Clindamycin generally is used for the treatment of serious infections caused by susceptible gram-positive bacteria and for the treatment of serious infections caused by susceptible anaerobic bacteria. Because the risk of severe, potentially fatal Clostridium difficile-associated diarrhea and colitis (CDAD; also known as antibiotic-associated diarrhea and colitis or pseudomembranous colitis) may be higher with clindamycin than with certain other anti-infectives, use of the drug should be limited to serious infections for which less toxic and/or more effective anti-infectives are not readily available. However, it should be noted that CDAD has been associated with the use of nearly all anti-infectives, being reported most frequently with clindamycin, cephalosporins, and ampicillin; second and third generation cephalosporins play an increasingly important role.Empiric therapy with clindamycin in infections that are highly likely to be nonbacterial in origin (e.g., many upper respiratory tract infections) should be avoided.
Prior to initiation of clindamycin therapy, the causative organism should be cultured and susceptibility tests conducted. Clindamycin therapy does not obviate incision, drainage, or certain other 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 parenterally in the treatment of bone and joint infections (including acute hematogenous osteomyelitis) caused by Staphylococcus aureus and as an adjunct to surgery in the treatment of chronic bone and joint infections caused by susceptible organisms. Clindamycin also is used orally or parenterally in the treatment of serious respiratory tract infections, skin and skin structure infections, or septicemia caused by susceptible strains of S. aureus, Streptococcus pneumoniae, or other streptococci (except Enterococcus faecalis). However, clindamycin is not considered the drug of choice in infections caused by gram-positive aerobic cocci and its use in these infections should be reserved for penicillin-allergic patients or other patients for whom less toxic alternatives are contraindicated. Clindamycin should not be used for the treatment of minor bacterial skin or dental infections or for nonbacterial upper respiratory tract infections.
Anaerobic Bacterial Infections
Clindamycin is used orally or parenterally in the treatment of serious lower respiratory tract infections (including empyema, pneumonia, and lung abscess), serious skin and skin structure infections, septicemia, intra-abdominal infections (including peritonitis and intra-abdominal abscess), and gynecologic infections (including endometritis, nongonococcal tubo-ovarian abscess, pelvic cellulitis, and postsurgical vaginal cuff infections) caused by susceptible anaerobic bacteria. Parenteral clindamycin also is used in the treatment of bone and joint infections (including acute hematogenous osteomyelitis) and as adjunctive therapy in the surgical treatment of chronic bone and joint infections caused by susceptible organisms. Most clinicians consider clindamycin to be a drug of choice for the treatment of infections caused by Bacteroides, including those caused by oropharyngeal strains of B. fragilis or B. melaninogenicus that often are penicillin resistant or do not respond to penicillin G. In the treatment of mixed aerobic-anaerobic bacterial infections, clindamycin has been used in conjunction with an IM or IV aminoglycoside.
(See Drug Interactions: Aminoglycosides.)
Acute Otitis Media
Clindamycin is used as an alternative for treatment of acute otitis media (AOM) known or presumed to be caused by penicillin-resistant Streptococcus pneumoniae. Clindamycin is not considered a first-line agent for treatment of AOM, but the American Academy of Pediatrics (AAP) and American Academy of Family Physicians (AAFP) state that use of the drug may be considered in individuals with penicillin hypersensitivity who may have AOM caused by penicillin-resistant S. pneumoniae. If AOM persists after initial management with anti-infective agents, a course of clindamycin may be considered in individuals with type I penicillin hypersensitivity. If AOM persists after treatment with amoxicillin and clavulanate potassium or parenteral ceftriaxone, AAP and AAFP recommend use of tympanocentesis to make a bacteriologic diagnosis. If tympanocentesis is not available, a course of clindamycin may 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 for retreatment, .
Pharyngitis and Tonsillitis
Oral clindamycin is used as an alternative agent for the treatment of pharyngitis and tonsillitis caused by S. pyogenes (group A β-hemolytic streptococci). Although clindamycin usually is effective in eradicating S. pyogenes from the nasopharynx, it is not recommended as a drug of choice for treatment of streptococcal pharyngitis and tonsillitis. Clindamycin is reserved for use as an alternative in patients who cannot receive β-lactam anti-infectives and have infections caused by S. pyogenes resistant to macrolides. In addition, clindamycin is recommended as one of several possible alternatives for the treatment of symptomatic patients who have multiple, recurrent episodes of pharyngitis known to be caused by S. pyogenes.
Because penicillin has a narrow spectrum of activity, is inexpensive, and generally is effective, the US Centers for Disease Control and Prevention (CDC), AAP, AAFP, Infectious Diseases Society of American (IDSA), AHA, American College of Physicians (ACP), and others consider natural penicillins (i.e., 10 days of oral penicillin V or a single IM dose of penicillin G benzathine) the treatment of choice for streptococcal pharyngitis and tonsillitis and prevention of initial attacks (primary prevention) of rheumatic fever, although oral amoxicillin often is used instead of penicillin V in small children because of a more acceptable taste. Other anti-infectives (e.g., oral cephalosporins, oral macrolides) generally are considered alternatives.
If there is recurrence of signs and symptoms of pharyngitis shortly after the initial recommended anti-infective regimen is completed (i.e., within a few weeks) and presence of S. pyogenes is detected, retreatment with the original regimen or another regimen of choice is indicated. If compliance with a 10-day oral regimen is a concern, IM penicillin G benzathine should be used for retreatment. Some clinicians suggest use of an alternative agent (e.g., amoxicillin and clavulanate, clindamycin, macrolide) for retreatment. However, if there are multiple, recurrent episodes of symptomatic pharyngitis within a period of months to years, it may be difficult to determine whether these are true episodes of S. pyogenes infection or whether the patient is a long-term streptococcal pharyngeal carrier who is experiencing repeated episodes of nonstreptococcal pharyngitis (e.g., viral pharyngitis) in whom treatment is not usually indicated. Continuous anti-infective prophylaxis (secondary prophylaxis) to prevent the recurrence of streptococcal pharyngitis is not recommended in these circumstances, unless the patient has a history of rheumatic fever. Instead, use of an alternative regimen is recommended by some clinicians. Although there are no controlled clinical studies evaluating efficacy, the IDSA suggests that symptomatic individuals with multiple, recurrent episodes of documented S. pyogenes pharyngitis receive a regimen of oral clindamycin, oral amoxicillin clavulanate, or IM penicillin G benzathine (with or without oral rifampin).
For additional information on treatment ofS. pyogenespharyngitis, see Pharyngitis and Tonsillitis under Gram-positive Aerobic Bacterial Infections: Streptococcus pyogenes Infections, in Uses in the Natural Penicillins General Statement 8:12.16.04.
Respiratory Tract Infections
Clindamycin is used for the treatment of serious respiratory tract infections (including pneumonia, empyema, lung abscess) caused by susceptible anaerobes, S. pneumoniae, other streptococci, or S. aureus.
For the treatment of community-acquired pneumonia (CAP) caused by anaerobes (including aspiration pneumonia), the IDSA and American Thoracic Society (ATS) recommend use of clindamycin or a β-lactam/β-lactamase inhibitor. The IDSA and ATS consider clindamycin an alternative agent for the treatment of CAP caused by S. pneumoniae or oxacillin-susceptible (methicillin-susceptible) S. aureus.
Oral clindamycin has been used for the treatment of inflammatory acne vulgaris. For information on use of topical clindamycin in the treatment of inflammatory acne vulgaris,
Clindamycin has been recommended for the treatment of actinomycosis caused by Actinomyces israelii. Some clinicians suggest that oral clindamycin is one of several options for long-term follow-up treatment (6-12 months) after initial parenteral treatment (4-6 weeks) with penicillin G or ampicillin.
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 received a parenteral regimen of ciprofloxacin (400 mg every 8 hours), rifampin (300 mg every 12 hours), and clindamycin (900 mg every 8 hours) for treatment.
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 CDC and other experts (e.g., the 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. For information on treatment of anthrax and recommendations for prophylaxis following exposure to anthrax spores,
A combination regimen of IV clindamycin and oral quinine is used for the treatment of babesiosis caused by Babesia microti.
Although several species of Babesia can infect humans, 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 Borrrelia 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.
The 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, treatment is not 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, the IDSA and other clinicians recommend that either a regimen of clindamycin and quinine or a regimen of atovaquone and azithromycin be used. The clindamycin and quinine regimen may be preferred in those with severe babesiosis. However, 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. 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.
Bacillus cereus Infections
Clindamycin is used for the treatment of invasive disease caused by Bacillus cereus. Anti-infectives are not usually indicated for the treatment of gastroenteritis caused by B. cereus.
Oral clindamycin is used for 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. Goals of treatment and recommended therapy differ for nonpregnant versus pregnant women. However, relief of signs and symptoms of infection is a principal goal of therapy, and all women with symptomatic bacterial vaginosis should be treated regardless of pregnancy status.
The CDC-recommended regimens for treatment of bacterial vaginosis in nonpregnant women are a 7-day regimen of oral metronidazole (500 mg twice daily); a 5-day regimen of intravaginal metronidazole gel; or a 7-day regimen of intravaginal clindamycin cream. Alternative regimens recommended by the CDC for these women are a 7-day regimen of oral clindamycin (300 mg twice daily) or a 3-day regimen of intravaginal clindamycin suppositories. (See Uses: Bacterial Vaginosis in or .) Intravaginal metronidazole results in clinical cure rates comparable to those of oral metronidazole therapy; intravaginal clindamycin appears to be less effective than the metronidazole regimens. Some clinicians prefer initial topical therapy because of the reduced risk of adverse systemic effects.
Regardless of the therapy chosen, relapse or recurrence of bacterial vaginosis is common, and some clinicians suggest that an alternative regimen (e.g., oral therapy when topical therapy was used initially) can be employed in such infections. A 7-day course of oral clindamycin (300 mg twice daily) may be used as an alternative regimen for the treatment of bacterial vaginosis in nonpregnant women (e.g., for treatment of relapse or recurrence following initial topical therapy, for initial therapy in patients in whom therapy with systemic metronidazole is contraindicated or not tolerated). However, experience with oral metronidazole is more extensive and studies of comparative efficacy with oral clindamycin are limited. The CDC suggests that intravaginal clindamycin is the preferred regimen for the treatment of bacterial vaginosis in women hypersensitive to metronidazole.
An increased risk of obstetric complications, including intraamniotic infection, chorioamnionitis, premature rupture of membranes, preterm delivery, and low-birthweight infants, is associated with the presence of bacterial vaginosis in pregnant women, and the organisms found in increased concentrations in the genital flora of women with bacterial vaginosis are frequently found in patients with postpartum or postcesarean endometritis. Evidence from randomized, controlled trials indicates that systemic treatment of bacterial vaginosis reduces the rate of preterm birth in pregnant women at high risk for complications of pregnancy.
Because of the increased risk of adverse pregnancy outcomes associated with the presence of bacterial vaginosis, the CDC recommends that all symptomatic pregnant women be treated for bacterial vaginosis. In addition, because there is evidence from randomized studies that treatment of bacterial vaginosis in asymptomatic pregnant women at high risk for complications of pregnancy (e.g., those who previously delivered of a premature infant) has reduced preterm delivery, some experts recommend that all women at high risk be screened and treated for bacterial vaginosis. Screening for bacterial vaginosis (if conducted) and treatment should be performed at the first prenatal visit. The preferred regimens for the treatment of bacterial vaginosis in pregnant women are a 7-day course of oral metronidazole (500 mg twice daily or 250 mg 3 times daily) or a 7-day course of oral clindamycin (300 mg twice daily).
Because recurrence of bacterial vaginosis is not unusual, and the treatment of this condition may prevent adverse pregnancy outcomes, particularly in women at high risk for complications of pregnancy, follow-up at 1 month after treatment to assess for cure and evaluate the need for additional treatment should be considered. If bacterial vaginosis persists, some clinicians suggest that additional therapy (e.g., second course of oral therapy in a pregnant woman at high risk for preterm delivery) may be used to treat relapsed or recurrent disease.
Recommendations for treatment and preferred regimens for bacterial vaginosis in patients with concurrent human immunodeficiency virus (HIV) infection are the same as those for patients without HIV infection.
Results of several randomized, double-blind, placebo-controlled trials indicate that concurrent treatment of male sexual contacts of a woman with symptomatic bacterial vaginosis generally does not appear to affect the clinical cure rate, including the risk of relapse or recurrence of the syndrome, in the woman. Therefore, routine treatment of male sexual contacts currently is not recommended. Further study is needed to elucidate the possible role, if any, of sexual transmission in bacterial vaginosis.
Clindamycin is used as an alternative to penicillin G for the treatment of infections caused by Capnocytophaga canimorsus.
Clindamycin is used as an alternative to penicillin G for the treatment of clostridial myonecrosis (gas gangrene) caused by Clostridium perfringens or other Clostridium. Anti-infectives are not usually indicated for the treatment of gastroenteritis caused by C. perfringens.
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.
The CDC and other clinicians state that the treatments of choice for uncomplicated chloroquine-resistant P. falciparum malaria are a regimen of oral quinine sulfate in conjunction with oral doxycycline, tetracycline, or clindamycin or a regimen of oral atovaquone and proguanil. The CDC states that use of mefloquine for treatment of chloroquine-resistant P. falciparum malaria should be reserved for circumstances when the treatments of choice cannot be used. When a quinine sulfate regimen is used, concomitant use with doxycycline or tetracycline generally is preferable to use with clindamycin because more efficacy data exist regarding regimens that include tetracyclines. However, for pregnant women with uncomplicated malaria caused by chloroquine-resistant P. falciparum infection, prompt treatment with 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.
Because doxycycline and tetracycline generally are contraindicated in children younger than 8 years of age, children in this age group with chloroquine-resistant P. falciparum malaria may receive a regimen of oral quinine sulfate alone for a full 7 days (regardless of geographic area where infection was acquired), oral quinine sulfate in conjunction with oral clindamycin, or oral atovaquone and proguanil. Mefloquine may be considered in these children if these other antimalarial agents are unavailable. 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 chloroquine-resistant Plasmodium falciparum malaria in adults and children. The 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 (3 days if malaria was acquired in Africa or South America or 7 days if acquired in Southeast Asia).
For additional information on treatment of severe malaria,
Pelvic Inflammatory Disease
The CDC and other clinicians suggest IV clindamycin in conjunction with an IV or IM aminoglycoside (e.g., gentamicin) as one possible parenteral regimen for the treatment of acute pelvic inflammatory disease (PID) in adults and adolescents. PID is a polymicrobial infection most frequently caused by N. gonorrhoeae and/or Chlamydia trachomatis; however, organisms that can be part of the normal vaginal flora (e.g., anaerobic bacteria, Garnerella vaginalis, H. influenzae, enteric gram-negative bacilli, S. agalactiae) or mycoplasma (e.g., Mycoplasma hominis, Ureaplasma 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 includes 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 the CDC and other clinicians. The clindamycin- aminoglycoside regimen is one of the recommended parenteral regimens. The parenteral regimen may be discontinued 24 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, many clinicians prefer clindamycin for follow-up oral therapy since it provides more effective coverage against anaerobes than doxycycline. Another recommended regimen for the treatment of PID consists of IV cefoxitin and oral doxycycline. However, if this regimen is used when tubo-ovarian abscess is present, many clinicians recommend use of clindamycin or metronidazole with doxycycline for follow-up oral therapy (instead of oral doxycycline alone) to provide more effective anaerobic coverage.
For additional information on treatment of PID, see Uses: PID in Ceftriaxone Sodium 8:12.06.12.
Pneumocystis jiroveci (Pneumocystis carinii) Pneumonia
Clindamycin is used in conjunction with primaquine for the treatment of mild to moderately severe Pneumocystis jiroveci (formerly Pneumocystis carinii) pneumonia (PCP) in HIV-infected adults and adolescents. Clindamycin is designated an orphan drug by the US Food and Drug Administration (FDA) for use in this condition.
Co-trimoxazole is the initial drug of choice for the treatment of PCP in most adults, adolescents, and children, including HIV-infected patients. A regimen of clindamycin and primaquine appears to be an effective alternative to co-trimoxazole, at least in those with mild to moderately severe PCP, and can be considered for adults and adolescents who have had an inadequate response to co-trimoxazole or when co-trimoxazole is contraindicated or not tolerated.
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 Recurrence
While a regimen of clindamycin and primaquine has been used as an alternative to usual regimens for prevention of recurrence (secondary prophylaxis or chronic maintenance therapy) of PCP in a limited number of AIDS patients, the Prevention and Opportunistic Infections Working Group of the US Public Health Service and the Infectious Diseases Society of America (USPHS/IDSA) generally does not recommend this combination for prophylaxis of PCP in HIV-infected individuals because current data are insufficient to determine efficacy of the regimen. Instead, the USPHS/IDSA states that a regimen of clindamycin and primaquine can be considered for primary or secondary prophylaxis of PCP in unusual situations when the usually recommended agents (co-trimoxazole, dapsone, dapsone with pyrimethamine and leucovorin, aerosolized pentamidine, atovaquone) cannot be administered. Clindamycin is designated an orphan drug by the FDA for use in this condition.
A regimen of clindamycin and pyrimethamine has been used with some success for the treatment of cerebral and/or ocular toxoplasmosis in immunocompromised patients (e.g., those with AIDS) who are unable to tolerate the regimen of choice (combination therapy with pyrimethamine and sulfadiazine) or who relapse or fail to respond to treatment with the pyrimethamine and sulfadiazine regimen. Leucovorin usually is added to pyrimethamine and clindamycin therapy to prevent pyrimethamine-induced adverse hematologic effects.
The CDC, National Institutes of Health (NIH), IDSA, and others state that a regimen of pyrimethamine and leucovorin in conjunction with sulfadiazine is the regimen of choice for initial treatment of toxoplasmosis, including toxoplasmosis in immunocompromised patients (e.g., HIV-infected individuals). A regimen of clindamycin in conjunction with pyrimethamine and leucovorin is the preferred alternative when the regimen of choice cannot be used. Although relative efficacy has not been determined, other alternative regimens that have been used for treatment of toxoplasmosis in adults and adolescents include pyrimethamine and leucovorin in conjunction with atovaquone, atovaquone alone or in conjunction with sulfadiazine, or pyrimethamine and leucovorin in conjunction with azithromycin. When a parenteral regimen is required for initial treatment in severely ill adults or adolescents, some experts suggest use of oral pyrimethamine in conjunction with parenteral co-trimoxazole or parenteral clindamycin.
Pyrimethamine and leucovorin in conjunction with sulfadiazine also is the regimen of choice for the treatment of acquired CNS, ocular, or systemic toxoplasmosis in HIV-infected children and for the treatment of congenital toxoplasmosis (especially when the disease is moderate to severe or occurs in HIV-infected neonates). The preferred alternative for treatment of toxoplasmosis in neonates, infants, and children with sulfonamide sensitivity is pyrimethamine and leucovorin in conjunction with clindamycin; other alternative regimens that have been used in adults and adolescents have not been adequately studied in children. Infants born to women who had symptomatic toxoplasmosis during pregnancy should be treated empirically for congenital toxoplasmosis, regardless of whether the mother received treatment for toxoplasmosis during the pregnancy.
Prevention of Recurrence
Because recurrence of toxoplasmosis has been reported commonly following initial recovery and/or discontinuance of anti-infective therapy in immunocompromised patients, prolonged anti-infective therapy usually is necessary for the treatment of acute toxoplasmosis in such patients; long-term suppressive therapy may be necessary.
The USPHS/IDSA, CDC, NIH, and others recommend combination therapy with pyrimethamine and sulfadiazine as the regimen of choice for long-term suppressive therapy (secondary prophylaxis or chronic maintenance therapy) to prevent relapse of toxoplasmosis in HIV-infected adults, adolescents, infants, and children. When this regimen cannot be used (e.g., in patients who cannot tolerate sulfonamides), a regimen of pyrimethamine and leucovorin in conjunction with clindamycin or a regimen of atovaquone with or without pyrimethamine and leucovorin is recommended for long-term suppressive therapy to prevent relapse. In a prospective, randomized study in HIV-infected patients with initial episodes of toxoplasmic encephalitis, the relapse rate was higher in patients who received initial and maintenance therapy with clindamycin in conjunction with pyrimethamine than in those who received a regimen of sulfadiazine in conjunction with pyrimethamine. In addition, only the pyrimethamine/sulfadiazine regimen appears to provide protection against both toxoplasmosis and Pneumocystis jiroveci (formerly known as Pneumocystis carinii) pneumonia.
Long-term suppressive therapy to prevent relapse or recurrence of toxoplasmosis in HIV-infected individuals generally is continued for life, unless immune recovery has occurred as the result of potent antiretroviral therapy. Limited data indicate that 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 greater than 200/ mm as the result of potent antiretroviral therapy that have been sustained for 6 months or longer are at low risk for recurrence of toxoplasmic encephalitis. Based on these data and more extensive cumulative data on safety of discontinuing secondary prophylaxis for other opportunistic infections, the USPHS/IDSA, CDC, and others state that it is reasonable to consider discontinuing secondary toxoplasmosis prophylaxis in adults and adolescents meeting these criteria. Some experts would obtain a magnetic resonance image of the brain as part of their evaluation to determine whether or not discontinuance of prophylaxis is appropriate and might be reluctant to stop secondary prophylaxis if any mass lesion or contrast enhancement persists. The USPHS/IDSA, CDC, and others state that secondary prophylaxis against toxoplasmosis should be restarted in adults and adolescents if CD4 T-cell counts decrease to less than 200/ mm. The safety of discontinuing secondary toxoplasmosis prophylaxis in HIV-infected children receiving potent antiretroviral therapy has not been extensively studied.
IV clindamycin is used perioperatively to reduce the incidence of infections in patients undergoing clean, contaminated head and neck surgery. While perioperative prophylaxis does not appear to reduce the rate of infection in patients undergoing clean procedures involving the head and neck (e.g., parotidectomy, thyroidectomy, submandibular-gland excision), there is evidence that antimicrobial prophylaxis decreases the incidence of postoperative infection following head and neck surgery involving an incision through oral or pharyngeal mucosa. The preferred regimens for perioperative prophylaxis in patients undergoing clean, contaminated head or neck surgery are IV clindamycin (with or without IV gentamicin) or, alternatively, IV cefazolin.
IV clindamycin also has been used for perioperative prophylaxis in patients undergoing certain GI procedures such as appendectomy. Although cephalosporins (cefazolin, cefoxitin, or cefotetan) usually are the preferred anti-infectives for perioperative prophylaxis in patients undergoing GI procedures (e.g., esophageal and gastroduodenal surgery, biliary tract surgery, colorectal surgery, nonperforated appendectomy), some clinicians suggest that a regimen of clindamycin and gentamicin, ciprofloxacin, levofloxacin, or aztreonam can be used for perioperative prophylaxis in patients hypersensitive to cephalosporins.
A cephalosporin (cefazolin, cefoxitin, or cefotetan) usually is recommended for perioperative prophylaxis in patients undergoing gynecologic and obstetric surgery (vaginal, abdominal, or laparoscopic hysterectomy); however, some clinicians suggest that a regimen of clindamycin and gentamicin, ciprofloxacin, levofloxacin, or aztreonam can be used for perioperative prophylaxis in patients hypersensitive to cephalosporins.
Although a regimen of cefoxitin or cefotetan usually is recommended for perioperative prophylaxis in patients with ruptured abdominal viscus, some clinicians suggest that a regimen of clindamycin and gentamicin, ciprofloxacin, levofloxacin, or aztreonam can be used as an alternative for perioperative prophylaxis in contaminated or dirty surgery involving a perforated abdominal viscus in patients hypersensitive to cephalosporins. When indicated in this situation, anti-infective therapy is continued postoperatively for about 5 days and is considered treatment rather than prophylaxis. Ruptured viscus in postoperative setting (dehiscence) requires anti-infectives that include coverage for nosocomial pathogens.
Prevention of Bacterial Endocarditis
Clindamycin is used as an alternative agent for prevention of α-hemolytic (viridans group) streptococcal bacterial endocarditis in penicillin-allergic adults and children with certain cardiac conditions who are undergoing certain dental procedures (i.e., procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of oral mucosa) or certain invasive respiratory tract procedures (i.e., procedures involving incision or biopsy of respiratory mucosa).
The American Heart Association (AHA) generally recommends routine use of prophylactic anti-infectives prior to certain procedures only in patients with cardiac conditions that are associated with the highest risk of adverse outcome from endocarditis, including congenital heart disease, prosthetic heart valves, cardiac valvulopathy after cardiac transplant, and previous bacterial endocarditis. The AHA no longer recommends prophylaxis against bacterial endocarditis based solely on an increased lifetime risk of acquisition of infective endocarditis. When selecting anti-infectives for prophylaxis of bacterial endocarditis, the current recommendations published by the 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.
When intrapartum prophylaxis is indicated in the mother, penicillin G is the regimen of choice and ampicillin is the preferred alternative. When intrapartum prophylaxis to prevent GBS in the neonate is indicated in women who are hypersensitive to penicillins, the CDC recommends a regimen of IV clindamycin or IV erythromycin for those allergic to penicillins who are at high risk for anaphylaxis (e.g., those with a history of immediate penicillin hypersensitivity, such as anaphylaxis, angioedema, or urticaria; those with a history of asthma or other conditions that would make anaphylaxis more dangerous or difficult to treat, including individuals receiving β-adrenergic blocking agents). For those allergic to penicillins who are not at high risk for anaphylaxis, the CDC states that a regimen of IV cefazolin should be used since this cephalosporin has a narrow spectrum of activity and is associated with high intraamniotic concentrations.
The fact that S. agalactiae (group B streptococci) with in vitro resistance to clindamycin and erythromycin have been reported with increasing frequency should be considered when choosing an alternative to penicillins. When use of erythromycin or clindamycin is being considered in a women hypersensitive to penicillin, in vitro susceptibility testing of clinical isolates obtained during GBS prenatal screening should be performed whenever possible to determine if the isolates are susceptible to these drugs. Strains of GBS resistant to erythromycin often are resistant to clindamycin, although this may not be evident in results of in vitro testing. If in vitro susceptibility testing is not possible, results are unknown, or isolates are found to be resistant to erythromycin or clindamycin, a regimen of vancomycin should be used for intrapartum prophylaxis in women with penicillin allergy who are at high risk for anaphylaxis.
For additional information on prevention of perinatal GBS disease, see Uses: Prevention of Perinatal Group B Streptococcal Disease, in the Natural Penicillins General Statement 8:12.16.04.
For topical uses of clindamycin,