Clindamycin is used for the treatment of certain serious infections caused by susceptible aerobic gram-positive bacteria (staphylococci, streptococci, pneumococci) and for the treatment of certain serious infections caused by susceptible anaerobic bacteria. Use of clindamycin generally should be reserved for the treatment of serious infections when less toxic anti-infectives cannot be used (e.g., penicillin-allergic patients or other patients for whom a penicillin is inappropriate). Because clindamycin has been associated with potentially fatal colitis
Certain infections may require incision and drainage or other indicated surgical procedures in addition to anti-infective treatment. Use of clindamycin does not eliminate the need for surgical procedures when indicated.
Because clindamycin does not distribute adequately into the CNS, the drug should not be used for the treatment of meningitis.
Gram-positive Aerobic Bacterial Infections
Clindamycin is used orally or parenterally for the treatment of serious respiratory tract infections caused by susceptible staphylococci, Streptococcus pneumoniae, or other streptococci or serious skin and skin structure infections caused by susceptible staphylococci, S. pneumoniae, or S. pyogenes (group A β-hemolytic streptococci; GAS). Clindamycin also is used parenterally for the treatment of septicemia caused by susceptible Staphylococcus aureus or streptococci, treatment of serious bone and joint infections (including acute hematogenous osteomyelitis) caused by susceptible S. aureus, and as adjunctive therapy in the surgical treatment of chronic bone and joint infections caused by susceptible bacteria. However, clindamycin generally should be reserved for use in penicillin-allergic or other patients when less toxic alternatives cannot be used.
Anaerobic Bacterial Infections
Clindamycin is used orally or parenterally for the treatment of serious lower respiratory tract infections (e.g., empyema, pneumonia, lung abscess), serious skin and skin structure infections, septicemia, intra-abdominal infections (e.g., peritonitis, intra-abdominal abscess), and gynecologic infections (e.g., endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, postsurgical vaginal cuff infections) caused by susceptible anaerobic bacteria. Parenteral clindamycin also is used for the treatment of serious bone and joint infections (including acute hematogenous osteomyelitis) caused by susceptible anaerobes and as adjunctive therapy in the surgical treatment of chronic bone and joint infections caused by susceptible bacteria. Although previously considered a drug of choice for the treatment of infections caused by Bacteroides, clindamycin is no longer routinely recommended for the treatment of intra-abdominal infections because of the increasing incidence of B. fragilis resistant to the drug. In the treatment of mixed aerobic-anaerobic bacterial infections (e.g., pelvic inflammatory disease), clindamycin has been used in conjunction with an IM or IV aminoglycoside.
Acute Otitis Media
Oral clindamycin is used as an alternative for the treatment of acute otitis media (AOM).
When anti-infective therapy is indicated for the treatment of AOM, the American Academy of Pediatrics (AAP) recommends high-dose amoxicillin or amoxicillin and clavulanate as the drug of first choice for initial treatment. These experts recommend certain cephalosporins (cefdinir, cefpodoxime, cefuroxime, ceftriaxone) as alternatives for initial treatment in penicillin-allergic patients who do not have a history of severe and/or recent penicillin-allergic reactions.
AAP states that clindamycin (with or without a third generation cephalosporin) is a possible alternative for the treatment of AOM in patients who fail to respond to initial treatment with first-line or preferred alternatives. When retreatment of AOM is indicated after failure of initial treatment, high-dose amoxicillin and clavulanate or IM ceftriaxone usually is recommended. Although clindamycin may be effective in infections caused by penicillin-resistant S. pneumoniae, the drug may not be effective against multidrug-resistant S. pneumoniae and usually is inactive against Haemophilus influenzae. If clindamycin is used for retreatment of AOM, concomitant use of an anti-infective active against H. influenzae and Moraxella catarrhalis (e.g., cefdinir, cefixime, cefuroxime) should be considered.
For additional information regarding treatment of AOM, including information on diagnosis and management strategies, anti-infectives for initial treatment, duration of initial treatment, and anti-infectives after initial treatment failure, .
Pharyngitis and Tonsillitis
Oral clindamycin is used as an alternative for the treatment of pharyngitis and tonsillitis caused by S. pyogenes (group A β-hemolytic streptococci; GAS). Although clindamycin usually is effective in eradicating S. pyogenes from the nasopharynx, it is reserved for use as an alternative in patients who cannot receive β-lactam anti-infectives. In addition, clindamycin is recommended as one of several possible alternatives for the treatment of symptomatic patients who failed to respond to initial penicillin treatment or have multiple, recurrent episodes of pharyngitis known to be caused by S. pyogenes.
Selection of an anti-infective for the treatment of S. pyogenes pharyngitis and tonsillitis should be based on the drug's spectrum of activity, bacteriologic and clinical efficacy, potential adverse effects, ease of administration, patient compliance, and cost. No regimen has been found to date that effectively eradicates group A β-hemolytic streptococci in 100% of patients.
Because the drugs have a narrow spectrum of activity, are inexpensive, and generally are effective with a low frequency of adverse effects, AAP, Infectious Diseases Society of America (IDSA), and American Heart Association (AHA) recommend a penicillin regimen (i.e., 10 days of oral penicillin V or oral amoxicillin or a single dose of IM penicillin G benzathine) as the treatment of choice for S. pyogenes pharyngitis and tonsillitis and prevention of initial attacks (primary prevention) of rheumatic fever. Other anti-infectives (e.g., oral cephalosporins, oral macrolides, oral clindamycin) are recommended as alternatives in penicillin-allergic patients.
Respiratory Tract Infections
Clindamycin is used for the treatment of serious respiratory tract infections (e.g., pneumonia, empyema, lung abscess) caused by susceptible S. aureus, S. pneumoniae, other streptococci, or anaerobes.
IDSA and American Thoracic Society (ATS) consider clindamycin an alternative agent for the treatment of community-acquired pneumonia (CAP) caused by S. pneumoniae or S. aureus (methicillin-susceptible strains) in adults. IDSA also considers clindamycin an alternative for the treatment of CAP caused by S. pneumoniae, S. pyogenes, or S. aureus in pediatric patients. For the treatment of pneumonia caused by methicillin-resistant S. aureus (MRSA; also known as oxacillin-resistant S. aureus or ORSA), IDSA states that clindamycin is one of several options, unless the strain is resistant to clindamycin.
For information regarding the treatment of CAP, including infections caused by MRSA, the current clinical practice guidelines from IDSA available at http://www.idsociety.org should be consulted.
Skin and Skin Structure Infections
Clindamycin is used for the treatment of serious skin and skin structure infections caused by susceptible staphylococci, S. pneumoniae, other streptococci, or anaerobes. Clindamycin is recommended as one of several options for the treatment of staphylococcal and streptococcal skin and skin structure infections, including those known or suspected to be caused by susceptible MRSA.
Clindamycin is used in conjunction with or as an alternative to penicillin G for the treatment of clostridial myonecrosis (gas gangrene) caused by Clostridium perfringens or other Clostridium.
Although the fixed combination of amoxicillin and clavulanate usually is the drug of choice for the treatment of infected human or animal (e.g., dog, cat, reptile) bite wounds, alternative regimens include clindamycin in conjunction with either an extended-spectrum cephalosporin or co-trimoxazole. Purulent bite wounds usually are polymicrobial and broad-spectrum anti-infective coverage is recommended. Nonpurulent infected bite wounds usually are caused by staphylococci and streptococci, but can be polymicrobial.
For information regarding the treatment of skin and skin structure infections, including infections caused by MRSA, the current clinical practice guidelines from IDSA available at http://www.idsociety.org should be consulted.
Clindamycin has been recommended as an alternative to penicillin G or ampicillin for the treatment of actinomycosis, including infections caused by Actinomyces israelii.
Although limited clinical data are available regarding use of clindamycin in the treatment of anthrax, clindamycin was included in a multiple-drug regimen that was effective for the treatment of several patients in the US who developed anthrax during September and October 2001 following exposure to an intentional release of anthrax spores (biologic warfare, bioterrorism). At least 2 patients were treated with a parenteral regimen of ciprofloxacin (400 mg every 8 hours), rifampin (300 mg every 12 hours), and clindamycin (900 mg every 8 hours).
Because of the rapid course of symptomatic inhalational anthrax and high mortality rate, prompt recognition of symptoms and early initiation of anti-infective therapy is essential. The US Centers for Disease Control and Prevention (CDC) and other experts (e.g., US Working Group on Civilian Biodefense) recommend that treatment of inhalational anthrax that occurs as the result of exposure to anthrax spores in the context of biologic warfare or bioterrorism should be initiated with a multiple-drug parenteral regimen that includes ciprofloxacin or doxycycline and 1 or 2 additional anti-infective agents predicted to be effective. Multiple-drug parenteral regimens also are recommended for the treatment of cutaneous anthrax if there are signs of systemic involvement, extensive edema, or lesions on the head and neck. Based on in vitro data, drugs that have been suggested as possibilities to augment ciprofloxacin or doxycycline in such multiple-drug regimens include chloramphenicol, clindamycin, rifampin, vancomycin, clarithromycin, imipenem, penicillin, or ampicillin. Strains of Bacillus anthracis that were associated with cases of inhalational or cutaneous anthrax that occurred in the US (Florida, New York, District of Columbia) during September and October 2001 following bioterrorism-related anthrax exposures were susceptible to clindamycin in vitro.
Based on in vitro data, clindamycin also has been suggested as a possible alternative for postexposure prophylaxis following a suspected or confirmed exposure to aerosolized anthrax spores (inhalational anthrax) when the drugs of choice (ciprofloxacin, doxycycline) are not tolerated or cannot be used.
For information on treatment of anthrax and recommendations for prophylaxis following exposure to anthrax spores,
Oral or IV clindamycin is used in conjunction with oral quinine sulfate for the treatment of babesiosis caused by Babesia microti or other Babesia.
Although several species of Babesia can infect humans (e.g., B. microti, B. divergens, B. duncani, B. venatorum), B. microti is the most common cause of babesiosis in the US.B. microti is transmitted by Ixodes scapularis ticks, which also may be simultaneously infected with and transmit Borrelia burgdorferi (causative agent of Lyme disease) and Anaplasma phagocytophilum (causative agent of human granulocytotropic anaplasmosis [HGA, formerly known as human granulocytic ehrlichiosis]). Therefore, the possibility of coinfection with B. burgdorferi and/or A. phagocytophilum should be considered in patients who have severe or persistent symptoms despite appropriate anti-infective treatment for babesiosis.
IDSA states that all patients with active babesiosis (i.e., symptoms of viral-like infection and identification of babesial parasites in blood smears or by polymerase chain reaction [PCR] amplification of babesial DNA) should receive anti-infective treatment because of the risk of complications; however, symptomatic patients whose serum contains antibody to babesia but whose blood lacks identifiable babesial parasites on smear or babesial DNA by PCR should not receive treatment. In addition, these experts state that treatment is not generally recommended initially for asymptomatic individuals, regardless of the results of serologic examination, blood smears, or PCR, but should be considered if parasitemia persists for longer than 3 months.
When anti-infective treatment of babesiosis is indicated, IDSA and other clinicians recommend that either a regimen of clindamycin and quinine or a regimen of atovaquone and azithromycin be used. There is some evidence that, in patients with mild or moderate illness, the atovaquone and azithromycin regimen may be as effective and better tolerated than the clindamycin and quinine regimen. However, the clindamycin and quinine regimen generally is preferred for the treatment of severe babesiosis caused by M. microti and infections caused by M. divergens, B. duncani, B. divergens-like organisms, or B. venatorum. Patients with moderate to severe babesiosis should be monitored closely during treatment to ensure clinical improvement. Exchange transfusions have been used successfully in asplenic patients with life-threatening babesiosis and should be considered, especially in severely ill patients with high levels of parasitemia (10% or more), significant hemolysis, or compromised renal, hepatic, or pulmonary function.
Oral clindamycin is used in the treatment of bacterial vaginosis (formerly called Haemophilus vaginitis, Gardnerella vaginitis, nonspecific vaginitis, Corynebacterium vaginitis, or anaerobic vaginosis). The drug also is used intravaginally as a vaginal cream or vaginal suppository for the treatment of bacterial vaginosis .
Bacterial vaginosis is a polymicrobial syndrome that can occur when normal hydrogen peroxide-producing Lactobacillus in the vagina are replaced by overgrowth of various anaerobic bacteria (e.g., Prevotella, Mobiluncus), Gardnerella vaginalis, Ureaplasma urealyticum, Mycoplasma hominis, Atopobium vaginae, or other bacteria. Treatment of bacterial vaginosis usually is recommended to relieve signs and symptoms of infection, regardless of pregnancy status.
For the treatment of bacterial vaginosis, CDC and other experts recommend a 7-day regimen of oral metronidazole (500 mg twice daily); a 5-day regimen of intravaginal metronidazole 0.75% gel; or a 7-day regimen of intravaginal clindamycin 2% cream. Alternative regimens include a 2-day regimen of oral tinidazole (2 g once daily); a 5-day regimen of oral tinidazole (1 g once daily); a 7-day regimen of oral clindamycin (300 mg twice daily); or a 3-day regimen of intravaginal clindamycin 100-mg suppositories. CDC and other clinicians state that the oral or intravaginal metronidazole or clindamycin regimens can be used to treat symptomatic bacterial vaginosis in pregnant women.
Regardless of the treatment regimen used, relapse or recurrence of bacterial vaginosis is common. Retreatment with the same regimen or an alternative regimen (e.g., oral therapy when topical therapy was used initially) can be effective for treating persistent or recurrent bacterial vaginosis after the first occurrence. Maintenance suppressive therapy with intravaginal metronidazole (0.75% gel twice weekly for 4-6 months) may reduce recurrences, but this benefit may not persist after suppressive therapy is discontinued.
Treatment of Uncomplicated Malaria
Oral clindamycin is used in conjunction with oral quinine sulfate for the treatment of uncomplicated chloroquine-resistant Plasmodium falciparum malaria or when the plasmodial species has not been identified. Clindamycin is not effective when used alone for the treatment of malaria.
For the treatment of uncomplicated malaria caused by chloroquine-resistant P. falciparum or the treatment of uncomplicated malaria when the plasmodial species has not been identified, CDC and other clinicians recommend the fixed combination of atovaquone and proguanil hydrochloride (atovaquone/proguanil), the fixed combination of artemether and lumefantrine (artemether/lumefantrine), or a regimen that includes quinine sulfate in conjunction with doxycycline, tetracycline, or clindamycin. Although mefloquine is another option for treatment in these patients, CDC states that mefloquine should only be considered when other options cannot be used and is not recommended if malaria was acquired in Southeast Asia.
When a quinine sulfate regimen is used, concomitant doxycycline or tetracycline generally is preferable to concomitant clindamycin because more efficacy data exist regarding regimens that include tetracyclines. However, for pregnant women with uncomplicated malaria caused by chloroquine-resistant P. falciparum, a regimen of quinine sulfate and clindamycin is recommended. Although tetracyclines generally are contraindicated in pregnant women, in rare circumstances (e.g., if other treatment options are not available or are not tolerated) quinine sulfate may be used in conjunction with doxycycline or tetracycline if the benefits outweigh the risks.
Pediatric patients with uncomplicated malaria generally can receive the same treatment regimens recommended for adults using age- and weight-appropriate drugs and dosages. However, because doxycycline and tetracycline generally are contraindicated in children younger than 8 years of age, children in this age group with uncomplicated chloroquine-resistant P. falciparum malaria or when the plasmodial species has not been identified may receive a regimen of oral quinine sulfate alone for a full 7 days (regardless of geographic area where infection was acquired) or atovaquone/proguanil, artemether/lumefantrine, or a regimen of oral quinine sulfate in conjunction with oral clindamycin. Mefloquine should only be considered in these children when other options cannot be used and is not recommended if malaria was acquired in Southeast Asia. In rare circumstances when other treatment options are unavailable or are not tolerated, CDC states that doxycycline or tetracycline may be used in conjunction with quinine sulfate in children younger than 8 years of age if the benefits of tetracycline therapy outweigh the risks.
Treatment of Severe Malaria
Oral or IV clindamycin is used in conjunction with IV quinidine gluconate for the treatment of severe P. falciparum malaria in adults and children.
Patients with severe malaria require aggressive antimalarial treatment initiated as soon as possible after the diagnosis using a parenteral regimen. CDC recommends that severe malaria be treated with IV quinidine gluconate therapy in conjunction with a 7-day course of doxycycline, tetracycline, or clindamycin administered orally or IV as tolerated. After parasitemia is reduced to less than 1% and the patient can tolerate oral therapy, IV quinidine gluconate can be discontinued and oral quinine sulfate initiated to complete 3 or 7 days of total quinidine and quinine therapy as determined by the geographic origin of the infecting parasite (7 days if acquired in Southeast Asia or 3 days if acquired elsewhere).
Assistance with diagnosis or treatment of malaria is available by contacting the CDC Malaria Hotline at 770-488-7788 or 855-856-4713 from 9:00 a.m. to 5:00 p.m. Eastern Standard Time or the CDC Emergency Operation Center at 770-488-7100 after hours and on weekends and holidays.
Pelvic Inflammatory Disease
IV clindamycin used in conjunction with IV or IM gentamicin is one of several possible parenteral regimens for the treatment of acute pelvic inflammatory disease (PID) in adults and adolescents. PID is a polymicrobial infection most frequently caused by Neisseria gonorrhoeae and/or Chlamydia trachomatis; however, organisms that can be part of the normal vaginal flora (e.g., anaerobic bacteria, G. vaginalis, H. influenzae, enteric gram-negative bacilli, S. agalactiae) or mycoplasma (e.g., M. hominis, U. urealyticum) also may be involved. PID is treated with an empiric regimen that provides broad-spectrum coverage. The regimen should be effective against N. gonorrhoeae and C. trachomatis and also probably should be effective against anaerobes. In addition, women with PID often have bacterial vaginosis concurrently, a polymicrobial infection that can include anaerobes.
(See Uses: Bacterial Vaginosis.)
The optimum regimen for the treatment of PID has not been identified. A variety of parenteral and oral regimens have been recommended by CDC and other clinicians. When a parenteral regimen is used, these experts recommend a regimen of IV cefotetan in conjunction with oral or IV doxycycline; IV cefoxitin in conjunction with oral or IV doxycycline; or IV clindamycin in conjunction with IM or IV gentamicin. The parenteral regimen should be continued until 24-48 hours after the patient improves clinically and then an oral regimen of either doxycycline (100 mg twice daily) or clindamycin (450 mg 4 times daily) is used to complete 14 days of therapy. If tubo-ovarian abscess is present, at least 24 hours of inpatient observation is recommended and use of oral clindamycin or oral metronidazole in addition to oral doxycycline is preferred for follow-up oral therapy since this provides more effective coverage against anaerobes than doxycycline alone.
Pneumocystis jirovecii Pneumonia
Treatment of Pneumocystis jirovecii Pneumonia
Clindamycin is used in conjunction with primaquine for the treatment of Pneumocystis jirovecii (formerly Pneumocystis carinii) pneumonia (PCP) in individuals with human immunodeficiency virus (HIV) infection. Clindamycin is designated an orphan drug by FDA for the treatment of PCP associated with acquired immunodeficiency syndrome (AIDS).
Co-trimoxazole is the drug of choice for the treatment of mild, moderate, or severe PCP, including PCP in HIV-infected adults, adolescents, and children. CDC, National Institutes of Health (NIH), and IDSA state that a regimen of primaquine and clindamycin is an alternative for the treatment of mild, moderate, or severe PCP in HIV-infected adults and adolescents who have had an inadequate response to co-trimoxazole or when co-trimoxazole is contraindicated or not tolerated. Although data are not available regarding use in children, CDC, NIH, IDSA, and AAP state that a regimen of primaquine and clindamycin also can be considered an alternative to co-trimoxazole for the treatment of PCP in HIV-infected children based on data in adults.
Results of clinical studies indicate that clindamycin administered IV (1.8-3.6 g given in 3 or 4 divided doses daily) or orally (1.2-3.6 g in 3 or 4 divided doses daily [in some cases oral clindamycin was administered after initial IV administration]) in conjunction with oral primaquine (15 or 30 mg daily) for a total 21 days of therapy is effective for the treatment of PCP in HIV-infected adults. Most patients exhibit clinical improvement within 2-7 days, and the combination generally appears to be well tolerated.
Prevention of Pneumocystis jirovecii Pneumonia
Co-trimoxazole is the drug of choice for prevention of initial episodes (primary prophylaxis) of PCP in HIV-infected adults, adolescents, and children. CDC, NIH, and IDSA state that a regimen of primaquine and clindamycin is not recommended for primary PCP prophylaxis because data are insufficient to determine efficacy of the regimen for such prophylaxis.
Although a regimen of clindamycin and primaquine has been used as an alternative to co-trimoxazole for long-term suppressive or chronic maintenance therapy (secondary prophylaxis) of PCP in a limited number of AIDS patients, this regimen is not included in CDC, NIH, IDSA, and AAP recommendations for secondary prophylaxis of PCP in HIV-infected adults, adolescents, or children. Co-trimoxazole is the drug of choice for secondary PCP prophylaxis in HIV-infected adults, adolescents, and children.
Treatment of Toxoplasmosis
Clindamycin is used in conjunction with pyrimethamine (and leucovorin) as an alternative for the treatment of toxoplasmosis caused by Toxoplasma gondii.
Pyrimethamine (and leucovorin) in conjunction with sulfadiazine is the regimen of choice for initial treatment of toxoplasmosis, including toxoplasmic encephalitis in HIV-infected adults, adolescents, and children. A regimen of pyrimethamine (and leucovorin) in conjunction with clindamycin is the preferred alternative in HIV-infected adults and adolescents who are unable to tolerate sulfadiazine or who failed to respond to an initial regimen of pyrimethamine and sulfadiazine. When a parenteral regimen is required for initial treatment of toxoplasmosis in severely ill adults or adolescents, some experts suggest parenteral co-trimoxazole or a regimen of oral pyrimethamine (and leucovorin) in conjunction with parenteral clindamycin.
Pyrimethamine (and leucovorin) in conjunction with sulfadiazine also is the regimen of choice for the treatment of congenital toxoplasmosis and the treatment of acquired CNS, ocular, or systemic toxoplasmosis in HIV-infected children. The preferred alternative for the treatment of toxoplasmosis in neonates or HIV-infected children with sulfonamide sensitivity is pyrimethamine (and leucovorin) in conjunction with clindamycin. Empiric treatment of congenital toxoplasmosis should be strongly considered in infants born to HIV-infected women who had symptomatic or asymptomatic toxoplasmosis during pregnancy, regardless of whether the mother received toxoplasmosis treatment during the pregnancy. Pregnant women with suspected or confirmed primary toxoplasmosis and neonates with possible or documented congenital toxoplasmosis should be managed in consultation with an appropriate infectious disease specialist.
Prevention of Recurrence of Toxoplasmosis
CDC, NIH, IDSA, and AAP state that HIV-infected adults, adolescents, and children who have completed initial treatment of T. gondii encephalitis should receive chronic maintenance therapy (secondary prophylaxis) to prevent relapse.
Pyrimethamine (and leucovorin) in conjunction with sulfadiazine is the regimen of choice for long-term suppressive or chronic maintenance therapy (secondary prophylaxis) of toxoplasmosis in HIV-infected adults, adolescents, and children. A regimen of pyrimethamine (and leucovorin) in conjunction with clindamycin is one of several alternatives for secondary prophylaxis of toxoplasmosis in HIV-infected adults, adolescents, and children who cannot tolerate sulfonamides.
CDC, NIH, and IDSA state that secondary prophylaxis against toxoplasmosis generally can be discontinued in HIV-infected adults and adolescents who have successfully completed initial therapy for toxoplasmic encephalitis, remain asymptomatic with respect to toxoplasmic encephalitis, and have CD4 T-cell counts that have remained greater than 200/mm for more than 6 months in response to antiretroviral therapy. Some experts recommend obtaining a magnetic resonance image (MRI) of the brain as part of the evaluation to determine whether discontinuance of secondary prophylaxis is appropriate. Secondary prophylaxis against toxoplasmosis should be reinitiated in HIV-infected adults and adolescents if CD4 T-cell counts decrease to less than 200/mm, regardless of plasma HIV viral load.
The safety of discontinuing secondary toxoplasmosis prophylaxis in HIV-infected children receiving potent antiretroviral therapy has not been extensively studied. However, based on data from adults, CDC, NIH, IDSA, and AAP state that discontinuance of secondary prophylaxis against toxoplasmosis can be considered in HIV-infected children 1 to less than 6 years of age who have completed toxoplasmosis treatment, have received more than 6 months of stable antiretroviral therapy, are asymptomatic with respect to toxoplasmosis, and have CD4 T-cell percentages that have remained greater than 15% for more than 6 consecutive months. In HIV-infected children 6 years of age or older who have received more than 6 months of antiretroviral therapy, consideration can be given to discontinuing secondary prophylaxis against toxoplasmosis if CD4 T-cell counts have remained greater than 200/mm for more than 6 consecutive months. Prophylaxis should be reinitiated in HIV-infected children if these parameters are not met.
IV clindamycin is recommended as an alternative for perioperative prophylaxis to reduce the incidence of infections in patients undergoing certain clean, contaminated surgeries when the drugs of choice (e.g., cefazolin, cefuroxime, cefoxitin, cefotetan) cannot be used because the patient is hypersensitive to β-lactam anti-infectives.
Some experts state that clindamycin or vancomycin is a reasonable alternative for perioperative prophylaxis in patients allergic to β-lactam anti-infectives who are undergoing cardiac surgery (e.g., coronary artery bypass grafting, valve repairs, cardiac device implantation), neurosurgery (e.g., craniotomy, spinal and CSF-shunting procedures, intrathecal pump placement), orthopedic surgery (e.g., spinal procedures, hip fracture, internal fixation, total joint replacement), non-cardiac thoracic surgery (e.g., lobectomy, pneumonectomy, lung resection, thoracotomy), vascular surgery (e.g., arterial procedures involving a prosthesis, the abdominal aorta, or a groin incision), lower extremity amputation for ischemia, or certain transplant procedures (e.g., heart and/or lung). These experts state that clindamycin also is a reasonable alternative for perioperative prophylaxis in patients allergic to β-lactam anti-infectives who are undergoing head and neck surgery (e.g., incisions through oral or pharyngeal mucosa).
For procedures that might involve exposure to enteric gram-negative bacteria, some experts state that clindamycin or vancomycin used in conjunction with an aminoglycoside (e.g., amikacin, gentamicin, tobramycin), aztreonam, or a fluoroquinolone is a reasonable alternative in patients allergic to β-lactam anti-infectives. These procedures include certain GI and biliary tract procedures (e.g., esophageal or gastroduodenal procedures, appendectomy for uncomplicated appendicitis, surgery involving unobstructed small intestine, colorectal procedures), gynecologic and obstetric surgery (e.g., cesarean section, hysterectomy), urologic procedures involving an implanted prosthesis, and certain transplant procedures (e.g., liver, pancreas and/or kidney).
Prevention of Bacterial Endocarditis
Clindamycin is used as an alternative to amoxicillin or ampicillin for prevention of α-hemolytic (viridans group) streptococcal bacterial endocarditis in penicillin-allergic adults and children undergoing certain dental or upper respiratory tract procedures who have cardiac conditions that put them at highest risk of adverse outcomes from endocarditis.
The cardiac conditions identified by AHA as those associated with highest risk and for which endocarditis prophylaxis is reasonable are prosthetic cardiac valves or prosthetic material used for cardiac valve repair, previous infective endocarditis, cardiac valvulopathy after cardiac transplantation, and certain forms of congenital heart disease (i.e., unrepaired cyanotic congenital heart disease including palliative shunts and conduits; a completely repaired congenital heart defect where prosthetic material or device was placed by surgery or catheter intervention within the last 6 months; repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device that inhibit endothelialization).
AHA states that anti-infective prophylaxis for prevention of α-hemolytic (viridans group) streptococcal bacterial endocarditis is reasonable for patients with the above cardiac risk factors if they are undergoing any dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (e.g., biopsies, suture removal, placement of orthodontic bands). AHA states that anti-infective prophylaxis is not needed for routine anesthetic injections through noninfected tissue, dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, or bleeding from trauma to the lips or oral mucosa.
AHA states that anti-infective prophylaxis for prevention of bacterial endocarditis also is reasonable for patients with these cardiac risk factors if they are undergoing invasive procedures of the respiratory tract that involve incision or biopsy of respiratory mucosa (e.g., tonsillectomy, adenoidectomy) and may be reasonable for such patients if they are undergoing surgical procedures that involve infected skin, skin structure, or musculoskeletal tissue. However, anti-infective prophylaxis solely to prevent infective endocarditis is no longer recommended by AHA for GI or genitourinary tract procedures.
For additional information on which cardiac conditions are associated with the highest risk of adverse outcomes from endocarditis and more specific information regarding use of prophylaxis to prevent endocarditis in these patients, the current recommendations published by AHA should be consulted.
Prevention of Perinatal Group B Streptococcal Disease
IV clindamycin is used as an alternative to parenteral penicillin G or ampicillin for prevention of perinatal group B streptococcal (GBS) disease in certain women who are hypersensitive to penicillins.
Pregnant women who are colonized with GBS in the genital or rectal areas can transmit GBS infection to their infants during labor and delivery, resulting in invasive neonatal infection that can be associated with substantial morbidity and mortality. Intrapartum anti-infective prophylaxis for prevention of early-onset neonatal GBS disease is administered selectively to women at high risk for transmitting GBS infection to their neonates. CDC and AAP recommend routine universal prenatal screening for GBS colonization (e.g., vaginal and rectal cultures) in all pregnant women at 35-37 weeks of gestation, unless GBS bacteriuria is known to be present during the current pregnancy or the woman had a previous infant with invasive GBS disease. Intrapartum anti-infective prophylaxis for prevention of perinatal GBS is indicated in pregnant women identified as GBS carriers during the routine prenatal GBS screening performed at 35-37 weeks during the current pregnancy, in women with GBS bacteriuria identified at any time during the current pregnancy, and in women who had a previous infant diagnosed with invasive GBS disease. Intrapartum anti-infective prophylaxis also is indicated in women with unknown GBS status at the time of onset of labor (i.e., culture not done, incomplete, or results unknown), if delivery is at less than 37 weeks of gestation, the duration of amniotic membrane rupture is 18 hours or longer, intrapartum temperature is 38°C or higher, or an intrapartum nucleic acid amplification test (NAAT) was positive for GBS.
When intrapartum anti-infective prophylaxis is indicated in the mother for prevention of GBS in the neonate, it should be initiated at the onset of labor or rupture of membranes. CDC, AAP, and others recommend penicillin G as the drug of choice and ampicillin as the preferred alternative for such prophylaxis. If intrapartum prophylaxis is indicated in a penicillin-allergic woman who is not at high risk for anaphylaxis (i.e., does not have a history of anaphylaxis, angioedema, respiratory distress, or urticaria after receiving a penicillin or cephalosporin), CDC, AAP, and others recommend IV cefazolin. If intrapartum prophylaxis is indicated in a penicillin-allergic woman who is at high risk for anaphylaxis (e.g., history of anaphylaxis, angioedema, respiratory distress, or urticaria after receiving a penicillin or cephalosporin), IV clindamycin is recommended if the GBS isolate is tested and found to be susceptible to clindamycin and erythromycin. GBS isolates susceptible to clindamycin but resistant to erythromycin in vitro should be evaluated for inducible clindamycin resistance. IV vancomycin can be used as an alternative in penicillin-allergic women if the GBS isolate is intrinsically resistant to clindamycin, demonstrates inducible resistance to clindamycin, or if susceptibility to clindamycin and erythromycin is unknown.
For additional information regarding prevention of perinatal group B streptococcal disease, the current guidelines from CDC or AAP should be consulted.
For topical uses of clindamycin,