Podcast #175 - EM ID: When and How to Use Clindamycin

EM ID is back again with Patrick Bafuma interviewing Dr. Nico Cortes-Penfeld from the University of Nebraska Medical Center.  He specializes in orthopedic infectious diseases.  Patrick interview Nico for two discussions, with the first being clindamycin.  Join back for the next discussion on septic arthritis.

When should you give IV antibiotics?

• Sepsis, particularly severe sepsis, is appropriate to treat with IV antibiotics given the poor absorption of the gut due to end organ dysfunction.
• Bacterial meningitis given the rapid progression of the disease and importance of early treatment.
• Necrotizing soft tissue infections has the same reasons as above with rapid progression.
• People who cannot tolerate oral medications (not directly discussed but important).

What are common issues with clindamycin?

• The bioavailability  of clindamycin is great which is why we see similar dosing regimens from IV and oral (which is why IV is usually not needed).
• As dosing frequency increases, adherence to the regimen decreases.
  • The frequency for clindamycin is usually three times daily.
  • There are often better twice daily options such as doxycycline, linezolid, or trimethoprim sulfamethoxazole.
• Resistant of multidrug resistant Staphylococcus aureus  (MRSA) is higher with clindamycin compared to other drugs (such as those above) limiting its benefit.
• Labs should be testing for inducible clindamycin resistant (D-test).

What is the dosing for clindamycin?

• Nico does not recommend four times daily due to the lack of adherence to this regimen.
• Clindamycin's half life is about three hours, so a three versus four times dosing regimen is about a two hour difference (less than one half-life).
• For these reasons, Nico usually does 600 mg every 8 hours for most infections.
• With other infections such as group A Streptococcus pyogenes (GAS) and bacterial vaginosis (BV) the dose will be lower.
• Endometritis/pelvic inflammatory disease (PID), systemic anthrax, and toxic shock syndrome are dosed higher at 900 mg every 8 hours.

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