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Clindamycin (systemic): Pediatric drug information

Clindamycin (systemic): Pediatric drug information
(For additional information see "Clindamycin (systemic): Drug information" and see "Clindamycin (systemic): Patient drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Colitis:

Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon, leading to overgrowth of C. difficile.

Because clindamycin therapy has been associated with severe colitis, which may end fatally, reserve it for serious infections for which less toxic antimicrobial agents are inappropriate. Do not use clindamycin in patients with nonbacterial infections, such as most upper respiratory tract infections.

C. difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin-producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary because CDAD has been reported to occur more than 2 months after the administration of antibacterial agents.

If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Institute appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation as clinically indicated.

Brand Names: US
  • Cleocin;
  • Cleocin in D5W [DSC];
  • Cleocin Phosphate;
  • CLIN Single Use [DSC]
Brand Names: Canada
  • AG-Clindamycin;
  • APO-Clindamycin;
  • Auro-Clindamycin;
  • Clindamycine-150 [DSC];
  • Clindamycine-300 [DSC];
  • Dalacin C;
  • Dalacin C Palmitate;
  • Dalacin C Phosphate;
  • JAMP Clindamycin;
  • M-Clindamycin;
  • MED-Clindamycin;
  • MYLAN-Clindamycin [DSC];
  • NRA-Clindamycin;
  • RIVA-Clindamycin;
  • TEVA-Clindamycin
Therapeutic Category
  • Antibiotic, Anaerobic;
  • Antibiotic, Miscellaneous
Dosing: Neonatal

General dosing, susceptible infection:

Age-directed dosing (Gonzalez 2016; Red Book [AAP 2021]): IV, Oral:

PMA

Dose

≤32 weeks

5 mg/kg/dose every 8 hours

>32 to 40 weeks

7 mg/kg/dose every 8 hours

>40 weeks

9 mg/kg/dose every 8 hours

Weight-directed dosing (Bradley 2021): IV, IM, Oral:

Body Weight

PNA

Dose

≤2 kg

≤28 days

5 mg/kg/dose every 8 hours

29 to 60 days

10 mg/kg/dose every 8 hours

>2 kg

≤7 days

7 mg/kg/dose every 8 hours

8 to 28 days

9 mg/kg/dose every 8 hours

29 to 60 days

10 mg/kg/dose every 8 hours

Manufacturer's labeling: IM, IV: 15 to 20 mg/kg/day divided every 6 to 8 hours.

Anthrax, treatment : Note: Consult public health officials for event-specific recommendations. Treatment must be followed by prophylaxis for a total antibiotic course of 60 days (AAP [Bradley 2014]).

Severe anthrax (eg, anthrax meningitis, inhalational anthrax, head or neck lesions, cutaneous anthrax with systemic involvement), initial parenteral therapy: Note: Administer as part of an appropriate combination regimen for ≥2 to 3 weeks and until patient is clinically stable. Linezolid is preferred over clindamycin if meningitis cannot be ruled out.

IV:

GA

PNA

Dose

32 to 34 weeks

≤7 days

5 mg/kg/dose every 12 hours

8 to 28 days

5 mg/kg/dose every 8 hours

>34 weeks

≤7 days

5 mg/kg/dose every 8 hours

8 to 28 days

5 mg/kg/dose every 6 hours

Postexposure prophylaxis (inhalational exposure); cutaneous anthrax without systemic involvement; oral step-down therapy for severe anthrax: Note: Treat for 7 to 10 days for naturally acquired cutaneous anthrax without systemic involvement; treat for ≥14 days and until patient is clinically stable for oral step-down therapy (as part of a combination regimen) for severe anthrax; and treat for 60 days for postexposure prophylaxis.

Oral:

GA

PNA

Dose

32 to 34 weeks

≤7 days

5 mg/kg/dose every 12 hours

8 to 28 days

5 mg/kg/dose every 8 hours

>34 weeks

≤7 days

5 mg/kg/dose every 8 hours

8 to 28 days

5 mg/kg/dose every 6 hours

Dosing: Pediatric

Note: Dosing presented in mg/kg/dose and mg/kg/day; use caution. Dosage should be based on total body weight for children ≥2 years of age and adolescents with and without obesity (Smith 2017; manufacturer's labeling).

General dosing, susceptible infection:

Infants, Children, and Adolescents:

IM, IV: 20 to 40 mg/kg/day divided every 6 to 8 hours; maximum daily dose: 2,700 mg/day (Red Book [AAP 2021]; manufacturer's labeling).

Oral: 10 to 25 mg/kg/day divided every 8 hours (Red Book [AAP 2021]; manufacturer's labeling); higher doses of 30 to 40 mg/kg/day divided every 6 to 8 hours recommended for some infections; maximum daily dose: 1,800 mg/day (Red Book [AAP 2021]).

Anthrax: Note: Consult public health officials for event-specific recommendations. After completion of therapy, initiate antimicrobial prophylaxis to complete an antimicrobial course of 60 days from onset of illness.

Infants, Children, and Adolescents: Limited data available:

Postexposure prophylaxis (inhalational exposure): Oral: 30 mg/kg/day divided every 8 hours for 60 days; maximum dose: 900 mg/dose.

Cutaneous, without systemic involvement: Oral: 30 mg/kg/day divided every 8 hours for 7 to 10 days for a naturally acquired infection or 60 days for a biological weapon-related event; maximum dose: 600 mg/dose.

Systemic involvement (including severe disease): IV: 40 mg/kg/day divided every 8 hours as part of an appropriate combination regimen for ≥14 days if meningitis is excluded or ≥14 to 21 days if meningitis cannot be excluded, and until patient clinically stable; maximum dose: 900 mg/dose.

Step-down therapy for severe infection: Oral: 30 mg/kg/day divided every 8 hours as part of an appropriate combination regimen to complete ≥14 days total therapy following appropriate initial treatment; maximum dose: 600 mg/dose.

Babesiosis (alternative agent):

Infants, Children, and Adolescents: Limited data available:

Mild to moderate disease or oral step-down therapy following initial parenteral treatment: Oral: 7 to 10 mg/kg/dose every 6 to 8 hours in combination with quinine for a total of 7 to 10 days; maximum dose: 600 mg/dose. A longer duration of ≥6 weeks, including 2 weeks after resolution of parasitemia, may be necessary in highly immunocompromised patients (IDSA [Krause 2021]).

Severe disease, initial therapy: IV: 7 to 10 mg/kg/dose every 6 to 8 hours in combination with quinine; maximum dose: 600 mg/dose; change to oral clindamycin once symptoms improve (IDSA [Krause 2021]).

Catheter (peritoneal dialysis); exit-site or tunnel infection: Infant, Children, and Adolescents: Oral: 10 mg/kg/dose 3 times daily; maximum dose: 600 mg/dose (ISPD [Warady 2012]).

Endocarditis, prophylaxis before invasive dental or respiratory tract procedures:

Note: Clindamycin is NOT recommended for prevention of endocarditis in penicillin-allergic patients at high risk due to C. difficile risk; preferred options include cephalexin, azithromycin, clarithromycin, and doxycycline. Recommended only in patients who are at highest risk for infective endocarditis (IE) or adverse outcomes (AHA [Baltimore 2015]; AHA [Wilson 2021]; AHA/ACC [Nishimura 2017]).

Infants, Children, and Adolescents: Limited data available: Oral, IV, IM: 20 mg/kg administered 30 to 60 minutes prior to procedure; maximum dose: 600 mg/dose (AHA [Wilson 2007]).

Intra-abdominal infection, complicated: Note: Not routinely recommended due to Bacteroides fragilis resistance.

Infants, Children, and Adolescents: IV: 30 to 40 mg/kg/day divided every 6 to 8 hours in combination with other antibiotics; maximum daily dose: 2,700 mg/day (Bradley 2021; Red Book [AAP 2021]; Solomkin 2010).

Malaria, uncomplicated; treatment (alternative agent): Infants, Children, and Adolescents: Oral: 20 mg/kg/day divided every 8 hours for 7 days in combination with quinine (CDC 2020).

Osteoarticular infection, acute (eg, septic [bacterial] arthritis, osteomyelitis): Infants, Children, and Adolescents: IV, Oral: 30 to 40 mg/kg/day divided every 6 to 8 hours; maximum dose: IV: 900 mg/dose; Oral: 600 mg/dose. Duration should be individualized based on several factors including causative pathogen, response to therapy, and normalization of inflammatory markers. Minimum total duration is ≥2 to 3 weeks for septic arthritis and ≥3 to 4 weeks for osteomyelitis; longer duration commonly necessary, particularly for infections caused by methicillin-resistant Staphylococcus aureus (MRSA) (Donaldson 2020; PIDS/IDSA [Woods 2021]; Saavedra-Lozano 2017).

Otitis media, acute: Infants ≥6 months, Children, and Adolescents: Oral: 30 to 40 mg/kg/day divided every 6 to 8 hours. For patients with severe disease or who are <2 years of age, treat for 10 days; for patients ≥2 years of age with mild to moderate disease, treatment for 5 to 7 days is likely adequate (AAP [Lieberthal 2013]; Kozyrskyj 2010; Red Book [AAP 2021]). Note: Combination therapy with a third-generation cephalosporin may be necessary (eg, following failure of amoxicillin/clavulanate or when Haemophilus influenzae or Moraxella catarrhalis activity is desired).

Peritonitis (peritoneal dialysis):

Infants, Children, and Adolescents:

Prophylaxis in patients receiving peritoneal dialysis (ISPD [Warady 2012]):

Invasive dental procedures: Oral: 20 mg/kg administered 30 to 60 minutes before procedure; maximum dose: 600 mg.

GI or genitourinary procedures: IV: 10 mg/kg administered 30 to 60 minutes before procedure; maximum dose: 600 mg.

Treatment: Intraperitoneal, continuous: Loading dose: 300 mg per liter of dialysate; maintenance dose: 125 to 150 mg per liter of dialysate (Aronoff 2007; ISPD [Warady 2012]).

Pharyngitis, streptococcal (group A):

Infants, Children, and Adolescents (IDSA [Shulman 2012]; Red Book [AAP 2021]):

Treatment and primary prevention of rheumatic fever: Oral: 21 mg/kg/day in divided doses every 8 hours for 10 days; maximum dose: 300 mg/dose.

Chronic carriage: Oral: 20 to 30 mg/kg/day in divided doses every 8 hours for 10 days; maximum dose: 300 mg/dose. Note: Most individuals with chronic carriage do not require antimicrobial treatment.

Pneumocystis jirovecii pneumonia (PCP), treatment (alternative agent):

HIV-exposed/-infected: Note: Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient ≥35 mm Hg) should receive adjunctive glucocorticoids (HHS [adult OI 2021]; HHS [pediatric OI 2021]).

Infants and Children: Limited data available: IV, Oral: 10 mg/kg/dose every 6 hours in combination with primaquine for 21 days; maximum IV dose: 600 mg/dose; maximum oral dose: 300 to 450 mg/dose (HHS [pediatric OI 2021].

Adolescents (HHS [adult OI 2021]):

Oral: Mild to severe disease: 450 mg every 6 hours or 600 mg every 8 hours in combination with primaquine for 21 days.

IV: Moderate to severe disease: 600 mg every 6 hours or 900 mg every 8 hours in combination with primaquine for 21 days.

Pneumonia, community-acquired: Note: Duration dependent upon pathogen and clinical course. Typical duration for uncomplicated infections is 5 to 10 days; however, infections caused by MRSA may require longer treatment (IDSA/PIDS [Bradley 2011]; Pernica 2021; Same 2021).

Infants ≥3 months, Children, and Adolescents (IDSA/PIDS [Bradley 2011]):

Moderate to severe infection: IV: 40 mg/kg/day divided every 6 to 8 hours; maximum daily dose: 2,700 mg/day.

Mild infection or oral step-down therapy: Oral: 30 to 40 mg/kg/day divided every 6 to 8 hours; maximum daily dose: 1,800 mg/day.

Rhinosinusitis, acute bacterial (alternative agent): Children and Adolescents: Oral: 30 to 40 mg/kg/day divided every 8 hours with concomitant cefixime or cefpodoxime for 10 to 14 days (IDSA [Chow 2012]).

Skin and soft tissue infection (SSTI):

Infants, Children, and Adolescents:

Impetigo, ecthyma (if MRSA is suspected or confirmed): Oral: 20 mg/kg/day in divided doses every 8 hours for 7 days; maximum dose: 400 mg/dose (IDSA [Stevens 2014]).

Cellulitis, erysipelas, purulent/fluctuant SSTI: Note: Typical duration is 5 days for uncomplicated infection but may be extended if clinical response is inadequate (Galli 2019; IDSA [Stevens 2014]).

IV: 25 to 40 mg/kg/day in divided doses every 8 hours; maximum dose: 600 mg/dose (IDSA [Stevens 2014]).

Oral:

Methicillin-susceptible Staphylococcus aureus (MSSA) infection: Oral: 25 to 30 mg/kg/day in divided doses every 8 hours; maximum dose: 450 mg/dose (IDSA [Stevens 2014]).

MRSA infection: Oral: 30 to 40 mg/kg/day in divided doses every 6 to 8 hours; maximum dose: 450 mg/dose (IDSA [Stevens 2014]; Red Book [AAP 2021]).

Necrotizing soft tissue infections: IV: 10 to 13 mg/kg/dose every 8 hours as part of an appropriate combination regimen in addition to surgical intervention; maximum dose: 900 mg/dose. Continue until further debridement is not necessary, patient has clinically improved, and patient is afebrile for 48 to 72 hours (IDSA [Stevens 2014]).

Surgical prophylaxis: Children and Adolescents: IV: 10 mg/kg within 30 to 60 minutes prior to procedure; may repeat dose in 6 hours for prolonged procedure or excessive blood loss; maximum dose: 900 mg/dose (ASHP/IDSA/SIS/SHEA [Bratzler 2013]).

Toxic shock syndrome, toxin production suppression (empiric therapy): Infants, Children, and Adolescents: IV: 40 mg/kg/day in divided doses every 6 to 8 hours; maximum dose: 900 mg/dose (Dietrich 2018; Ondusko 2018; Wong 2013).

Toxoplasmosis (alternative agent):

HIV-exposed/-infected: Infants, Children, and Adolescents:

Initial treatment: IV, Oral: 5 to 7.5 mg/kg/dose every 6 hours in combination with pyrimethamine and leucovorin; maximum dose: 600 mg/dose. For congenital toxoplasmosis, continue therapy for 12 months. For acquired toxoplasmosis, continue for ≥6 weeks followed by chronic maintenance therapy; longer duration may be required if incomplete response or extensive disease (HHS [OI adult 2021]; HHS [OI pediatric 2021]).

Chronic maintenance therapy (secondary prophylaxis): Oral: 7 to 10 mg/kg/dose every 8 hours in combination with pyrimethamine and leucovorin; maximum dose: 600 mg/dose. May consider discontinuation when asymptomatic, CD4 percentage is ≥15% (or CD4 count is >200 cells/mm3 for ages ≥6 years), and the patient has an undetectable HIV viral load in response to antiretroviral therapy for ≥6 months (HHS [OI adult 2021]; HHS [OI pediatric 2021]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Pediatric

Altered kidney function: Infants, Children, and Adolescents: IV, Oral:

Mild to severe impairment: No dosage adjustment necessary.

Hemodialysis, intermittent (thrice weekly): Poorly dialyzed; based on adult information, no supplemental dose or dosage adjustment necessary (Cimino 1969).

Peritoneal dialysis: Poorly dialyzed; based on adult information, no dosage adjustment necessary (Malacoff 1975).

Continuous renal replacement therapy (CRRT): Based on adult information, no dosage adjustment necessary (Heintz 2009).

Dosing: Hepatic Impairment: Pediatric

No adjustment required. Use caution with severe hepatic impairment.

Dosing: Adult

(For additional information see "Clindamycin (systemic): Drug information")

Usual dose:

Oral: 600 to 1,800 mg/day in 2 to 4 divided doses; up to 2,400 mg/day in 4 divided doses may be given for severe infections.

IM, IV: 600 to 2,700 mg/day in 2 to 4 divided doses; according to the manufacturer, up to 4,800 mg/day IV (in divided doses) has been used in life-threatening infections; however, data supporting this dose are lacking; maximum: 600 mg/dose IM.

Anthrax

Anthrax (off-label use): Note: Consult public health officials for event-specific recommendations.

Inhalational exposure postexposure prophylaxis (PEP) (alternative agent): Oral: 600 mg every 8 hours for 42 to 60 days.

Note: Anthrax vaccine should also be administered to exposed individuals (CDC [Bower 2019]; CDC [Hendricks 2014]). Duration of therapy: If the PEP anthrax vaccine series is administered on schedule (for all regimens), antibiotics may be discontinued in immunocompetent adults 18 to 65 years of age at 42 days after initiation of vaccine or 2 weeks after the last dose of the vaccine (whichever comes last and not to exceed 60 days); if the vaccination series cannot be completed, antibiotics should continue for 60 days (CDC [Bower 2019]). In addition, adults with immunocompromising conditions or receiving immunosuppressive therapy, patients >65 years of age, and patients who are pregnant or breastfeeding should receive antibiotics for 60 days (CDC [Bower 2019]).

Cutaneous, without systemic involvement, empiric therapy (alternative agent): Oral: 600 mg every 8 hours for 60 days following biological weapon-related event; duration is 7 to 10 days after naturally acquired infection. Note: Patients with cutaneous lesions of the head or neck or extensive edema should be treated for systemic involvement (CDC [Hendricks 2014]).

Systemic, meningitis excluded: IV: 900 mg every 8 hours in combination with other appropriate agents for at least 2 weeks or until clinically stable, whichever is longer (CDC [Hendricks 2014]).

Meningitis (alternative agent): IV: 900 mg every 8 hours in combination with other appropriate agents for at least 2 to 3 weeks or until clinically stable, whichever is longer (CDC [Hendricks 2014]).

Note: Antitoxin should also be administered for systemic anthrax. Following the course of IV combination therapy for systemic anthrax infection (including meningitis), patients exposed to aerosolized spores require oral monotherapy to complete a total antimicrobial course of 60 days (CDC [Hendricks 2014]).

Babesiosis

Babesiosis (alternative agent) (off-label use):

Mild to moderate disease or oral step-down therapy following initial parenteral treatment: Oral: 600 mg every 8 hours in combination with quinine for a total of 7 to 10 days; a longer duration of ≥6 weeks, including 2 weeks after resolution of parasitemia, may be necessary for patients at high risk of relapse (eg, highly immunocompromised patients) (IDSA [Krause 2021]; Krause 2008; Sanchez 2016).

Severe disease, initial therapy: IV: 600 mg every 6 hours in combination with quinine; may switch to oral clindamycin once symptoms improve (IDSA [Krause 2021]).

Bacterial vaginosis

Bacterial vaginosis (alternative agent) (off-label use):

Note: Treatment is generally not warranted for asymptomatic patients who are not pregnant (CDC [Workowski 2021]).

Oral: 300 mg twice daily for 7 days (CDC [Workowski 2021]).

Bite wound infection, prophylaxis of high-risk bite or treatment

Bite wound infection, prophylaxis of high-risk bite or treatment (animal or human bite) (alternative agent) (off-label use): Note: For animal bite, use in combination with an appropriate agent for Pasteurella multocida. For human bite, use in combination with an appropriate agent for Eikenella corrodens (IDSA [Stevens 2014]).

Oral: 300 to 450 mg 3 times daily (Baddour 2021a; Baddour 2021b; IDSA [Stevens 2014]).

IV: 600 mg every 6 to 8 hours (IDSA [Stevens 2014]). Note: In selected patients with high-risk wounds, some experts recommend parenteral therapy be given initially until infection is resolving, followed by oral therapy (Baddour 2021a; Baddour 2021b).

Note: For prophylaxis, duration is 3 to 5 days (IDSA [Stevens 2014]); for treatment of established infection, duration is typically 5 to 14 days and varies based on patient-specific factors, including clinical response (Baddour 2021a; Baddour 2021b).

Diabetic foot infection, mild to moderate

Diabetic foot infection, mild to moderate (alternative agent) (off-label use): Oral: 300 to 450 mg every 6 to 8 hours (Bader 2008; IDSA [Lipsky 2012]; Lipsky 1990; Weintrob 2020). Note: May be used alone for empiric therapy of mild infections; if there are risk factors for gram-negative bacilli, must be used in combination with other appropriate agents. Duration of therapy should be tailored to individual clinical circumstances; most patients respond to 1 to 2 weeks of therapy (IDSA [Lipsky 2012]; Weintrob 2020).

Hidradenitis suppurativa

Hidradenitis suppurativa (off-label use): Oral: 300 mg twice daily in combination with rifampin for 10 to 12 weeks (Dessinioti 2016; Gener 2009; Gulliver 2016; Zouboulis 2015).

Malaria, treatment

Malaria, treatment (alternative agent) (off-label use): Oral: 20 mg/kg/day in divided doses every 8 hours for 7 days in combination with quinine sulfate (quinine sulfate duration is region specific). Note: If used for P. vivax or P. ovale, use this regimen in combination with primaquine. If used for severe malaria (after completion of IV therapy), use full 7-day schedule of clindamycin. (CDC 2020).

Neutropenic fever, empiric therapy for low-risk cancer patients

Neutropenic fever, empiric therapy for low-risk cancer patients (alternative agent for penicillin-allergic patients) (off-label use): Oral: 600 mg every 8 hours (Rubenstein 1993); some experts recommend 300 mg every 6 hours (Bow 2018) (data on appropriate dose are limited). Use in combination with oral ciprofloxacin; continue until afebrile and neutropenia has resolved. Note: Avoid in patients who have received fluoroquinolone prophylaxis. Administer first dose in the health care setting (after blood cultures are drawn); observe patient for ≥4 hours before discharge (ASCO/IDSA [Taplitz 2018]; IDSA [Freifeld 2011]).

Odontogenic infection

Odontogenic infection (alternative agent for penicillin-allergic patients) (off-label use):

IV: 600 mg every 8 hours until improved, then transition to oral clindamycin (Bhagania 2018; Chow 2018).

Oral (initial therapy for mild infection or step-down after parenteral treatment): 450 mg every 8 hours to complete a 7- to 14-day course (Chow 2018); doses in the literature varied from 150 mg every 6 hours (Tancawan 2015) to 300 mg every 6 hours (Cachovan 2011) to 600 mg every 8 hours (Bhagania 2018).

Osteomyelitis

Osteomyelitis :

Osteomyelitis due to methicillin-resistant Staphylococcus aureus (MRSA) (alternative agent): IV, Oral: 600 mg 3 times daily for a minimum of 8 weeks; some experts combine with rifampin (IDSA [Liu 2011]).

Osteomyelitis, native vertebral due to staphylococci, methicillin-susceptible (alternative agent):

IV: 600 to 900 mg every 8 hours for 6 weeks (IDSA [Berbari 2015]).

Oral: 300 to 450 mg 4 times daily (IDSA [Berbari 2015]) or 600 mg 3 times daily (IDSA [Liu 2011]) for 6 weeks (IDSA [Berbari 2015]). Note: Clindamycin may also be used as suppressive therapy in selected patients (Osmon 2019).

Osteomyelitis, native vertebral due to Cutibacterium acnes (alternative agent): IV: 600 to 900 mg every 8 hours for 6 weeks (IDSA [Berbari 2015]).

Pelvic inflammatory disease, severe

Pelvic inflammatory disease, severe (including tubo-ovarian abscess) (alternative agent):

IV: 900 mg every 8 hours in combination with gentamicin; after 24 to 48 hours of sustained clinical improvement, transition to an oral regimen to complete 14 days of treatment. (CDC [Workowski 2021]). Note: Some experts reserve this regimen for patients who cannot use preferred agents due to greater associated adverse effects (Wiesenfeld 2022).

Oral: 450 mg 4 times daily, beginning after 24 to 48 hours of sustained clinical improvement on an appropriate parenteral regimen, to complete 14 days of therapy. Note: If tubo-ovarian abscess is present, use as part of an appropriate combination regimen (CDC [Workowski 2021]).

Pneumocystis jirovecii pneumonia, treatment

Pneumocystis jirovecii pneumonia (PCP), treatment (alternative agent) (off-label use):

Mild to moderate disease: Oral: 450 mg every 6 hours or 600 mg every 8 hours with primaquine for 21 days (HHS [OI adult 2020]).

Severe disease: IV: 600 mg every 6 hours or 900 mg every 8 hours with primaquine for 21 days; following clinical improvement, clindamycin can be given orally at 450 mg every 6 hours or 600 mg every 8 hours (HHS [OI adult 2020]; Thomas 2018).

Note: Patients with moderate or severe infection (PaO2 <70 mm Hg at room air or alveolar-arterial oxygen gradient ≥35 mm Hg) should receive adjunctive glucocorticoids (HHS [OI adult 2020]).

Pneumonia

Pneumonia

Aspiration pneumonia (alternative agent):

Note: Reserve for patients with penicillin allergy, as initial treatment for mild, community-acquired infection or as oral step-down therapy for patients requiring initial parenteral therapy (Klompas 2022).

Oral: 300 to 450 mg 3 times daily; duration of therapy is generally 5 to 7 days (Allewelt 2004; Klompas 2022).

Pathogen-specific therapy for methicillin-resistant S. aureus pneumonia (alternative agent):

Note: Data in adults are limited (IDSA [Liu 2011]; Lobo 2010).

Oral, IV: 600 mg 3 times daily; duration of therapy varies based on disease severity and response to therapy; treatment is typically given for 7 days (IDSA [Liu 2011]).

Postpartum endometritis

Postpartum endometritis: IV: 900 mg every 8 hours as part of an appropriate combination regimen; treat until the patient is clinically improved (no fundal tenderness) and afebrile for 24 to 48 hours (Chen 2021; Gall 1996).

Prosthetic joint infection

Prosthetic joint infection (off-label use):

Cutibacterium acnes, treatment (alternative agent for penicillin allergy):

IV: 600 to 900 mg every 8 hours for 4 to 6 weeks (IDSA [Osmon 2013]).

Oral: 300 to 450 mg every 6 hours (IDSA [Osmon 2013]), following at least 2 weeks of parenteral therapy (Kanafani 2018).

Methicillin-resistant staphylococci, treatment (chronic suppression): Oral: 600 mg every 8 hours (Berbari 2022).

Rhinosinusitis, acute bacterial

Rhinosinusitis, acute bacterial (alternative agent for patients with penicillin allergy who are able to tolerate cephalosporins) (off-label use):

Note: In uncomplicated acute bacterial rhinosinusitis, initial observation and symptom management without antibiotic therapy is appropriate in most patients. Reserve antibiotic therapy for poor follow-up or lack of improvement over the observation period (AAO-HNS [Rosenfeld 2015]; ACP/CDC [Harris 2016]).

Oral: 300 mg every 6 to 8 hours in combination with an oral third-generation cephalosporin for 5 to 7 days (AAO-HNS [Rosenfeld 2016]; IDSA [Chow 2012]; Patel 2021).

Septic arthritis due to S. aureus

Septic arthritis due to S. aureus (including MRSA) (alternative agent): Oral, IV: 600 mg 3 times daily for 3 to 4 weeks (Goldenberg 2018; IDSA [Liu 2011]). Note: A longer course of parenteral therapy (4 weeks) may be required for patients with concomitant bacteremia (in the absence of endocarditis) (Goldenberg 2019).

Skin and soft tissue infection

Skin and soft tissue infection:

Cellulitis, nonpurulent with risk for methicillin-resistant S. aureus or erysipelas (alternative agent):

Oral: 300 mg 4 times daily or 450 mg 3 times daily (IDSA [Stevens 2014]; Spelman 2021).

IV: 600 to 900 mg every 8 hours; transition to oral therapy once patient begins to clinically improve (IDSA [Stevens 2014]; Spelman 2021).

Cellulitis, purulent or abscess: Oral: 300 mg 4 times daily or 450 mg 3 times daily. Note: Systemic antibiotics only indicated for abscess in certain instances (eg, immunocompromised patients, signs of systemic infection, large or multiple abscesses, indwelling device, high risk for adverse outcome with endocarditis). If at risk for gram-negative bacilli, use in combination with an appropriate agent (IDSA [Stevens 2014]; Spelman 2021).

Duration: Treat for ≥5 days but may extend up to 14 days depending on severity and clinical response (IDSA [Stevens 2014]; Spelman 2021).

Cellulitis, long-term suppression of recurrent infection: Note: For patients with ≥3 episodes/year of known or presumed staphylococcal cellulitis when predisposing factors cannot be controlled (Spelman 2021).

Oral: 150 mg once daily after completion of treatment (Spelman 2021).

Impetigo or ecthyma if methicillin-resistant S. aureus is suspected or confirmed (alternative agent): Note: For impetigo, reserve systemic therapy for patients with numerous lesions or in outbreak settings to decrease transmission (IDSA [Stevens 2014]).

Oral: 300 mg 4 times daily or 450 mg 3 times daily for 7 days (Baddour 2021c; IDSA [Stevens 2014]).

Necrotizing soft tissue infection (alternative agent): IV: 600 to 900 mg every 8 hours as part of an appropriate combination regimen. Note: Antibiotic therapy must be used in conjunction with early and aggressive surgical exploration and debridement of necrotic tissue (IDSA [Stevens 2014]; Stevens 2021a).

Streptococcus

Streptococcus (group A):

Bloodstream infection: IV: 900 mg every 8 hours in combination with IV penicillin G; duration is individualized, but clindamycin may be discontinued within 48 hours for patients without septic shock, organ failure, or necrotizing infection. Continue penicillin G to complete ≥14 days of therapy (Stevens 2021b).

Pharyngitis (alternative agent for penicillin-allergic patients) (off-label use): Oral: 300 mg 3 times daily for 10 days (IDSA [Shulman 2012]).

Chronic carriage (off-label use): Oral: 300 mg 3 times daily for 10 days. Note: Most individuals with chronic carriage do not require antimicrobial treatment (IDSA [Shulman 2012]).

Streptococcus, maternal prophylaxis for prevention of neonatal disease

Streptococcus (group B) , maternal prophylaxis for prevention of neonatal disease (alternative agent) (off-label use):

IV: 900 mg at onset of labor or prelabor rupture of membranes, then every 8 hours until delivery. Note: Reserve use for patients with penicillin allergy that are at high risk for anaphylaxis and who have documented clindamycin-susceptible group B streptococci (ACOG 2020).

Surgical prophylaxis

Surgical prophylaxis (in combination with other appropriate agents when coverage for MRSA is indicated or for gram-positive coverage in patients unable to tolerate cephalosporins) (off-label use): IV: 900 mg started within 60 minutes prior to initial surgical incision. Clindamycin doses may be repeated intraoperatively at 6-hour intervals if procedure is lengthy or if there is excessive blood loss (ASHP/IDSA/SIS/SHEA [Bratzler 2013]). In cases where an extension of prophylaxis is warranted postoperatively, total duration should be ≤24 hours (Anderson 2014; ASHP/IDSA/SIS/SHEA [Bratzler 2013]). For clean and clean-contaminated procedures, continued prophylactic antibiotics beyond surgical incision closure is not recommended, even in the presence of a drain (CDC [Berríos-Torres 2017]).

Toxic shock syndrome, toxin production suppression

Toxic shock syndrome, toxin production suppression (empiric therapy): IV: 900 mg every 8 hours as part of an appropriate combination regimen (Lappin 2009; Wong 2013). Duration is until clinically and hemodynamically stable for at least 48 to 72 hours; then discontinue clindamycin and give monotherapy with an appropriate agent (Chu 2021; Stevens 2021b).

Toxoplasma gondii encephalitis and pneumonitis

Toxoplasma gondii encephalitis and pneumonitis (alternative agent) (off-label use):

Initial treatment: Oral, IV: 600 mg every 6 hours in combination with pyrimethamine and leucovorin. Continue therapy for at least 6 weeks; longer duration may be required if incomplete response or extensive disease; after completion of acute therapy, all patients should receive long-term maintenance therapy (HHS [OI adult 2020]; Schwartz 2013).

Long-term maintenance therapy: Oral: 600 mg every 8 hours in combination with pyrimethamine and leucovorin (HHS [OI adult 2020]; Schwartz 2013); in patients with HIV, may discontinue when asymptomatic with a CD4 count >200 cells/mm3 and an undetectable HIV viral load for >6 months in response to ART (HHS [OI adult 2020]).

Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

IV, Oral:

Mild to severe impairment: No dosage adjustment necessary.

Hemodialysis, intermittent (thrice weekly): Poorly dialyzed; no supplemental dose or dosage adjustment necessary (Cimino 1969).

Peritoneal dialysis: Poorly dialyzed; no dosage adjustment necessary (Malacoff 1975).

CRRT: No dosage adjustment necessary (Heintz 2009).

PIRRT (eg, sustained, low-efficiency diafiltration): No dosage adjustment necessary (expert opinion).

Dosing: Hepatic Impairment: Adult

Mild impairment: There are no dosage adjustments provided in the manufacturer's labeling.

Moderate to severe impairment: There are no dosage adjustments provided in the manufacturer's labeling. In studies of patients with moderate or severe liver disease, half-life is prolonged; however, when administered on an every-8-hour schedule, accumulation should rarely occur. In severe liver disease, use caution and monitor liver enzymes periodically during therapy.

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product

Capsule, Oral, as hydrochloride [strength expressed as base]:

Cleocin: 75 mg, 150 mg [contains brilliant blue fcf (fd&c blue #1), tartrazine (fd&c yellow #5)]

Cleocin: 300 mg [contains brilliant blue fcf (fd&c blue #1)]

Generic: 75 mg, 150 mg, 300 mg

Kit, Injection, as phosphate [strength expressed as base]:

CLIN Single Use: 300 mg/2 mL [DSC] [contains benzyl alcohol, edetate (edta) disodium]

Solution, Injection, as phosphate [strength expressed as base]:

Cleocin Phosphate: 300 mg/2 mL (2 mL); 600 mg/4 mL (4 mL); 900 mg/6 mL (6 mL); 9 g/60 mL (60 mL) [contains benzyl alcohol, edetate (edta) disodium]

Generic: 300 mg/2 mL (2 mL); 600 mg/4 mL (4 mL); 900 mg/6 mL (6 mL); 9000 mg/60 mL (60 mL); 9 g/60 mL (60 mL)

Solution, Intravenous, as phosphate [strength expressed as base]:

Cleocin in D5W: 600 mg/50 mL (50 mL [DSC]) [contains benzyl alcohol, edetate (edta) disodium]

Cleocin Phosphate: 300 mg/2 mL (2 mL [DSC]); 600 mg/4 mL (4 mL [DSC]); 900 mg/6 mL (6 mL [DSC]) [contains benzyl alcohol, edetate (edta) disodium]

Generic: 600 mg/50 mL (50 mL); 900 mg/50 mL (50 mL); 300 mg/2 mL (2 mL [DSC]); 600 mg/4 mL (4 mL [DSC]); 900 mg/6 mL (6 mL [DSC])

Solution, Intravenous, as phosphate [strength expressed as base, preservative free]:

Cleocin in D5W: 300 mg/50 mL (50 mL [DSC]) [contains benzyl alcohol, edetate (edta) disodium]

Cleocin in D5W: 300 mg/50 mL (50 mL [DSC]); 600 mg/50 mL (50 mL [DSC]) [contains edetate (edta) disodium]

Cleocin in D5W: 900 mg/50 mL (50 mL [DSC]) [contains benzyl alcohol, edetate (edta) disodium]

Cleocin in D5W: 900 mg/50 mL (50 mL [DSC]) [contains edetate (edta) disodium]

Generic: 300 mg/50 mL (50 mL); 600 mg/50 mL (50 mL); 900 mg/50 mL (50 mL); 300 mg/50 mL in NaCl 0.9% (50 mL); 600 mg/50 mL in NaCl 0.9% (50 mL); 900 mg/50 mL in NaCl 0.9% (50 mL)

Solution Reconstituted, Oral, as palmitate hydrochloride [strength expressed as base]:

Cleocin: 75 mg/5 mL (100 mL) [contains ethylparaben]

Generic: 75 mg/5 mL (100 mL)

Generic Equivalent Available: US

May be product dependent

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Capsule, Oral, as hydrochloride [strength expressed as base]:

Dalacin C: 150 mg, 300 mg

Generic: 150 mg, 300 mg

Solution, Injection:

Dalacin C Phosphate: 150 mg/mL (2 mL, 4 mL, 6 mL, 60 mL) [contains benzyl alcohol, edetate (edta) disodium]

Generic: 150 mg/mL (2 mL, 4 mL, 6 mL, 60 mL, 120 mL)

Solution, Intravenous, as phosphate [strength expressed as base]:

Generic: 300 mg/50 mL (50 mL); 600 mg/50 mL (50 mL); 900 mg/50 mL (50 mL)

Solution Reconstituted, Oral, as palmitate hydrochloride [strength expressed as base]:

Dalacin C Palmitate: 75 mg/5 mL (100 mL) [contains ethylparaben]

Administration: Pediatric

Oral: Capsule should be taken with a full glass of water to avoid esophageal irritation. Shake oral solution well before use; solution should be administered using an accurate measuring device (eg, oral syringe). May administer with or without meals.

Parenteral:

IM: Administer undiluted deep IM; rotate sites. Do not exceed 600 mg in a single injection.

IV: Infuse over at least 10 to 60 minutes, at a rate not to exceed 30 mg/minute; hypotension and cardiopulmonary arrest have been reported following rapid IV administration.

Administration: Adult

IM: Deep IM sites, rotate sites; do not exceed 600 mg in a single injection.

IV: Never administer undiluted as bolus; administer by IV intermittent infusion over at least 10 to 60 minutes, at a maximum rate of 30 mg/minute (do not exceed 1,200 mg/hour).

Oral: Capsule should be taken with a full glass of water to avoid esophageal irritation; shake oral solution well before use; may administer with or without meals.

Storage/Stability

Oral: Store at 20°C to 25°C (68°F to 77°F). Do not refrigerate the reconstituted oral solution (it will thicken); the solution is stable for 2 weeks at room temperature.

IV: Store intact vials and premixed bags at 20°C to 25°C (68°F to 77°F). Infusion solution in NS or D5W solution is stable for 16 days at room temperature, 32 days refrigerated, or 8 weeks frozen. After initial use, discard any unused portion of vial after 24 hours.

Use

Treatment of infections involving the respiratory tract, skin and soft tissue, and female pelvis and genital tract; sepsis and intra-abdominal infections due to susceptible organisms (All indications: FDA approved in all ages); has also been used for endocarditis prophylaxis, preoperative prophylaxis, and prophylaxis of peritonitis in patients with peritoneal dialysis catheters undergoing invasive dental, GI, or genitourinary procedures; treatment of peritonitis, exit-site, and tunnel infections in patients with peritoneal dialysis catheters; treatment of osteoarticular infections; and treatment of anthrax, babesiosis, malaria, toxoplasmosis, and Pneumocystis jiroveci pneumonia.

Medication Safety Issues
Sound-alike/look-alike issues:

Cleocin may be confused with bleomycin, Clinoril, Cubicin, Lincocin

Clindamycin may be confused with clarithromycin, Claritin, vancomycin, lincomycin

Adverse Reactions (Significant): Considerations
Antibiotic-associated (non-Clostridioides difficile) diarrhea

GI effects range from antibiotic-associated [non-C. difficile] diarrhea (AAD), nausea, and vomiting. Most cases of AAD are mild and self-limiting. However, Clostridioides difficile may account for as many as >20% of cases in children, adolescents, and adults (discussed separately) and result in more severe AAD (Ref).

Mechanism: Dose- and time-related; antibiotic disruption of indigenous gut microbiota (Ref).

Onset: Varied; mean time to onset of AAD is 3 to 18 days for adult patients and 2 to 6 days for pediatric patients. The majority of AAD cases occur during (versus after) antibiotic therapy in pediatric patients (Ref).

Risk factors:

• Duration of therapy (Ref)

• Age (pediatric patients <2 years of age and older adults) (Ref)

• Length of hospitalization or ICU stay (Ref)

• Duration of proton pump inhibitor use (Ref)

• Parenteral nutrition (Ref)

• Combinations of antibiotics (Ref)

Clostridioides difficile infection

Clostridioides difficile infection (CDI) has occurred, including Clostridioides difficile associated diarrhea (CDAD) and Clostridioides difficile colitis. Clindamycin has been associated with a several fold increased risk of CDI (Ref). CDAD must be considered in all patients who present with diarrhea following antibiotic use. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile should be discontinued if possible. Institute appropriate fluid and electrolyte management, antibiotic treatment of C. difficile, and surgical evaluation as clinically indicated.

Mechanism: Dose- and time-related; related to cumulative antibiotic exposure. Clindamycin causes disruption of the intestinal microbiota resulting in the overgrowth of pathogens, such as C. difficile (Ref). In addition, C. difficile is highly resistant to clindamycin (Ref).

Onset: Varied; may start on the first day of antibiotic therapy or up to 3 months postantibiotic (Ref).

Risk factors:

• Antibiotic exposure (highest risk factor) (Ref)

• Type of antibiotic (clindamycin among the highest risk) (Ref)

• Long durations in a hospital or other health care setting (recent or current) (Ref)

• Older adults (Ref)

• Immunocompromised conditions (Ref)

• A serious underlying condition (Ref)

• GI surgery/manipulation (Ref)

• Antiulcer medications (eg, proton pump inhibitors and H2 blockers) (Ref)

• Chemotherapy (Ref)

Hypersensitivity reactions (immediate and delayed)

Hypersensitivity reactions (immediate and delayed) range from maculopapular rash to rare cases of anaphylaxis (Ref). Severe cutaneous adverse reactions (SCARs), including drug reaction with eosinophilia and systemic symptoms, acute generalized exanthematous pustulosis, Stevens-Johnson syndrome, and toxic epidermal necrolysis have been reported (Ref).

Mechanism: Non–dose-related; immunologic. Immediate hypersensitivity reactions (eg, anaphylaxis) are IgE-mediated. Delayed hypersensitivity reactions, including maculopapular rash and SCARs, are T-cell-mediated (Ref).

Onset: Anaphylaxis: Rapid; may occur within an hour of administration (Ref). Other reactions: Varied; may occur after days to weeks of therapy (Ref).

Risk factors:

• HLA-B*51:01 allele in Han Chinese (Ref)

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Frequency not defined.

Dermatologic: Maculopapular rash, urticaria, vesiculobullous dermatitis

Gastrointestinal: Abdominal pain, Clostridioides difficile-associated diarrhea (Slimings 2014), Clostridioides difficile colitis (Slimings 2014), diarrhea (Nasiri 2018), esophagitis, nausea, vomiting

Genitourinary: Azotemia, oliguria, proteinuria

Hepatic: Abnormal hepatic function tests, jaundice

Postmarketing:

Cardiovascular: Hypotension (following rapid IV administration), thrombophlebitis (IV)

Dermatological: Acute generalized exanthematous pustulosis (Aiempanakit 2020), erythema multiforme, exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis (Paquet 1995)

Gastrointestinal: Esophageal ulcer (Bestari 2019), unpleasant taste

Genitourinary: Vaginitis

Hematologic & oncologic: Agranulocytosis (Pisciotta 1993), eosinophilia (transient), neutropenia (transient) (Bubalo 2003), pancytopenia (Morales 2014), thrombocytopenia (Morales 2014)

Hypersensitivity: Anaphylactic shock, anaphylaxis (Paradis 2020, Vilchez-Sánchez 2020), angioedema

Immunologic: Drug reaction with eosinophilia and systemic symptoms (Miller Quidley 2012)

Local: Abscess at injection site (IM), induration at injection site (IM), irritation at injection site (IM), pain at injection site (IM)

Nervous system: Metallic taste

Neuromuscular & skeletal: Inflammatory polyarthritis

Renal: Acute kidney injury (Subedi 2019)

Contraindications

Hypersensitivity to clindamycin, lincomycin, or any component of the formulation.

Canadian labeling: Additional contraindications (not in US labeling): Oral clindamycin: Infants <30 days of age.

Warnings/Precautions

Concerns related to adverse effects:

• Renal toxicity: Acute kidney injury including acute renal failure has been reported.

• Superinfection: Use may result in overgrowth of nonsusceptible organisms, particularly yeast. Should superinfection occur, appropriate measures should be taken as indicated by the clinical situation.

Disease-related concerns:

• GI disease: Use with caution in patients with a history of GI disease, particularly colitis.

• Hepatic impairment: Use with caution in patients with moderate to severe liver disease, however, when administered at every-8-hour intervals, drug accumulation is rare. Monitor hepatic enzymes periodically as dosage adjustments may be necessary in patients with severe liver disease.

• Renal impairment: Use with caution in patients with renal impairment; acute renal failure may occur.

Special populations:

• Atopic patients: Use with caution in atopic patients.

• Elderly: A subgroup of older patients with associated severe illness may tolerate diarrhea less well. Monitor carefully for changes in bowel frequency.

Dosage form specific issues:

• Benzyl alcohol and derivatives: Some dosage forms may contain benzyl alcohol; large amounts of benzyl alcohol (≥99 mg/kg/day) have been associated with a potentially fatal toxicity (“gasping syndrome”) in neonates; the “gasping syndrome” consists of metabolic acidosis, respiratory distress, gasping respirations, CNS dysfunction (including convulsions, intracranial hemorrhage), hypotension and cardiovascular collapse (AAP ["Inactive" 1997]; CDC 1982); some data suggests that benzoate displaces bilirubin from protein binding sites (Ahlfors 2001); avoid or use dosage forms containing benzyl alcohol with caution in neonates. See manufacturer’s labeling.

• Tartrazine: Some products may contain tartrazine (FD&C yellow no. 5), which may cause allergic reactions in certain individuals. Allergy is frequently seen in patients who also have an aspirin hypersensitivity.

Other warnings/precautions:

• Administration (IV): Do not inject IV undiluted as a bolus. Product should be diluted in compatible fluid and infused over 10 to 60 minutes.

• Appropriate use: Not appropriate for use in the treatment of meningitis due to inadequate penetration into the CSF.

Metabolism/Transport Effects

Substrate of CYP3A4 (major); Note: Assignment of Major/Minor substrate status based on clinically relevant drug interaction potential

Drug Interactions

Bacillus clausii: Antibiotics may diminish the therapeutic effect of Bacillus clausii. Management: Bacillus clausii should be taken in between antibiotic doses during concomitant therapy. Risk D: Consider therapy modification

BCG (Intravesical): Antibiotics may diminish the therapeutic effect of BCG (Intravesical). Risk X: Avoid combination

BCG Vaccine (Immunization): Antibiotics may diminish the therapeutic effect of BCG Vaccine (Immunization). Risk C: Monitor therapy

Cholera Vaccine: Antibiotics may diminish the therapeutic effect of Cholera Vaccine. Management: Avoid cholera vaccine in patients receiving systemic antibiotics, and within 14 days following the use of oral or parenteral antibiotics. Risk X: Avoid combination

Clofazimine: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

CYP3A4 Inducers (Moderate): May decrease the serum concentration of Clindamycin (Systemic). Risk C: Monitor therapy

CYP3A4 Inducers (Strong): May decrease the serum concentration of Clindamycin (Systemic). Risk C: Monitor therapy

CYP3A4 Inhibitors (Moderate): May increase the serum concentration of Clindamycin (Systemic). Risk C: Monitor therapy

CYP3A4 Inhibitors (Strong): May increase the serum concentration of Clindamycin (Systemic). Risk C: Monitor therapy

Erdafitinib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Erdafitinib: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk C: Monitor therapy

Fexinidazole: May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Fusidic Acid (Systemic): May increase the serum concentration of CYP3A4 Substrates (High risk with Inhibitors). Risk X: Avoid combination

Immune Checkpoint Inhibitors: Antibiotics may diminish the therapeutic effect of Immune Checkpoint Inhibitors. Risk C: Monitor therapy

Ivosidenib: May decrease the serum concentration of CYP3A4 Substrates (High risk with Inducers). Risk C: Monitor therapy

Kaolin: May decrease the absorption of Lincosamide Antibiotics. Risk C: Monitor therapy

Lactobacillus and Estriol: Antibiotics may diminish the therapeutic effect of Lactobacillus and Estriol. Risk C: Monitor therapy

Mecamylamine: Lincosamide Antibiotics may enhance the neuromuscular-blocking effect of Mecamylamine. Risk X: Avoid combination

Neuromuscular-Blocking Agents: Lincosamide Antibiotics may enhance the neuromuscular-blocking effect of Neuromuscular-Blocking Agents. Risk C: Monitor therapy

Pectin: May decrease the absorption of Lincosamide Antibiotics. Risk C: Monitor therapy

Sodium Picosulfate: Antibiotics may diminish the therapeutic effect of Sodium Picosulfate. Management: Consider using an alternative product for bowel cleansing prior to a colonoscopy in patients who have recently used or are concurrently using an antibiotic. Risk D: Consider therapy modification

Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Management: Avoid use of live attenuated typhoid vaccine (Ty21a) in patients being treated with systemic antibacterial agents. Postpone vaccination until 3 days after cessation of antibiotics and avoid starting antibiotics within 3 days of last vaccine dose. Risk D: Consider therapy modification

Pregnancy Considerations

Clindamycin crosses the placenta and can be detected in the cord blood and fetal tissue (Philipson 1973; Weinstein 1976). Clindamycin injection contains benzyl alcohol, which may also cross the placenta.

Clindamycin pharmacokinetics are not affected by pregnancy (Philipson 1976; Weinstein 1976).

Clindamycin is recommended for use in pregnant patients for the prophylaxis of group B streptococcal disease in newborns (alternative option for patients at high risk for anaphylaxis to penicillin [or whose risk is unknown], and who have GBS susceptible to clindamycin) (ACOG 797 2020); prophylaxis and treatment of Toxoplasma gondii encephalitis (alternative therapy), or treatment of Pneumocystis pneumonia (PCP) (alternative therapy) (HHS [OI adult 2020]); bacterial vaginosis (CDC [Workowski 2021]); anthrax (Meaney-Delman 2014); or malaria (CDC 2020). Clindamycin is also one of the antibiotics recommended for prophylactic use prior to cesarean delivery and may be used in certain situations prior to vaginal delivery in women at high risk for endocarditis (ACOG 199 2018).

Monitoring Parameters

Observe for changes in bowel frequency; during prolonged therapy, monitor CBC with differential and hepatic and renal function tests periodically.

Mechanism of Action

Reversibly binds to 50S ribosomal subunits preventing peptide bond formation thus inhibiting bacterial protein synthesis; bacteriostatic or bactericidal depending on drug concentration, infection site, and organism

Pharmacokinetics (Adult data unless noted)

Absorption: Oral, hydrochloride: Rapid (90%); clindamycin palmitate must be hydrolyzed in the GI tract before it is active.

Distribution: Distributed in body fluids and tissues; no significant levels in CSF, even with inflamed meninges.

Neonates (Gonzalez 2016):

PMA ≤28 weeks: Median: 1.2 L/kg (range: 0.87 to 2.26 L/kg).

PMA >28 to 32 weeks: Median: 1.3 L/kg (range: 0.74 to 1.88 L/kg).

PMA >32 to 40 weeks: Median: 1.03 L/kg (range: 0.7 to 2.12 L/kg).

Neonates and Infants ≤5 months (PMA >40 to 60 weeks): Median: 0.99 L/kg (range: 0.64 to 1.27 L/kg) (Gonzalez 2016).

Infants >5 months: Median: 0.83 L/kg (range: 0.7 to 1.17 L/kg) (Gonzalez 2016).

Children ≥2 years and Adolescents (Smith 2017):

Non-obese: Median range: 0.81 to 0.9 L/kg.

Obese: Median range: 0.86 to 1.03 L/kg.

Protein binding: 94%

Metabolism: Biologically inactive clindamycin phosphate (intravenous formulation) is rapidly converted to active clindamycin. Clindamycin is metabolized predominantly by CYP3A4, with minor contribution by CYP3A5, to form clindamycin sulfoxide (major metabolite) and N-desmethylclindamycin (minor metabolite).

Bioavailability: Oral: ~90%.

Half-life elimination:

Neonates (Gonzalez 2016):

PMA ≤28 weeks: Median: 5.89 hours (range: 2.42 to 12.9 hours).

PMA >28 to 32 weeks: Median: 5.25 hours (range: 2.34 to 8.87 hours).

PMA >32 to 40 weeks: Median: 3.96 hours (range: 1.3 to 8.83 hours).

Neonates and Infants ≤5 months (Gonzalez 2016): PMA >40 to 60 weeks: Median: 2.35 hours (range: 0.94 to 6.44 hours).

Infants >5 months to 1 year (Gonzalez 2016): Median: 2.05 hours (range: 1.26 to 3.47 hours).

Children ≥2 years and Adolescents (Smith 2017):

Non-obese: Median range: 2.15 to 2.84 hours.

Obese: Median range: 2.15 to 3.55 hours.

Adults: 3 hours.

Elderly (oral) ~4 hours (range: 3.4 to 5.1 hours).

Time to peak, serum: Oral: Within 60 minutes; IM: 1 to 3 hours.

Excretion: Urine (~10%) and feces (3.6%) as active drug and metabolites.

Pricing: US

Capsules (Cleocin Oral)

75 mg (per each): $0.27

150 mg (per each): $0.17

300 mg (per each): $0.34

Capsules (Clindamycin HCl Oral)

75 mg (per each): $0.72

150 mg (per each): $0.73 - $1.19

300 mg (per each): $1.31 - $3.76

Solution (Cleocin Phosphate Injection)

9 g/60 mL (per mL): $0.47

300 mg/2 mL (per mL): $1.49

600 mg/4 mL (per mL): $0.88

900 mg/6 mL (per mL): $0.85

Solution (Clindamycin Phosphate in D5W Intravenous)

300 mg/50 mL (per mL): $0.17 - $0.20

600 mg/50 mL (per mL): $0.10 - $0.30

900 mg/50 mL (per mL): $0.12 - $0.36

Solution (Clindamycin Phosphate in NaCl Intravenous)

300 mg/50 mL 0.9% (per mL): $0.17

600 mg/50 mL 0.9% (per mL): $0.26

900 mg/50 mL 0.9% (per mL): $0.31

Solution (Clindamycin Phosphate Injection)

9 g/60 mL (per mL): $0.47 - $0.59

300 mg/2 mL (per mL): $1.32 - $1.78

600 mg/4 mL (per mL): $1.05 - $1.11

900 mg/6 mL (per mL): $0.92 - $0.95

Solution (reconstituted) (Cleocin Oral)

75 mg/5 mL (per mL): $0.37

Solution (reconstituted) (Clindamycin Palmitate HCl Oral)

75 mg/5 mL (per mL): $0.29 - $1.08

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Acnocin (TH);
  • Albiotin (ID);
  • Aledo Gel (TW);
  • BB (TW);
  • Chinacin-T (TH);
  • Cleocin (BB);
  • Cleocin HCl (AU, PK, TW);
  • Cleocin T (TR, TW);
  • Clicin (VN);
  • Clidacor (ID);
  • Clidets (VE);
  • Climadan (ID, SG);
  • Climax (BD);
  • Clinacin (AE, CY, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Clinbac (PH);
  • Clinbercin (ID);
  • Clincin (TW);
  • Clinda (DE);
  • Clinda-P (TH);
  • Clindabact (LK);
  • Clindac-A (IN);
  • Clindacid (PY);
  • Clindacin (AE, BH, CY, IQ, IR, JO, KW, LB, LY, OM, PE, SA, SY, YE);
  • Clindagen (PH);
  • Clindal (PH);
  • Clindala (ID);
  • Clindalin (TH);
  • Clindam (EG);
  • Clindatec (PH);
  • Clindavid (TH);
  • Clindox (JO);
  • Clinott (TH);
  • Cliz (PH);
  • Dacin (SG);
  • Daclin (BD);
  • Daklin (PH);
  • Dalace (PH);
  • Dalacin (AE, BD, ES, HU, IE, IS, JO, QA, TH, UA);
  • Dalacin C (AT, AU, BE, BF, BG, BH, BJ, BR, CH, CI, CL, CN, CO, CR, CY, CZ, DK, DO, EC, EE, EG, ET, GB, GH, GM, GN, GR, GT, HK, HN, HR, ID, IE, IL, IN, IQ, IR, IT, KE, KW, LB, LK, LR, LT, LU, LV, LY, MA, ML, MR, MT, MU, MW, MY, NE, NG, NI, NL, NZ, OM, PA, PE, PH, PL, PT, QA, RO, SA, SC, SD, SG, SI, SK, SL, SN, SV, SY, TH, TN, TR, TZ, UA, UG, UY, VN, YE, ZA, ZM, ZW);
  • Dalacine (FR);
  • Dalaclin (PH);
  • Dalamed (PH);
  • Dalcap (IN);
  • Damicine (CO);
  • Damiclin V (CO);
  • Euroclin (EC);
  • Fullgram (KR);
  • Jutaclin (DE);
  • Klimicin (CZ, HR);
  • Klincyn (PH);
  • Klinda RX (TH);
  • Klindamycin (TH);
  • Lacin (TH);
  • Lanacin (AE, CY, IQ, IR, JO, KW, LB, LY, OM, SA, SY, YE);
  • Lando (ID);
  • Librodan (ID);
  • Lindacin (MY);
  • Luoqing (CN);
  • Magicmycin (EG);
  • Neotasin (KR);
  • Nildacin (ID);
  • Peldacyn (PH);
  • Potecin (PH);
  • Qualiclinda (HK);
  • Queritan (PY);
  • Tidact (LK, PH, TW);
  • Todacin (TH)


For country abbreviations used in Lexicomp (show table)
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  3. Aiempanakit K, Apinantriyo B. Clindamycin-induced acute generalized exanthematous pustulosis: a case report. Medicine (Baltimore). 2020;99(21):e20389. doi:10.1097/MD.0000000000020389 [PubMed 32481338]
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  8. American Dental Association Council on Scientific Affairs. Combating antibiotic resistance. J Am Dent Assoc. 2004;135(4):484-487. [PubMed 15127872]
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