Clindamycin Hcl (clindamycin HCl)

Dosage of clindamycin hydrochloride, clindamycin palmitate hydrochloride, and clindamycin phosphate is expressed in terms of clindamycin.

Dosage and duration of treatment depend on the severity of the infection. If clindamycin is used in infections caused by Streptococcus pyogenes (group A beta-hemolytic streptococci; GAS), therapy should be continued for at least 10 days. At least 6 weeks of therapy may be required for certain serious infections (e.g., osteomyelitis).

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Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

Antibiotics/Fecal Microbiota

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Fecal microbiota is a suspension of live bacteria, which may be compromised by concurrent use of antibiotics.(1)

CLINICAL EFFECTS: Antibiotics may decrease the effectiveness of fecal microbiota.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Antibiotics should not be used concurrently with fecal microbiota. Antibacterial treatment should be completed for 24 to 72 hours before initiating treatment with fecal microbiota. Do not use antibiotics for up to 8 weeks after fecal microbiota.(1)

DISCUSSION: Antibiotics may compromise the effectiveness of fecal microbiota.

Antibiotics/Fecal Microbiota Spores

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Fecal microbiota spores is a suspension of live bacterial spores, which may be compromised by concurrent use of antibiotics.(1)

CLINICAL EFFECTS: Antibiotics may decrease the effectiveness of fecal microbiota spores.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Antibiotics should not be used concurrently with fecal microbiota spores. Antibacterial treatment should be completed for 2 to 4 days before initiating treatment with fecal microbiota spores.(1)

DISCUSSION: Antibiotics may compromise the effectiveness of fecal microbiota spores.

Antimicrobials/Live Typhoid Vaccine

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: The antimicrobial may be active against the organism in the live-vaccine. Antimicrobial therapy may prevent the vaccine organism from replicating enough to trigger an immune response.(1)

CLINICAL EFFECTS: Vaccination may be ineffective.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Do not give oral typhoid vaccine until 72 hours after the last dose of antimicrobial. If possible, to optimize vaccine effectiveness, do not start antibacterial drugs for 72 hours after the last dose of oral typhoid vaccine. A longer interval should be considered for long-acting antimicrobials, such as azithromycin.(3)

DISCUSSION: Because antimicrobial therapy may prevent sufficient vaccine-organism replication to generate an immune response, the manufacturer of live-attenuated typhoid vaccine and the Centers for Disease Control (CDC) state that the vaccine should not be administered to patients receiving antimicrobial therapy.(1-3)

There are no severe interactions for this drug.

Moderate Interaction: Assess the risk to the patient and take action as needed.

Clindamycin/Strong Cyp3a4 Inducers

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Strong CYP3A4 inducers may induce the metabolism of clindamycin.

CLINICAL EFFECTS: Concurrent or recent use of a strong CYP3A4 inducer may result in decreased antimicrobial activity of clindamycin.

PREDISPOSING FACTORS: Induction effects may be more likely with regular use of the inducer for longer than 1-2 weeks.

PATIENT MANAGEMENT: Monitor the response to clindamycin. Adjust the dose of clindamycin or consider administration of a non-interacting antimicrobial if necessary.

DISCUSSION: The effects of the interaction develop over approximately one to two weeks after starting the inducer and reverse over a period of several weeks after stopping the inducer. Serum clindamycin concentrations may increase when the inducer is stopped. In an observational study, 6 patients treated concomitantly with clindamycin and rifampin showed significantly lower clindamycin trough concentrations. None of the patients reached the target clindamycin minimum concentration (Cmin) (1.7 mg/L).(2) A retrospective review of patients on concomitant clindamycin and rifampin showed a 82-93% decrease in the clindamycin median peak and trough concentrations.(3) Several other studies showed significant decreases in median peak and trough concentrations of clindamycin with concomitant rifampin.(4,6,7) In a study in patients on oral or intravenous clindamycin (600 mg three times daily), patients on concomitant rifampin showed a 43% increase in clindamycin clearance.(5) In another study, concomitant rifampin with intravenous or oral clindamycin led to a 2.7-fold and 7-fold increase in clindamycin clearance, respectively.(7) Strong CYP3A4 inducers linked to this monograph include: apalutamide, barbiturates, carbamazepine, encorafenib, enzalutamide, fosphenytoin, ivosidenib, lumacaftor, mitotane, phenobarbital, phenytoin, primidone, and St. John's Wort.(9)

Lincosamides/Kaolin

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Adsorption of antibiotic to kaolin-pectin.

CLINICAL EFFECTS: Decreased or delayed pharmacological effect of the antibiotic.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Administer the antibiotic two hours after kaolin-pectin.

DISCUSSION: When kaolin-pectin suspension was coadministered with lincomycin only 9% of the antibiotic was absorbed. Coadministration of kaolin-pectin and clindamycin decreased the peak clindamycin concentration by 61% and delayed the time to reach peak serum concentration by 1.5 hours.

Lincosamides/Neuromuscular Blocking Agents

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Lincosamides appear to augment the neuromuscular blocking effects of nondepolarizing muscle relaxants.

CLINICAL EFFECTS: The effects of nondepolarizing neuromuscular relaxants may be prolonged leading to profound sedation, respiratory depression, coma, and/or death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Monitor respiratory function of the patient and provide the necessary support. In patients who have received nondepolarizing muscle relaxants, avoid use of lincosamides in the recovery room. If concurrent use is necessary, monitor patients for unusual dizziness or lightheadedness, extreme sleepiness, slowed or difficult breathing, or unresponsiveness.

DISCUSSION: Lincomycin has been reported to augment the neuromuscular blocking effect of pancuronium in seven anesthetized patients. The effect was readily antagonized by neostigmine administration. In a case report, clindamycin produced prolonged neuromuscular blockade in a patient who had received pancuronium. Neostigmine was ineffective in antagonizing the blockade.

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There are no contraindication contraindications for this drug.

• Bloody stools
• Clostridioides difficile infection
• Crohn's disease
• Diarrhea
• Myasthenia gravis
• Ulcerative colitis

• Atopic dermatitis
• Disease of liver
• Kidney disease with reduction in glomerular filtration rate (GFr)

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More Frequent

• Clostridioides difficile infection

Less Frequent

• Abnormal hepatic function tests
• Allergic dermatitis
• Skin rash
• Urticaria

Rare or Very Rare

• Acute generalized exanthematous pustulosis
• Acute kidney injury
• Acute renal failure
• Agranulocytosis
• Anaphylaxis
• Angioedema
• Bullous dermatitis
• Cholestasis
• Cutaneous vasculitis
• DRESS syndrome
• Drug-induced hepatitis
• Eosinophilia
• Erythema multiforme
• Esophageal ulcer
• Exfoliative dermatitis
• Hypersensitivity drug reaction
• Jaundice
• Neutropenic disorder
• Stevens-johnson syndrome
• Thrombocytopenic disorder
• Toxic epidermal necrolysis

More Frequent

• Acute abdominal pain
• Diarrhea
• Nausea
• Vomiting

Less Frequent

• Erythema
• Esophagitis
• Genital organ pruritus
• Oral candidiasis
• Pruritus of skin
• Vaginitis
• Vulvovaginal candidiasis

Rare or Very Rare

• Arthritis
• Azotemia
• Dysgeusia
• Maculopapular rash
• Symmetrical drug-related intertriginous and flexural exanthema
• Thrombophlebitis

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Reproduction studies in rats and mice using oral or parenteral dosages of clindamycin up to 600 mg/kg daily (3.2 and 1.6 times, respectively, the maximum recommended human oral dosage or 2.1 and 1.1 times, respectively, the maximum recommended human parenteral dosage on a mg/m2 basis) have not revealed evidence of teratogenicity.

In clinical trials that included pregnant women, systemic clindamycin administered during the second and third trimesters was not associated with an increased frequency of congenital abnormalities. There are no adequate and well-controlled studies to date using clindamycin in pregnant women during the first trimester of pregnancy. Because animal reproduction studies are not always predictive of human response, clindamycin should be used during pregnancy only when clearly needed.

Clindamycin phosphate injection contains benzyl alcohol as a preservative; benzyl alcohol can cross the placenta. (See Cautions: Pediatric Precautions.)

Clindamycin is distributed into milk (see Pharmacokinetics: Distribution), and has the potential to cause adverse effects on the GI flora of breast-fed infants.

The manufacturer states that use of oral or IV clindamycin in the mother is not a reason to discontinue breast-feeding; however, it may be preferable to use an alternate anti-infective. If clindamycin is used in a breast-feeding mother, the infant should be monitored for possible adverse effects on GI flora, including diarrhea and candidiasis (thrush, diaper rash) or, rarely, blood in the stool indicating possible antibiotic-associated colitis. The benefits of breast-feeding and the importance of clindamycin to the woman should be considered along with potential adverse effects on the breast-fed child from the drug or from the underlying maternal condition.

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