral lincomycins have good activity against anaerobes; increasing resistance with B. fragilis makes metronidazole more reliable for intrabdominal infections. On per pt basis, clindamycin is antimicrobial most likely to cause C. difficile colitis, but many more pts get diarrhea without C. difficile colitis. Prescribe with caution in individuals with h/o colitis. four times a day dosing may limit patient adherence. Clindamycin-primaquine is good 2nd-line regimen for PCP in pts who can not tolerate TMP/SMX. Inferior to pyrimethamine/sulfadiazine for treatment to CNS toxoplasmosis but clindamycin/pyrimethamine can be considered as an alternative treatment regimen in sulfa allergic pts. A first-line oral treatment option for CA-MRSA soft tissue infection.

REFERENCES

REFERENCED WITHIN THIS GUIDE


 
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