CLINDAMYCIN PHOSPHATE (Generic for CLEOCIN)

General Administration Information
For storage information, see the specific product information within the How Supplied section.

Route-Specific Administration

Oral Administration
-Administration with food may help minimize gastrointestinal adverse effects.
Oral Liquid Formulations
-Tap the bottle to loosen the powder. The water should be added in 2 portions; shake well after each aliquot.
-Review the reconstitution instructions for the particular product and package size, as the amount of water required for reconstitution may vary from manufacturer to manufacturer.
-Storage: Solution is stable at room temperature for 2 weeks; do not refrigerate.
-Administer with a full glass of water to avoid esophageal irritation; may administer with or without food.
-Undesirable taste can be a challenge for many patients; the taste of the oral solution can be improved by adding a flavoring agent (e.g., FLAVORx).



Injectable Administration
-Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.
Intravenous Administration
Dilution
-Vials-Dilute with a compatible diluent to a usual concentration of 6 to 12 mg/mL (Max concentration: 18 mg/mL). Some acceptable diluents are 5% Dextrose Injection, 0.9% NaCl Injection, 10% Dextrose Injection, or Lactated Ringer's Injection.

-ADD-Vantage Vials-Dilute 300 and 600 mg ADD-Vantage containers with 50 mL of 0.9% NaCl Injection or 5% Dextrose Injection. Dilute 900 mg ADD-Vantage containers with 100 mL of 0.9% NaCl Injection or 5% Dextrose Injection.

-Pre-mixed Galaxy IV solution-Check for leaks by squeezing bag firmly.
-Do not add supplementary medication.
-Do not use plastic containers in series connections as this could result in an embolism due to residual air being drawn from the primary container before administration of the fluid from the secondary container is complete.

-Storage: Pharmacy bulk vials should be discarded within 24 hours of initial entry. When diluted in 5% Dextrose Injection, 0.9% NaCl Injection, or Lactated Ringer's Injection, solutions with concentrations of 6, 9, or 12 mg/mL are stable for 16 days at room temperature or 32 days under refrigeration when stored in glass bottles or minibags. When diluted in 5% Dextrose Injection, solutions with a concentration of 18 mg/mL are stable for 16 days at room temperature

Intermittent IV Infusion
-Infuse over at least 10 to 60 minutes. Do not exceed an infusion rate of 30 mg/minute, and no more than 1.2 g should be infused in a 1 hour period.

Intramuscular Administration
-Administer undiluted.
-Single doses should not exceed 600 mg.
-Inject deeply into a large muscle mass (e.g., anterolateral thigh or deltoid [children and adolescents only]).
-In general, IM administration of drugs in very low birth weight premature neonates is not practical due to small muscle mass, and absorption is unreliable due to hemodynamic instability that is relatively common in this population.



Topical Administration
-Topical skin products are not for intravaginal therapy and are for external use only. Do not use skin products near the eyes, nose, or mouth.
-Wash hands before and after use. Wash affected area and gently pat dry.
Cream/Ointment/Lotion Formulations
-For lotions, shake well before use.
-Apply a thin film to the cleansed affected area. Massage gently into affected areas.

Other Topical Formulations
Foam
-Do not dispense foam directly onto hands or face; the warmth of the skin will cause the foam to melt. Instead, dispense desired amount directly into the cap or onto a cool surface. Make sure enough foam is dispensed to cover the affected area(s). If the can feels warm or the foam seems runny, run the can under cold water. To apply, pick up small amounts of the foam with the fingertips and gently massage into the affected areas until the foam disappears.
-Avoid application near eyes, mouth, lips, or broken skin; rinse well with water if contact occurs.

Pledget
-Do not use if the seal on jar is broken.
-Remove pledget from jar just before use.
-More than 1 pledget may be used. Use each pledget only once and then discard.
-Keep jar tightly closed when not in use.

Solution

-Apply a thin film to the cleansed affected area. Massage gently into affected areas.



Intravaginal Administration
-Only use those dosage formulations specified for intravaginal use. Intravaginal dosage forms are not for topical therapy; do not ingest.
-Instruct patient on proper administration of the vaginal cream, gel, or ovules/suppositories.
-Instruct patients of appropriate age to avoid vaginal intercourse or use of other vaginal products (tampons or douches) during treatment with these products. For the vaginal gel, avoid vaginal intercourse or use of other vaginal products for an additional 3 days after use.

Suppository Formulations:
-Unwrap vaginal ovule (suppository) prior to insertion.
-Use applicator(s) supplied by the manufacturer.
-Ingredients contained in the suppository base may weaken latex or rubber products (i.e., condoms or vaginal contraceptive diaphragms). Patients of appropriate age should be cautioned that use of these products within 72 hours after treatment is not recommended and that these contraceptive methods may not be as effective during this time.

Cream Formulations:
-Use applicator(s) supplied by the manufacturer.

Gel Formulations:
-Use applicator(s) supplied by the manufacturer.
-Clindamycin vaginal gel is not compatible with and may weaken polyurethane condoms. Patients of appropriate age should be cautioned that use of polyurethane condoms within 7 days after treatment is not recommended and that these products may not be reliable for preventing pregnancy or for protecting against transmission of HIV or other sexually transmitted infections during this time. Latex or polyisoprene condoms can be used.

Gastrointestinal (GI) adverse events are more commonly associated with systemic clindamycin therapy; however, GI disturbances have also been reported in association with the use of topical and vaginal preparations. Diarrhea has been reported in up to 20% of patients receiving systemic therapy and is more common with the oral formulation; it has also been reported in less than 1% of patients using vaginal products and has occurred with the use of topical products. Other adverse events reported in less than 1% of patients using vaginal products and also with other formulations include abdominal pain/cramps, halitosis, nausea, vomiting, dyspepsia, flatulence, and gastrointestinal disorder. Constipation has been reported in 2% or less of patients using the vaginal product. Administration of oral formulations with food can reduce minor gastric distress. Esophagitis may occur with the oral formulations of clindamycin. Esophagitis may be associated with odynophagia, dysphagia, and retrosternal pain. Most symptoms resolve within a few days to weeks after discontinuing the drug. A metallic taste (dysgeusia) has been reported with the administration of the intravenous and oral clindamycin products and taste perversion has been reported in less than 1% of patients receiving the vaginal cream. Hematochezia was noted in postmarketing reports with the vaginal cream.

Transient neutropenia (leukopenia) and eosinophilia have been reported during systemic clindamycin therapy. Reports of agranulocytosis and thrombocytopenia have been made. No direct relationship to concurrent clindamycin therapy has been made. Some systemic absorption does occur during topical or vaginal therapy and the possibility of these adverse reactions occurring with these routes cannot be excluded.

Rashes including rash, maculopapular rash, vesicular rash, or bullous rash as well as urticaria have been observed during systemic clindamycin therapy and may be associated with hypersensitivity. Severe skin reactions, such as toxic epidermal necrolysis and Stevens-Johnson syndrome, have been reported and some cases have been fatal. Clindamycin should be permanently discontinued if severe skin or hypersensitivity reactions occur. Acute generalized exanthematous pustulosis (AGEP), angioedema, drug reaction with eosinophilia and systemic symptoms (DRESS), erythema multiforme, and exfoliative dermatitis have also been reported with systemic clindamycin. Pruritus/itching has also been noted with topical (1% to 11%), vaginal (1% or less), and systemic therapy. Topical application has been associated with burning (6% to 11%), xerosis (dry skin) (1% to 23%), erythema (7% to 16%), oiliness/oily skin (1% to 18%), peeling (7% to 11%), seborrhea, application site rash, folliculitis, and application site pain. Xerosis may be attributed to the solvent used in the topical preparation. Alcohol in some topical formulations may cause ocular irritation or ocular pain or irritate the mucous membranes or abraded skin resulting in contact dermatitis.

Intramuscular injection of clindamycin can cause an injection site reaction consisting of pain, induration, and sterile abscess. Thrombo-phlebitis has been reported after intravenous infusion.

Nephrotoxicity, described as cases of acute kidney injury, has been reported with clindamycin. Consider monitoring renal function during clindamycin therapy. Discontinue clindamycin when no other etiology is identified for acute kidney injury. Some systemic absorption does occur during topical or vaginal therapy and the possibility of adverse reactions occurring with these routes cannot be excluded. Dysuria was reported in less than 1% of patients using vaginal clindamycin.

Anaphylactic shock and anaphylactoid reactions have been reported with clindamycin. Clindamycin should be permanently discontinued if anaphylactic or serious hypersensitivity reactions occur. Treat patients with an allergy to tartrazine dye cautiously since some oral capsule preparations contain the dye.

Adolescent females were not included in clinical trials with the vaginal clindamycin products. In women treated with vaginal clindamycin preparations, vaginitis/vaginal infections were reported in up to 10.7% of patients. Other urogenital disorders reported include vulvovaginal disorder (3.2% to 6.7%) and vaginal pain (up to 1.9%). Vaginal discomfort was reported in up to 6% of patients and included vulvovaginal pruritus, vulvovaginal burning sensation, vulvovaginal erythema, and vulvovaginal dryness. Other adverse events reported in less than 1% of patients include menstrual disorder, dysuria, vaginal discharge, metrorrhagia, endometriosis, dysfunctional uterine bleeding, dysmenorrhea, intermenstrual bleeding, pelvic pain, vaginal irritation, and vulvitis. Vaginal bleeding and vaginal swelling were noted in postmarketing reports. Abnormal labor was noted in 1.1% of pregnant patients. Vaginitis has also been reported with the systemic use of clindamycin.

Jaundice and abnormal/elevated hepatic enzymes have been observed during systemic clindamycin therapy. Some systemic absorption does occur during topical or vaginal therapy and the possibility of these adverse reactions occurring with these routes cannot be excluded.

Headache (7% or less) and dizziness (less than 1%) were noted with the use of the topical clindamycin foam as well as the vaginal products. Vertigo (less than 1%) was also reported with the vaginal products.

Back pain (5%) has been reported with the use of vaginal clindamycin. Cases of polyarthritis have been reported with systemic therapy.

Rare cases of cardiopulmonary/cardiac arrest and hypotension have been reported with an intravenous infusion that was administered too rapidly.

Microbial overgrowth and superinfection can occur with antibiotic use. C. difficile-associated diarrhea (CDAD) or pseudomembranous colitis has been reported with clindamycin. If pseudomembranous colitis is suspected or confirmed, ongoing antibacterial therapy not directed against C. difficile may need to be discontinued. Institute appropriate fluid and electrolyte management, protein supplementation, C. difficile-directed antibacterial therapy, and surgical evaluation as clinically appropriate. Systemic or local fungal infections, including candidiasis, may occur. Vaginal candidiasis has been reported to occur in 1.5% to 17% of adult patients, and systemic candidiasis has been reported in 1.7% or less of adult patients receiving vaginal clindamycin. Urinary tract infection was reported in 2% or less of adult patients using vaginal clindamycin, with pyelonephritis reported in less than 1% of patients. Upper respiratory tract infection and unspecified bacterial infection were also reported in less than 1% of adult patients using the vaginal product.

General adverse events reported in less than 1% of patients with the use of clindamycin vaginal products include inflammatory swelling, hyperthyroidism, epistaxis, fever, generalized pain, localized edema, and fatigue.

Clindamycin is contraindicated in patients with known clindamycin hypersensitivity. Because some cross-sensitivity may occur, lincomycin hypersensitivity is also a contraindication for clindamycin use. Use the drug with caution in patients with asthma or a significant history of allergy (atopy). Some oral capsule preparations contain tartrazine dye and can precipitate bronchial asthma or other allergic reactions in patients with tartrazine dye hypersensitivity.

Clindamycin can cause the overgrowth of non-susceptible bacteria resulting in superinfection, particularly yeast and fungal infection. Should superinfection occur, appropriate measures should be taken.

Clindamycin topical products (topical solution, gel, and lotion) and vaginal (cream, ovules) are contraindicated in patients with a history of regional enteritis (Crohn's disease) or ulcerative colitis, or a history of pseudomembranous colitis; other product preparations warn against use in patients with pseudomembranous colitis. Clindamycin has been associated with severe colitis, more so than some other antimicrobials. Consider pseudomembranous colitis in patients presenting with diarrhea after antibacterial use. Careful medical history is necessary as pseudomembranous colitis has been reported to occur over 2 months after the administration of antibacterial agents. Almost all antibacterial agents, including clindamycin, have been associated with pseudomembranous colitis or C. difficile-associated diarrhea (CDAD) which may range in severity from mild to life-threatening. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.

Use parenteral clindamycin with caution in neonates; the injectable preparation contains benzyl alcohol, which has been associated with a fatal 'gasping syndrome' in premature infants.

Clindamycin should be used with caution in patients with hepatic disease. Studies indicate that the clindamycin half-life is prolonged in patients with moderate to severe liver disease. However, extrapolation from these studies indicates that when the drug is given every 8 hours, accumulation should not occur and dosage modification for liver disease may not be necessary. Liver function tests (LFTs) should be monitored regularly during therapy in patients with severe liver disease.

Clindamycin topical solution contains an alcohol base that will cause burning and irritation of the eye; therefore, avoid ocular exposure. In the event of accidental contact with sensitive surfaces (eye, abraded skin, mucous membranes), bathe with water.

Serious rash events, including toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and Stevens-Johnson syndrome (SJS), some with fatal outcomes, have been reported with systemic clindamycin therapy. Clindamycin should be permanently discontinued if severe skin or hypersensitivity reactions occur.

Consider monitoring of renal function during clindamycin therapy, particularly in patients with pre-existing renal impairment or those taking concomitant nephrotoxic drugs. Clindamycin is potentially nephrotoxic and acute kidney injury has been reported with use.

Description: Clindamycin is an antibiotic structurally similar to lincomycin, from which it is derived. It is available in oral, parenteral, topical, and vaginal formulations. Clindamycin traditionally has been used for anaerobic infections. It has become commonly used in children for the treatment of community-acquired methicillin-resistant Staphylococcal aureus infections, including skin and soft tissue infections, osteomyelitis, septic arthritis, and pneumonia. Clindamycin is also an effective alternative for treating acute otitis media, sinusitis, and streptococcal pharyngitis in children with penicillin allergy. Diarrhea is common with clindamycin, and it has been associated with severe C. difficile colitis, although reports of C. difficile-associated disease in children are rare. Systemic clindamycin formulations are FDA approved for use in pediatric patients as young as neonates. Topical formulations are FDA approved for use in adolescents. Some vaginal formulations are FDA approved for use in pediatrics as young as 12 years.

General dosing information:
-While clindamycin can be administered intramuscularly if necessary, this route should typically be reserved for situations in which IV access is not possible.
-In general, IM administration of drugs in very low birth weight premature neonates is not practical due to small muscle mass, and absorption is unreliable due to hemodynamic instability that is relatively common in this population.

Per the manufacturer, this drug has been shown to be active against most strains of the following microorganisms either in vitro and/or in clinical infections: Actinomyces israelii, Bacteroides fragilis, Clostridium clostridioforme, Clostridium perfringens, Cutibacterium acnes, Eggerthella lenta, Fusobacterium necrophorum, Fusobacterium nucleatum, Peptostreptococcus anaerobius, Peptostreptococcus magnus, Peptostreptococcus micros, Prevotella bivia, Prevotella intermedia, Prevotella melaninogenica, Propionibacterium sp., Staphylococcus aureus (MSSA), Staphylococcus epidermidis, Streptococcus agalactiae (group B streptococci), Streptococcus anginosus, Streptococcus mitis, Streptococcus oralis, Streptococcus pneumoniae, Streptococcus pyogenes (group A beta-hemolytic streptococci)
NOTE: The safety and effectiveness in treating clinical infections due to organisms with in vitro data only have not been established in adequate and well-controlled clinical trials.

This drug may also have activity against the following microorganisms: Babesia microti, Plasmodium falciparum, Pneumocystis jirovecii (formerly Pneumocystis carinii), Staphylococcus aureus (MRSA), Toxoplasma gondii
NOTE: Some organisms may not have been adequately studied during clinical trials; therefore, exclusion from this list does not necessarily negate the drug's activity against the organism.

For the treatment of bacteremia and sepsis:
-for the treatment of bacteremia:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours. Treat for 7 to 14 days as an alternative option for S. aureus bacteremia.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours. Treat for 7 to 14 days as an alternative option for S. aureus bacteremia.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. Treat for 7 to 14 days as an alternative option for S. aureus bacteremia. The FDA-approved dosage is 15 to 20 mg/kg/day IV divided every 6 to 8 hours.
Infants, Children, and Adolescents 1 month to 16 years: 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours. Treat for 7 to 14 days as an alternative option for S. aureus bacteremia.
Adolescents 17 years: 600 to 900 mg IV every 8 to 12 hours. For life-threatening infections, doses up to 4,800 mg/day IV have been used have been used in adults. Treat for 7 to 14 days as an alternative option for S. aureus bacteremia.
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Infants, Children, and Adolescents: 10 to 25 mg/kg/day (Max: 1,800 mg/day) PO divided every 8 hours. The FDA-approved dosage is 8 to 20 mg/kg/day PO for the capsule and 8 to 25 mg/kg/day PO for the solution divided every 6 to 8 hours (Max: 450 mg/dose).
-for the treatment of sepsis:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. The FDA-approved dosage is 15 to 20 mg/kg/day IV divided every 6 to 8 hours. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response. Neonates younger than 37 weeks gestational age were excluded from guideline scope.
Infants, Children, and Adolescents 1 month to 16 years: 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.
Adolescents 17 years: 600 to 900 mg IV every 8 hours. For life-threatening infections, doses up to 4,800 mg/day IV have been used in adults. Start within 1 hour for septic shock or within 3 hours for sepsis-associated organ dysfunction without shock. Duration of therapy is not well-defined and dependent on patient- and infection-specific factors. Assess patient daily for deescalation of antimicrobial therapy based on pathogen identification and/or adequate clinical response.

For the treatment of lower respiratory tract infections (LRTIs), including anaerobic pneumonia, aspiration pneumonia, community-acquired pneumonia (CAP), lung abscess, and pleural empyema:
-for the treatment of nonspecific lower respiratory tract infections (LRTIs), anaerobic pneumonia, aspiration pneumonia, and lung abscess:
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours. The FDA-approved dosage is 8 to 25 mg/kg/day PO divided every 6 to 8 hours.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours. The FDA-approved dosage is 8 to 25 mg/kg/day PO divided every 6 to 8 hours.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours. The FDA-approved dosage is 8 to 25 mg/kg/day PO divided every 6 to 8 hours.
Infants, Children, and Adolescents: 10 to 25 mg/kg/day (Max: 1,800 mg/day) PO divided every 8 hours. The FDA-approved dosage is 8 to 25 mg/kg/day divided every 6 to 8 hours (Max: 450 mg/dose).
Intravenous or Intramuscular dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. The FDA-approved dosage is 15 to 20 mg/kg/day IV or IM divided every 6 to 8 hours.
Infants, Children, and Adolescents 1 month to 16 years: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV or IM divided every 6 to 8 hours.
Adolescents 17 years: 300 mg IV or IM every 6 to 12 hours for less severe infections and 600 mg IV or IM every 6 to 12 hours to 900 mg IV every 8 to 12 hours for severe infections. May further increase dose for life-threatening infections; doses up to 4,800 mg/day IV have been used in adults.
-for the treatment of methicillin-resistant S. aureus pneumonia:
Oral dosage:
Infants, Children, and Adolescents: 30 to 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours for 7 to 21 days. Guidelines recommend clindamycin as empirical therapy if the patient is stable without ongoing bacteremia and local clindamycin resistance rates are low (less than 10%).
Intravenous dosage:
Infants, Children, and Adolescents: 30 to 40 mg/kg/day (Max: 1,800 mg/day) IV divided every 6 to 8 hours for 7 to 21 days. Guidelines recommend clindamycin as empirical therapy if the patient is stable without ongoing bacteremia and local clindamycin resistance rates are low (less than 10%).
-for the treatment of community-acquired pneumonia (CAP):
Oral dosage:
Infants, Children, and Adolescents: 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours for 5 to 7 days. Guidelines recommend clindamycin for susceptible strains of MRSA, as an alternative for MSSA, penicillin-resistant S. pneumoniae, and S. pyogenes (group A beta-hemolytic streptococci).
Intravenous dosage:
Infants, Children, and Adolescents: 40 mg/kg/day (Max: 1,800 mg/day) IV divided every 6 to 8 hours for 5 to 7 days. Guidelines recommend clindamycin for susceptible strains of MRSA, as an alternative for MSSA, penicillin-resistant S. pneumoniae, and S. pyogenes (group A beta-hemolytic streptococci).
-for the treatment of community-acquired pleural empyema:
Oral dosage:
Infants, Children, and Adolescents: 10 to 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours. Use in combination with a second- or third-generation cephalosporin an alternative therapy. Treat for at least 2 weeks after drainage and defervescence.
Intravenous dosage:
Infants, Children, and Adolescents 1 month to 16 years: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours. Use in combination with a second- or third-generation cephalosporin. Treat for at least 2 weeks after drainage and defervescence.
Adolescents 17 years: 600 mg IV every 6 to 12 hours up to 900 mg IV every 8 to 12 hours. Use in combination with a second- or third-generation cephalosporin for at least 2 weeks after drainage and defervescence.

For the treatment of intraabdominal infections, including peritonitis, appendicitis, intraabdominal abscess, neonatal necrotizing enterocolitis, peritoneal dialysis-related peritonitis*, and peritoneal dialysis catheter-related infection*:
-for the general treatment of intraabdominal infections:
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours. The FDA-approved dosage for all pediatric patients, including neonates, is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Infants, Children, and Adolescents: 8 to 25 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours.
Intravenous or Intramuscular dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. The FDA-approved dosage is 15 to 20 mg/kg/day IV or IM divided every 6 to 8 hours.
Infants, Children, and Adolescents 1 month to 16 years: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV or IM divided every 6 to 8 hours.
Adolescents 17 years: 300 mg IV or IM every 6 to 12 hours for less severe infections and 600 mg IV or IM every 6 to 12 hours to 900 mg IV every 8 to 12 hours for severe infections. For life-threatening infections, doses may be increased; doses up to 4,800 mg/day IV have been used in adults. Dosing intervals of every 6 or 8 hours are most commonly used in pediatric practice.
-for the treatment of complicated intraabdominal infections with adequate source control:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours as part of combination therapy for 7 to 10 day. Clindamycin is an option for necrotizing enterocolitis.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours as part of combination therapy for 7 to 10 day. Clindamycin is an option for necrotizing enterocolitis.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours as part of combination therapy for 7 to 10 days. Clindamycin is an option for necrotizing enterocolitis.
Infants, Children, and Adolescents: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours as part of combination therapy for 3 to 7 days. Complicated infections include peritonitis and appendicitis complicated by rupture, and intraabdominal abscess.
-for the treatment of peritoneal dialysis-related peritonitis*:
Continuous Intraperitoneal dosage*:
Infants, Children, and Adolescents: 300 mg/L intraperitoneal loading dose, followed by 150 mg/L in each dialysate exchange. Treat for 14 to 21 days.
-for the treatment of peritoneal dialysis catheter-related infection*:
Oral dosage:
Infants, Children, and Adolescents: 30 mg/kg/day (Max: 1,800 mg/day) PO divided every 8 hours for at least 14 to 28 days.

For the treatment of bone and joint infections, including osteomyelitis, infectious arthritis, and infectious bursitis:
-for the treatment of osteomyelitis:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Infants 1 to 2 months: 30 to 40 mg/kg/day IV divided every 6 to 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Infants, Children, and Adolescents 3 months to 17 years: 30 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 3 to 4 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
Oral dosage*:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Infants 1 to 2 months: 30 to 40 mg/kg/day PO divided every 6 to 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Infants, Children, and Adolescents 3 months to 17 years: 30 to 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 3 to 4 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for severe or complicated infections.
-for the treatment of infectious arthritis:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Infants 1 to 2 months: 30 to 40 mg/kg/day IV divided every 6 to 8 hours. Treat for 14 to 21 days or until clinically improved, followed by oral step-down therapy for a total duration of 4 to 6 weeks. A longer course (several months) may be needed for severe or complicated infections.
Infants, Children, and Adolescents 3 months to 17 years: 30 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours. Treat for 2 to 4 days or until clinically improved, followed by oral step-down therapy for a total duration of 2 to 3 weeks for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
Oral dosage*:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Infants 1 to 2 months: 30 to 40 mg/kg/day PO divided every 6 to 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 4 to 6 weeks (parenteral plus oral). A longer course (several months) may be needed for severe or complicated infections.
Infants, Children, and Adolescents 3 months to 17 years: 30 to 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours as step-down therapy after initial parenteral therapy. Treat for a total duration of 2 to 3 weeks (parenteral plus oral) for uncomplicated cases. A longer course (i.e., 4 to 6 weeks or longer) may be needed for septic hip arthritis or severe or complicated infections.
-for the treatment of infectious bursitis:
Intravenous dosage:
Children and Adolescents: 30 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.
Oral dosage*:
Children and Adolescents: 30 to 40 mg/kg/day (Max: 1,800 mg/day) PO divided every 6 to 8 hours for 2 to 3 weeks. Generally, 2 weeks is appropriate for most patients; immunocompromised patients may require a longer duration.

For the treatment of skin and skin structure infections, including impetigo, cellulitis, erysipelas, skin abscesses, furunculosis, carbuncle, necrotizing infections such as gas gangrene, and infectious neonatal pustulosis:
-for the treatment of impetigo:
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours for 5 to 7 days.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours for 5 to 7 days.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours for 5 to 7 days. The FDA-approved dose is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Infants, Children, and Adolescents: 20 mg/kg/day PO divided every 8 hours (Max: 1,800 mg/day) for 5 to 7 days.
-for the treatment of nonpurulent skin infections, such as cellulitis and erysipelas:
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours for 5 to 14 days.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours for 5 to 14 days.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours for 5 to 14 days. The FDA-approved dose is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Infants, Children, and Adolescents: 25 to 40 mg/kg/day PO divided every 6 to 8 hours (Max: 1,800 mg/day) for 5 to 14 days.
Intravenous or Intramuscular dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours for 5 to 14 days.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours for 5 to 14 days.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours for 5 to 14 days. The FDA-approved dose is 15 to 20 mg/kg/day IV or IM divided every 6 to 8 hours.
Infants, Children, and Adolescents: 20 to 40 mg/kg/day IV or IM divided every 6 to 8 hours (Max: 2,700 mg/day) for 5 to 14 days.
-for the treatment of purulent skin infections, such as furunculosis, carbuncle, and skin abscesses:
Oral dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose PO every 8 hours for 5 to 10 days plus incision and drainage.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose PO every 8 hours for 5 to 10 days plus incision and drainage.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose PO every 8 hours for 5 to 10 days plus incision and drainage. The FDA-approved dose is 8 to 25 mg/kg/day PO divided every 6 to 8 hours depending on the severity of infection.
Infants, Children, and Adolescents: 25 to 40 mg/kg/day PO divided every 6 to 8 hours (Max: 1,800 mg/day) for 5 to 10 days plus incision and drainage.
Intravenous or Intramuscular dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours for 5 to 10 days plus incision and drainage.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours for 5 to 10 days plus incision and drainage.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours for 5 to 10 days plus incision and drainage. The FDA-approved dose is 15 to 20 mg/kg/day IV or IM divided every 6 to 8 hours.
Infants, Children, and Adolescents: 20 to 40 mg/kg/day IV or IM divided every 6 to 8 hours (Max: 2,700 mg/day) for 5 to 10 days plus incision and drainage.
-for the treatment of necrotizing infections of the skin, fascia, and muscle (i.e., gas gangrene):
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours. Clindamycin is used as a single agent for S. aureus and in combination with penicillin for streptococcal infections (including toxic shock) or clostridial infections (including gas gangrene). Clindamycin may also be considered empirically as part of combination broad spectrum therapy for mixed infections.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours. Clindamycin is used as a single agent for S. aureus and in combination with penicillin for streptococcal infections (including toxic shock) or clostridial infections (including gas gangrene). Clindamycin may also be considered empirically as part of combination broad spectrum therapy for mixed infections.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours. Clindamycin is used as a single agent for S. aureus and in combination with penicillin for streptococcal infections (including toxic shock) or clostridial infections (including gas gangrene). Clindamycin may also be considered empirically as part of combination broad spectrum therapy for mixed infections.
Infants, Children, and Adolescents: 30 to 40 mg/kg/day IV divided every 8 hours (Max: 2,700 mg/day) until further debridement is not necessary, the patient has improved clinically, and fever has been absent for 48 to 72 hours. Clindamycin is used as a single agent for S. aureus and in combination with penicillin for streptococcal infections (including toxic shock) or clostridial infections (including gas gangrene). Clindamycin may also be considered empirically as part of combination broad spectrum therapy for mixed infections.
-for the treatment of infectious neonatal pustulosis:
Intravenous dosage:
Neonates 32 weeks postmenstrual age and younger: 5 mg/kg/dose IV every 8 hours. Initial treatment with clindamycin is recommended as a treatment option for premature or very low birthweight neonates until bacteremia is excluded.
Neonates 33 to 40 weeks postmenstrual age: 7 mg/kg/dose IV every 8 hours. Initial treatment with clindamycin is recommended as a treatment option for premature or very low birthweight neonates or for more extensive disease involving multiple sites in term neonates until bacteremia is excluded.
Neonates older than 40 weeks postmenstrual age: 9 mg/kg/dose IV every 8 hours. Initial treatment with clindamycin is recommended as a treatment option for premature or very low birthweight neonates or for more extensive disease involving multiple sites in term neonates until bacteremia is excluded.

For the treatment of gynecologic infections, including endometritis, pelvic cellulitis, postsurgical vaginal cuff infections, and pelvic inflammatory disease (PID), with or without associated tubo-ovarian abscess:
-for the general treatment of gynecologic infections:
Intravenous or Intramuscular dosage:
Adolescents 13 to 16 years: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV or IM divided every 6 to 8 hours.
Adolescents 17 years: 600 mg IV or IM every 6 to 8 hours up to 900 mg IV every 8 hours. The FDA-approved dosage is 300 mg IV or IM every 6 to 12 hours for less severe infections and 600 mg IV or IM every 6 to 12 hours to 900 mg IV every 8 to 12 hours for severe infections. For life-threatening infections, doses may be increased; doses up to 4,800 mg/day IV have been used.
Oral dosage:
Adolescents: 8 to 25 mg/kg/day PO divided every 6 to 8 hours (Max: 450 mg/dose).
-for the treatment of acute PID, with or without associated tubo-ovarian abscess:
Intravenous dosage:
Adolescents: 900 mg IV every 8 hours in combination with gentamicin as an alternative. IV therapy should be continued for at least 24 to 48 hours after clinical improvement, and then stepdown to oral clindamycin or doxycycline for total of 14 days of therapy. When tubo-ovarian abscess is present, oral clindamycin or metronidazole plus doxycycline should be used for a total of 14 days of therapy.
Oral dosage:
Adolescents: 450 mg PO 4 times daily to complete a total of 14 days after IV therapy. When tubo-ovarian abscess is present, add doxycycline.

For the treatment of bacterial vaginosis:
Intravaginal dosage (cream - Clindesse):
Adolescents (post-menarchal): 1 applicatorful (100 mg clindamycin/5 g cream) intravaginally as a single dose at any time of the day.
Intravaginal dosage (cream - standard formulations)*:
Adolescents: 1 applicatorful (100 mg clindamycin/5 g cream) intravaginally at bedtime for 7 days.
Intravaginal dosage (ovules/suppositories):
Adolescents (post-menarchal): 1 ovule (100 mg clindamycin) inserted intravaginally at bedtime for 3 days as an alternative.
Intravaginal dosage (gel):
Children and Adolescents 12 to 17 years: 1 applicatorful (100 mg clindamycin/5 g cream) intravaginally as a single dose at any time of the day.
Oral dosage*:
Adolescents: 300 mg PO twice daily for 7 days as an alternative.

For the treatment of acne vulgaris:
Topical dosage (gel, lotion, pledget, or solution):
Children and Adolescents 12 to 17 years: Apply a thin layer topically to the affected skin area(s) twice daily. Topical antibiotic monotherapy is not recommended due to increased bacterial resistance; if topical monotherapy is continued for longer than a few weeks, the addition of topical benzoyl peroxide is recommended.
Topical dosage (foam):
Children and Adolescents 12 to 17 years: Apply topically to the affected skin area(s) once daily. Use enough to cover the entire affected area. If there is no improvement after 6 to 8 weeks, or if the condition worsens, discontinue treatment. Topical antibiotic monotherapy is not recommended due to increased bacterial resistance; if topical monotherapy is continued for longer than a few weeks, the addition of topical benzoyl peroxide is recommended.

For the treatment of acute otitis media*:
Oral dosage:
Infants and Children 6 months and older: 30 to 40 mg/kg/day PO divided every 8 hours (Max: 1,800 mg/day) with or without a third-generation cephalosporin for 10 days as an alternative in patients who have failed initial antibiotic therapy. Use in combination with a third-generation cephalosporin after failure of a second antibiotic.

For the treatment of acute bacterial sinusitis*:
Oral dosage:
Infants, Children, and Adolescents: 30 to 40 mg/kg/day PO divided every 8 hours (Max: 1,800 mg/day) plus cefixime or cefpodoxime for 10 to 14 days. Combination therapy with clindamycin and a third-generation cephalosporin is recommended as second-line therapy for patients with penicillin allergy or those from areas with high endemic rates of penicillin-sensitive S. pneumoniae. However, increased resistance has been reported among S. pneumoniae serotype 19A isolates, in which case a fluoroquinolone is recommended as an alternative.

For the treatment of acute dental infection*, dentoalveolar infection*, or endodontic infection*, including periodontitis*, in combination with conventional treatment (e.g., scaling and root planing):
Oral dosage:
Children and Adolescents: 8 to 12 mg/kg/day PO divided every 6 to 8 hours (Max: 300 mg/dose) for 10 days.

For the treatment of group A beta-hemolytic streptococcal (GAS) pharyngitis* (primary rheumatic fever prophylaxis*) and tonsillitis*:
Oral dosage:
Infants, Children, and Adolescents: 7 mg/kg/dose (Max: 600 mg/dose) PO every 8 hours for 10 days as an alternative in patients allergic to penicillin.

For surgical infection prophylaxis*:
-for general surgical infection prophylaxis*:
Intravenous dosage:
Infants, Children, and Adolescents: 10 mg/kg (Max: 900 mg/dose) IV as a single dose within 60 minutes prior to the surgical incision; consider intraoperative redosing 6 hours from the first preoperative dose. May continue 10 mg/kg (Max: 900 mg/dose) every 8 hours for no more than 24 hours post-operatively if necessary. Guidelines recommend clindamycin as an alternative monotherapy in patients with beta-lactam allergy for multiple types of surgical procedures, including hernia repair, neurosurgical, orthopedic, vascular, plastic surgery, clean urologic, and clean and clean-contaminated head and neck procedures. Clindamycin is generally recommended as alternate therapy in combination with other anti-infectives for gastrointestinal, biliary tract, and urogynecology procedures as well as liver, pancreas, and pancreas-kidney transplantation.
-for surgical prophylaxis for cardiothoracic procedures*:
Intravenous dosage:
Infants, Children, and Adolescents: 10 mg/kg (Max: 900 mg/dose) IV as a single dose within 60 minutes prior to the surgical incision; consider intraoperative redosing 6 hours from the first preoperative dose. May continue 10 mg/kg (Max: 900 mg/dose) every 8 hours for no more than 24 hours post-operatively if necessary. A longer prophylaxis duration of 48 hours for certain cardiothoracic procedures is controversial. Guidelines recommend clindamycin as an alternative monotherapy in patients with beta-lactam allergy for multiple types of surgical procedures, including cardiothoracic and heart and/or lung transplantations.

For the treatment of anthrax*:
-for the treatment of cutaneous anthrax* without aerosol exposure or signs and symptoms of meningitis:
Oral dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met.
Neonates 37 weeks gestation and older: 9 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met.
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 600 mg/dose) PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met.
-for the treatment of cutaneous anthrax* with aerosol exposure and without signs and symptoms of meningitis:
Oral dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Neonates 37 weeks gestation: 9 mg/kg/dose PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 600 mg/dose) PO every 8 hours for 7 to 10 days or until clinical criteria for stability are met and then transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course.
-for the treatment of systemic anthrax* without aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy:
Intravenous or Intramuscular dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose IV or IM every 8 hours for at least 14 days; may consider step-down to oral therapy.
Neonates 37 weeks gestation and older: 9 mg/kg/dose IV or IM every 8 hours for at least 14 days; may consider step-down to oral therapy.
Infants, Children, and Adolescents: 13.3 mg/kg/dose (Max: 900 mg/dose) IV every 8 hours for at least 14 days; may consider step-down to oral therapy.
-for the treatment of systemic anthrax* with aerosol exposure, including those with signs and symptoms of meningitis, as part of combination therapy:
Intravenous or Intramuscular dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose IV or IM every 8 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Neonates 37 weeks gestation and older: 9 mg/kg/dose IV or IM every 8 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.
Infants, Children, and Adolescents: 13.3 mg/kg/dose (Max: 900 mg/dose) IV every 8 hours for at least 14 days; may consider step-down to oral therapy.
Immunocompromised Infants, Children, and Adolescents: 13.3 mg/kg/dose (Max: 900 mg/dose) IV every 8 hours for at least 14 days; may consider step-down to oral therapy. Transition to a postexposure prophylaxis regimen to complete a 60-day total treatment course from illness onset.

For postexposure anthrax prophylaxis*:
-for postexposure anthrax prophylaxis* after nonaerosol exposure (cutaneous or ingestion):
Oral dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose PO every 8 hours for 7 days after exposure.
Neonates 37 weeks gestation and older: 9 mg/kg/dose PO every 8 hours for 7 days after exposure.
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 600 mg/dose) PO every 8 hours for 7 days after exposure.
-for postexposure anthrax prophylaxis* after aerosol exposure:
Oral dosage:
Neonates 32 to 36 weeks gestation: 7 mg/kg/dose PO every 8 hours for 60 days after exposure.
Neonates 37 weeks gestation and older: 9 mg/kg/dose PO every 8 hours for 60 days after exposure.
Infants, Children, and Adolescents: 10 mg/kg/dose (Max: 600 mg/dose) PO every 8 hours for 60 days after exposure.

For the treatment of toxoplasmosis*, including toxoplasmic encephalitis*:
Intravenous dosage:
Infants and Children: 5 to 7.5 mg/kg/dose IV every 6 hours (Max: 600 mg/dose) in combination with pyrimethamine and leucovorin is recommended by the HIV guidelines as an alternative therapy in sulfonamide-intolerant patients. For acquired toxoplasmosis, treatment duration should be at least 6 weeks; however, a longer duration may be necessary if clinical or radiologic disease is extensive or if the response is incomplete at 6 weeks. For congenital toxoplasmosis, treatment duration is for 12 months. Adjunctive corticosteroids may be administered when clinically indicated for the treatment of mass effect attributed to focal lesions or associated edema; however, discontinue as soon as possible. Anticonvulsants may be administered to patients with a seizure history during the acute treatment phase; however, they should not be used prophylactically.
Adolescents: 600 mg IV every 6 hours plus pyrimethamine and leucovorin is recommended by the HIV guidelines as an alternative therapy in sulfonamide-intolerant patients. Treatment duration should be at least 6 weeks; however, a longer duration may be necessary if clinical or radiologic disease is extensive or if the response is incomplete at 6 weeks. Chronic maintenance therapy should start after acute treatment. Adjunctive corticosteroids may be administered when clinically indicated for the treatment of mass effect attributed to focal lesions or associated edema; however, discontinue as soon as possible. Anticonvulsants may be administered to patients with a seizure history during the acute treatment phase; however, they should not be used prophylactically.
Oral dosage:
Infants and Children: 5 to 7.5 mg/kg/dose PO every 6 hours (Max: 600 mg/dose) in combination with pyrimethamine and leucovorin is recommended by the HIV guidelines as an alternative therapy in sulfonamide-intolerant patients. For acquired toxoplasmosis, treatment duration should be at least 6 weeks; however, a longer duration may be necessary if clinical or radiologic disease is extensive or if the response is incomplete at 6 weeks. For congenital toxoplasmosis, treatment duration is for 12 months. Adjunctive corticosteroids may be administered when clinically indicated for the treatment of mass effect attributed to focal lesions or associated edema; however, discontinue as soon as possible. Anticonvulsants may be administered to patients with a seizure history during the acute treatment phase; however, they should not be used prophylactically.
Adolescents: 600 mg PO every 6 hours plus pyrimethamine and leucovorin is recommended by the HIV guidelines as an alternative therapy in sulfonamide-intolerant patients. Treatment duration should be at least 6 weeks; however, a longer duration may be necessary if clinical or radiologic disease is extensive or if the response is incomplete at 6 weeks. Chronic maintenance therapy should start after acute treatment. Adjunctive corticosteroids may be administered when clinically indicated for the treatment of mass effect attributed to focal lesions or associated edema; however, discontinue as soon as possible. Anticonvulsants may be administered to patients with a seizure history during the acute treatment phase; however, they should not be used prophylactically.

For secondary toxoplasmosis prophylaxis* in HIV-infected patients intolerant of sulfa drugs:
Oral dosage:
Infants and Children: 7 to 10 mg/kg/dose PO every 8 hours (Max: 600 mg/dose) in combination with pyrimethamine and leucovorin. Unlike the preferred regimen containing sulfadiazine and pyrimethamine, this regimen does not provide adequate prophylaxis against Pneumocystis pneumonia. Discontinuation of secondary prophylaxis may be considered for patients who have completed at least 6 months of stable antiretroviral therapy, remain asymptomatic, and have a CD4 percentage of at least 15% (children 1 to 5 years of age) or CD4 count more than 200 cells/mm3 (children 6 years and older) for more than 6 consecutive months. Prophylaxis should not be discontinued in children younger than 1 year of age. Secondary prophylaxis should be reintroduced if the CD4 percentage is less than 15% (children 1 to 5 years of age) or CD4 count decreases to less than 200 cells/mm3 (children 6 years and older).
Adolescents: 600 mg PO every 8 hours in combination with pyrimethamine plus leucovorin. Unlike the preferred regimen containing sulfadiazine and pyrimethamine, this regimen does not provide adequate prophylaxis against Pneumocystis pneumonia. Consideration may be given to discontinuing secondary prophylaxis in asymptomatic patients who have a sustained increase in their CD4 counts more than 200 cells/mm3 after receiving antiretroviral therapy for at least 6 months; however, a limited number of patients have been evaluated and recurrences have been observed. Secondary prophylaxis should be reintroduced if the CD4 count decreases to less than 200 cells/mm3.

For the treatment of Pneumocystis pneumonia (PCP)*:
-for the treatment of PCP in HIV-infected patients*:
Oral dosage:
Infants and Children: 10 mg/kg/dose (Max: 450 mg/dose) PO every 6 hours in combination with primaquine for 21 days as alternative therapy then chronic suppressive therapy.
Adolescents: 450 mg PO every 6 hours or 600 mg PO every 8 hours in combination with primaquine for 21 days as alternative therapy then chronic suppressive therapy.
Intravenous dosage:
Infants and Children: 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 hours in combination with primaquine for 21 days as alternative therapy for moderate to severe infection then chronic suppressive therapy.
Adolescents: 600 mg IV every 6 hours or 900 mg IV every 8 hours in combination with primaquine for 21 days as alternative therapy for moderate to severe infection then chronic suppressive therapy.
-for the treatment of PCP in patients with hematological malignancies, cancer, or autoimmune/inflammatory disease*:
Oral dosage:
Infants and Children: 10 mg/kg/dose (Max: 450 mg/dose) PO every 6 hours in combination with primaquine for 14 to 21 days as alternative therapy.
Adolescents: 300 mg PO every 6 hours or 450 mg PO every 8 hours in combination with primaquine for 14 to 21 days as alternative therapy.
Intravenous dosage:
Infants and Children: 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 hours in combination with primaquine for 14 to 21 days as alternative therapy.
Adolescents: 600 mg IV every 6 hours in combination with primaquine for 14 to 21 days as alternative therapy.

For the treatment of malaria*:
-for the treatment of uncomplicated malaria* due to P. falciparum, P. vivax, P. ovale, P. malariae, or P. knowlesi:
Oral dosage:
Infants, Children, and Adolescents: 20 mg/kg/day PO divided 3 times daily for 7 days plus quinine. For P. vivax or P. ovale infections, add primaquine phosphate. Guidelines recommend for chloroquine-resistant infections and for infections of unknown resistance in combination with quinine; may also use for chloroquine-sensitive infections if necessary.
-for the treatment of severe malaria* after IV artesunate therapy is completed:
Oral dosage:
Infants and Children 1 month to 7 years: 20 mg/kg/day PO divided 3 times daily for 7 days plus quinine.

For the treatment of babesiosis*:
-for the treatment of babesiosis* in immunocompetent ambulatory patients with mild to moderate disease in combination with quinine:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours for 7 to 10 days as an alternative. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for the treatment of babesiosis* in immunocompromised ambulatory patients with mild to moderate disease in combination with quinine:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours for at least 7 to 10 days as an alternative; duration may need to be extended in these patients. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for the initial treatment of babesiosis* in immunocompetent hospitalized patients with acute, severe disease in combination with quinine:
Intravenous dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 to 8 hours until symptoms abate, followed by oral stepdown therapy for a total treatment duration of 7 to 10 days as an alternative. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for the initial treatment of babesiosis* in immunocompromised hospitalized patients with acute, severe disease in combination with quinine:
Intravenous dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 to 8 hours until symptoms abate, followed by oral stepdown therapy for a total treatment duration of at least 7 to 10 days as an alternative; duration may need to be extended in these patients. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for oral stepdown treatment of babesiosis* in immunocompetent hospitalized patients in combination with quinine after initial IV therapy:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours for a total treatment duration of 7 to 10 days as an alternative. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for oral stepdown treatment of babesiosis* in immunocompromised hospitalized patients in combination with quinine after initial IV therapy:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours for a total treatment duration of at least 7 to 10 days as an alternative; duration may need to be extended in these patients. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for the initial treatment of babesiosis* in highly immunocompromised patients in combination with quinine:
Intravenous dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 to 8 hours until symptoms abate, followed by oral stepdown therapy for a total duration of at least 6 weeks, including 2 final weeks during which parasites are no longer detected on peripheral blood smear as an alternative. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for oral stepdown treatment of babesiosis* in highly immunocompromised patients in combination with quinine after initial IV therapy:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours for a total duration of at least 6 weeks, including 2 final weeks during which parasites are no longer detected on peripheral blood smear as an alternative. Clindamycin plus quinine is preferred when parasitemia and symptoms have failed to abate after the initiation of atovaquone plus azithromycin.
-for the initial treatment of refractory or relapsed babesiosis* as part of combination therapy:
Intravenous dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) IV every 6 to 8 hours until symptoms abate, followed by oral stepdown therapy as part of combination therapy which may include atovaquone, atovaquone plus azithromycin, or atovaquone plus azithromycin plus quinine.
-for oral stepdown treatment of refractory or relapsed babesiosis* after initial IV therapy:
Oral dosage:
Infants, Children, and Adolescents: 7 to 10 mg/kg/dose (Max: 600 mg/dose) PO every 6 to 8 hours as part of combination therapy which may include atovaquone, atovaquone plus azithromycin, or atovaquone plus azithromycin plus quinine.

For group A streptococci chronic pharyngeal carriage eradication*:
Oral dosage:
Infants, Children, and Adolescents: 20 to 30 mg/kg/day PO divided every 8 hours (Max: 300 mg/dose) for 10 days. Most chronic streptococcal carriers do not need antimicrobial therapy. Treatment may be considered during a community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis or invasive group A streptococcal (GAS) infection; during an outbreak of GAS pharyngitis in a closed or partially closed community; in the presence of a family or personal history of acute rheumatic fever; in a family with excessive anxiety about GAS infections; or when tonsillectomy is being considered only because of carriage.

For bacterial infection prophylaxis* after penetrating trauma:
-for bacterial infection prophylaxis after penetrating chest trauma without esophageal disruption*:
Oral dosage:
Infants, Children, and Adolescents: 10 to 25 mg/kg/day (Max: 1.35 g/day) PO divided every 8 hours for 1 day as an alternative.
Intravenous dosage:
Infants, Children, and Adolescents: 20 to 40 mg/kg/day (Max: 1.8 g/day) IV divided every 6 to 8 hours for 1 day as an alternative.
-for bacterial infection prophylaxis after penetrating extremity trauma (including skin, soft tissue, and bone with or without open fractures)*:
Oral dosage:
Infants, Children, and Adolescents: 10 to 25 mg/kg/day (Max: 1.35 g/day) PO divided every 8 hours for 1 to 3 days as an alternative.
Intravenous dosage:
Infants, Children, and Adolescents: 20 to 40 mg/kg/day (Max: 1.8 g/day) IV divided every 6 to 8 hours for 1 to 3 days as an alternative.

For the treatment of epiglottitis*:
Intravenous dosage:
Infants, Children, and Adolescents: 20 to 40 mg/kg/day (Max: 2,700 mg/day) IV divided every 6 to 8 hours for 5 to 10 days.

Maximum Dosage Limits:
-Neonates
20 mg/kg/day IV/IM and 25 mg/kg/day PO are the FDA-approved maximum dosages; however, the following doses have been recommended based on postmenstrual age (PMA):
-Neonates 32 weeks PMA and younger: 5 mg/kg/dose IV/IM/PO every 8 hours.
-Neonates 33 to 40 weeks PMA: 7 mg/kg/dose IV/IM/PO every 8 hours.
-Neonates older than 40 weeks PMA: 9 mg/kg/dose IV/IM/PO every 8 hours.
-Infants
40 mg/kg/day IV/IM; 25 mg/kg/day PO is FDA-approved maximum dosage; however, doses up to 40 mg/kg/day PO are used off-label.
-Children
1 to 11 years: 40 mg/kg/day IV/IM (Max: 2,700 mg/day IV; 2,400 mg/day IM); 25 mg/kg/day PO is FDA-approved maximum dosage; however, doses up to 40 mg/kg/day PO (Max: 1,800 mg/day) are used off-label.

12 years: 40 mg/kg/day IV/IM (Max: 2,700 mg/day IV; 2,400 mg/day IM); 25 mg/kg/day PO is FDA-approved maximum dosage; however, doses up to 40 mg/kg/day PO (Max: 1,800 mg/day) are used off-label. Topical formulations: 2 applications/day topically for gel, solution, lotion, or pledget; 1 application/day topically for foam.

-Adolescents
13 to 16 years: 40 mg/kg/day IV/IM (Max: 2,700 mg/day IV; 2,400 mg/day IM); 25 mg/kg/day PO is FDA-approved maximum dosage; however, doses up to 40 mg/kg/day PO (Max: 1,800 mg/day) are used off-label. Topical formulations: 2 applications/day topically for gel, solution, lotion, or pledget; 1 application/day topically for foam. Vaginal creams: 1 applicatorful (100 mg clindamycin/5 g cream)/day for most products; 1 applicatorful (100 mg clindamycin/5 g cream) once for Clindesse. Vaginal ovules/suppositories: 1 ovule (100 mg clindamycin)/day.

17 years: 2,700 mg/day IV; 2,400 mg/day IM; 25 mg/kg/day PO is FDA-approved maximum dosage; however, doses up to 40 mg/kg/day PO (Max: 1,800 mg/day) are used off-label. Topical formulations: 2 applications/day topically for gel, solution, lotion, or pledget; 1 application/day topically for foam. Vaginal creams: 1 applicatorful (100 mg clindamycin/5 g cream)/day for most products; 1 applicatorful (100 mg clindamycin/5 g cream) once for Clindesse. Vaginal ovules/suppositories: 1 ovule (100 mg clindamycin)/day.



Patients with Hepatic Impairment Dosing
No dosage adjustment is needed.

Patients with Renal Impairment Dosing
No dosage adjustment is needed.

Intermittent hemodialysis
Hemodialysis is not effective in removing clindamycin from the serum. A supplemental dosage is not recommended for hemodialysis.

Peritoneal dialysis
Peritoneal dialysis is not effective in removing clindamycin from the serum. A supplemental dosage is not recommended for peritoneal dialysis.

*non-FDA-approved indication

Monograph content under development

Mechanism of Action: Clindamycin binds to the 23S RNA of the 50S ribosomal subunit of the bacteria, which inhibits protein synthesis. As with lincomycin, antibacterial activity results from inhibition of protein synthesis. Clindamycin is bacteriostatic. The mechanism of action of clindamycin in treating acne vulgaris is unknown.

The susceptibility interpretive criteria for clindamycin are delineated by pathogen. The MICs are defined for beta-hemolytic streptococci, S. viridans group, S. pneumoniae, E. rhusiopathiae, Gemella sp., Abiotrophia sp., and Granulicatella sp. as susceptible at 0.25 mcg/mL or less, intermediate at 0.5 mcg/mL, and resistant at 1 mcg/mL or more. The MICs are defined for Lactobacillus sp. as susceptible at 0.5 mcg/mL or less, intermediate at 1 mcg/mL, and resistant at 2 mcg/mL or more. The MICs are defined for Staphylococcus sp., R. mucilaginosa, Lactococcus sp., Corynebacterium sp., Bacillus sp. (excluding B. anthracis), Micrococcus sp., and M. catarrhalis as susceptible at 0.5 mcg/mL or less, intermediate at 1 to 2 mcg/mL, and resistant at 4 mcg/mL or more. The MICs are defined for anaerobes as susceptible at 2 mcg/mL or less, intermediate at 4 mcg/mL, and resistant at 8 mcg/mL or more.

Resistance to clindamycin is most often caused by modification of specific bases of the 23S ribosomal RNA. Cross-resistance between clindamycin and lincomycin is complete. Due to overlapping binding sites, cross-resistance is sometimes observed among lincosamides, macrolides, and streptogramin B. Clindamycin inducible resistance has been identified in macrolide-resistant organisms; therefore, macrolide-resistant and clindamycin-susceptible strains should be screened for inducible clindamycin resistance using the D-zone test.

Clindamycin is a well-known cause of pseudomembranous colitis, possibly due to overgrowth of C. difficile, and 10% to 20% of strains of C. perfringens can be resistant to clindamycin. Increased resistance has also been seen in some strains of B. fragilis. One study reported marked antibiotic resistance after treatment of bacterial vaginosis with clindamycin; resistance persisted for up to 90 days after treatment.

Pharmacokinetics: Clindamycin is administered by the oral, parenteral, topical, and vaginal routes. Oral or parenteral doses are widely distributed into most body tissues, with high concentrations in bone, bile, and urine. Cerebrospinal fluid (CSF) concentrations are poor, and clindamycin is not indicated for the treatment of meningitis. It is, however, useful in treating toxoplasma encephalitis. It is highly protein bound (80% to 95%), primarily to alpha1-acid glycoprotein. Clindamycin is metabolized to 2 bioactive metabolites, clindamycin sulfoxide and N-desmethylclindamycin, and various inactive metabolites. After oral dosage, only about 10% is excreted in the urine as active drug and metabolites, and about 3.6% in the feces. The remainder is excreted as inactive metabolites. The plasma half-life in children with normal renal function is 2 to 3 hours.

Affected cytochrome P450 isoenzymes and drug transporters: CYP3A4, CYP3A5
Clindamycin is metabolized primarily by CYP3A4, and to a lesser extent by CYP3A5. Drugs that are inhibitors or inducers of these enzymes may interact with clindamycin. In vitro studies have shown that clindamycin does not inhibit CYP1A2, CYP2C9, CYP2C19, CYP2E1, or CYP2D6, and only moderately inhibits CYP3A4.


-Route-Specific Pharmacokinetics
Oral Route
About 90% of an oral dose of clindamycin is absorbed after oral administration. Absorption from the gut is rapid. The rate but not the extent of absorption can be delayed by food. Clindamycin palmitate and clindamycin phosphate require hydrolysis to form free clindamycin, which occurs readily in the bloodstream. Peak serum concentrations are achieved within 45 to 60 minutes after oral administration. Peak serum concentrations are similar after oral administration of either the hydrochloride or the palmitate salt.

Intravenous Route
By the end of a short-term infusion (10 to 30 minutes), peak serum concentrations are reached.

Intramuscular Route
Peak concentrations are reached within 1 hour after IM administration.

Topical Route
Some systemic absorption does occur after topical administration, depending on the surface area covered. Clindamycin phosphate appears to be less well absorbed through the skin than is the hydrochloride. Topical preparations are marketed as clindamycin phosphate.

Other Route(s)
Vaginal Route
Clinicians should note that up to 30% of a vaginally applied clindamycin dosage (ovules) is systemically absorbed; systemic absorption with clindamycin vaginal cream is approximately 5%.


-Special Populations
Pediatrics
Neonates and Infants
The clearance of clindamycin is significantly slower in neonates compared with older children and adults. In a pharmacokinetic study in neonates (n = 12; 26 to 39 weeks gestational age), mean clearance and volume of distribution after IV clindamycin were 61.6 mL/kg/hour and 567 mL/kg, respectively. Mean elimination half-life was 6.3 hours, which is approximately 2 to 3 times longer than that in older children and adults. Another study (n = 40; infants younger than 1 year of age) reported an elimination half-life of 8.7 hours in premature neonates younger than 4 weeks of age compared with 3.6 hours in full-term neonates younger than 4 weeks of age after administration of IV clindamycin. The elimination half-life in full-term neonates was similar to that of infants in the first year of life (3 hours). Body weight was a factor affecting both clearance and elimination half-life.

Children
Elimination half-life in children is approximately 2 to 3 hours.

Hepatic Impairment
Hepatic impairment significantly prolongs the elimination of clindamycin.

Renal Impairment
Renal impairment prolongs the elimination of clindamycin. Since clindamycin is minimally excreted by the kidneys, elimination half-life in adult patients with end-stage renal disease is only slightly prolonged to 3 to 5 hours. Clindamycin is not removed by hemodialysis or peritoneal dialysis.

Obesity
Based on a pharmacokinetic analysis in obese pediatric patients aged 2 to 17 years and obese adults aged 18 to 20 years, clindamycin clearance and volume of distribution, normalized by total body weight, are comparable regardless of obesity.