Common side effects include nausea and vomiting, diarrhea, skin rashes, and pain at the site of injection.[5] It increases the risk of hospital-acquired
Clostridium difficile colitis about fourfold and thus is only recommended for use when other antibiotics are not appropriate.[10][5] It appears to be generally safe in pregnancy.[5] It is of the
lincosamide class and works by blocking bacteria from making protein.[5]
For the treatment of acne, in the long term, the combined use of topical clindamycin and
benzoyl peroxide was similar to
salicylic acid plus benzoyl peroxide.[22][23] Topical clindamycin plus topical benzoyl peroxide is more effective than topical clindamycin alone.[22][23]
Susceptible bacteria
It is most effective against infections involving the following types of organisms:
When testing a gram-positive culture for sensitivity to clindamycin, it is common to perform a "D-test" to determine if there is a sub-population of
bacteria present with the
phenotype known as iMLSB. This phenotype of bacteria are resistant to the
macrolide-
lincosamide-
streptogramin B group of antibiotics, however, the resistance mechanism is only induced by the presence of 14-membered ring macrolides, such as
erythromycin. During a D-test, bacteria of the iMLSB phenotype demonstrate in vitro erythromycin-induced in vitro resistance to clindamycin. This is because of the activity of the macrolide-inducible
plasmid-encoded erm gene.[30]
To perform a D-test, an
agar plate is inoculated with the bacteria in question and two drug-impregnated disks (one with
erythromycin, one with clindamycin) are placed 15–20 mm apart on the plate. If the area of inhibition around the clindamycin disk is D-shaped, the test result is positive. Despite the apparent susceptibility to clindamycin in the absence of erythromycin, a positive D-test precludes therapeutic use of clindamycin. This is because the erythromycin-inducible erm gene is prone to
mutations causing the inducible activity to switch to constitutive (permanently switched on).[31] This in turn, may lead to the therapeutic failure of clindamycin.
If the area of inhibition around the clindamycin disk is circular, the test result is negative and clindamycin can be used.[31]
Malaria
Given with
chloroquine or
quinine, clindamycin is effective and well tolerated in treating Plasmodium falciparum malaria; the latter combination is particularly useful for children, and is the treatment of choice for pregnant women who become infected in areas where
resistance to chloroquine is common.[32][33] Clindamycin should not be used as an antimalarial by itself, although it appears to be very effective as such, because of its slow action.[32][33] Patient-derived isolates of Plasmodium falciparum from the Peruvian Amazon have been reported to be resistant to clindamycin as evidenced by in vitro drug susceptibility testing.[34]
Other
Clindamycin may be useful in skin and
soft tissue infections caused by
methicillin-resistant Staphylococcus aureus (MRSA).[7] Many strains of MRSA are still susceptible to clindamycin; however, in the United States spreading from the West Coast eastwards, MRSA is becoming increasingly resistant.[medical citation needed]
While it has been used in
intraabdominal infections, such use is generally not recommended due to resistance.[5]
Clindamycin is used in cases of suspected
toxic shock syndrome,[35] often in combination with a
bactericidal agent such as
vancomycin. The rationale for this approach is a presumed synergy between vancomycin, which causes the death of the bacteria by
breakdown of the cell wall, and clindamycin, which is a powerful inhibitor of
toxin synthesis. Both in vitro and in vivo studies have shown clindamycin reduces the production of
exotoxins by staphylococci;[36] it may also induce changes in the surface structure of bacteria that make them more sensitive to
immune system attack (
opsonization and
phagocytosis).[37][38]
Clindamycin has been proven to decrease the risk of
premature births in women diagnosed with
bacterial vaginosis during early pregnancy to about a third of the risk of untreated women.[39]
The combination of clindamycin and quinine is the standard treatment for severe
babesiosis.[40]
Common
adverse drug reactions associated with systemic clindamycin therapy – found in over 1% of people – include: diarrhea,
pseudomembranous colitis,
nausea,
vomiting,
abdominal pain or
cramps and/or
rash. High doses (both intravenous and oral) may cause a
metallic taste. Common adverse drug reactions associated with topical formulations – found in over 10% of people – include: dryness, burning, itching, scaliness, or peeling of skin (lotion, solution); erythema (foam, lotion, solution); oiliness (gel, lotion). Additional side effects include
contact dermatitis.[45][46] Common side effects – found in over 10% of people – in vaginal applications include fungal infection.[medical citation needed]
Pseudomembranous colitis is a potentially lethal condition commonly associated with clindamycin, but which also occurs with other antibiotics.[10][47] Overgrowth of Clostridioides difficile, which is inherently
resistant to clindamycin, results in the production of a toxin that causes a range of adverse effects, from diarrhea to colitis and
toxic megacolon.[45][48]
Pregnancy and breastfeeding
Use of clindamycin during pregnancy is generally considered safe.[49]
Clindamycin is classified as compatible with breastfeeding by the
American Academy of Pediatrics,[50] however, the WHO categorizes it as "avoid if possible".[51] It is classified as
L2 probably compatible with breastfeeding according to Medications and Mothers' Milk.[52] A 2009 review found it was likely safe in breastfeeding mothers, but did find one complication (
hematochezia) in a breastfed infant which might be attributable to clindamycin.[53] LactMed lists potentially negative gastrointestinal effects in babies whose mothers take it while breastfeeding but did not see that as justification to stop breastfeeding.[54]
Clindamycin is a
semisynthetic derivative of
lincomycin, a natural antibiotic produced by the
actinobacteriumStreptomyces lincolnensis. It is obtained by 7(S)-
chloro-
substitution of the 7(R)-
hydroxyl group of lincomycin.[59][60] The synthesis of clindamycin was first announced by BJ Magerlein, RD Birkenmeyer, and F Kagan on the fifth Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in 1966.[61] It has been on the market since 1968.[46]
Clindamycin is white or yellow powder that is very soluble in water.[62] The topically used clindamycin phosphate is a phosphate-
ester prodrug of clindamycin.[58]
Mechanism of action
Clindamycin has a primarily
bacteriostatic effect. At higher concentrations, it may be bactericidal.[62] It is a bacterial
protein synthesis inhibitor by inhibiting ribosomal translocation,[63] in a similar way to
macrolides. It does so by binding to the rRNA of the bacterial
50Sribosome subunit, overlapping with the binding sites of the
oxazolidinone,
pleuromutilin, and
macrolide antibiotics, among others.[24][64] The binding is reversible.[65] Clindamycin is more effective than lincomycin.[62]
Clindamycin preparations that are taken by mouth include
capsules (containing clindamycin
hydrochloride) and oral suspensions (containing clindamycin
palmitate hydrochloride).[32] Oral suspension is not favored for administration of clindamycin to children, due to its extremely foul taste and odor. Clindamycin is formulated in a vaginal cream and as
vaginal ovules for treatment of
bacterial vaginosis.[39] It is also available for topical administration in
gel form, as a lotion, and in a foam delivery system (each containing clindamycin
phosphate) and a solution in ethanol (containing clindamycin hydrochloride) and is used primarily as a prescription acne treatment.[71]
Several combination acne treatments containing clindamycin are also marketed, such as single-product formulations of clindamycin with
benzoyl peroxide—sold as BenzaClin (
Sanofi-Aventis),
Duac (a
gel form made by
Stiefel), and Acanya, among other trade names—and, in the United States, a combination of clindamycin and
tretinoin, sold as
Ziana.[72] In India, vaginal suppositories containing clindamycin in combination with
clotrimazole are manufactured by Olive Health Care and sold as Clinsup-V. In Egypt, vaginal cream containing clindamycin produced by Biopharmgroup sold as Vagiclind indicated for vaginosis.[citation needed]
Clindamycin is available as a
generic drug, for both systemic (oral and intravenous) and topical use.[32] (The exception is the vaginal suppository, which is not available as a generic in the US[73]).
Veterinary use
The
veterinary uses of clindamycin are quite similar to its human indications, and include treatment of
osteomyelitis,[74] skin infections, and
toxoplasmosis, for which it is the preferred drug in dogs and cats.[75] They can be used both by mouth and topically.[62] A disadvantage is that bacterial resistance can develop fairly quickly.[62] Gastrointestinal upset may also occur.[62] Toxoplasmosis rarely causes symptoms in cats, but can do so in very young or
immunocompromised kittens and cats.[citation needed]
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