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August 2008
Vol. 18 No. 8
EIN: Alternative Dosages for Clinamycin


The Emerging Infections Network (EIN) is a forum for infectious diseases consultants and public health officials to report information on clinical phenomena and epidemiological issues with public health significance. Any diagnostic or therapeutic recommendations and all opinions presented are those of the individual contributor. They do not necessarily represent the views of EIN, IDSA (EIN's sponsor), or the Centers for Disease Control and Prevention, which funds the EIN. The reader assumes all risks in using this information.

 

Is IV clindamycin effective at dosages lower than the recommended 900 mg every 8 hours? An EIN member in California suggested to the Network that this dosage “has crept into common usage, with little or no data” to support it.

Several members responded that they routinely used other dosages. “For many years we have been using clindamycin 900 mg IV q 12 hours on a routine basis,” said a member in Montana. “Where we go to 900 mg q 8 hours is in a situation like necrotizing fasciitis or a synergistic gangrene, for the anti-protein effect, along with another antibiotic like penicillin. I have felt the half life and effect of clindamycin would allow the longer interval. No increase in toxicity, no increase in Clostridium difficile, and no increase in clinical failures were seen when we made this switch in about 1993.”

A member from Texas said, “I remember that we used to give 600 mg every 6 to 8 hours until Upjohn started promoting the 900 mg q 8 hours as saving pharmacy costs compared to the q 6 hour regimen. That was back in the days when we were doing aminoglycosides q 8 hours as well, and mixing the clindamycin plus gentamicin/ tobramycin in the same bag was also supposed to cut down on administration costs. We certainly use lower doses orally with good success.”

A member involved in early studies of clindamycin for treatment of Pneumocystis carinii pneumonia in the early 1990s said the dosages were empirically derived. “An oral dose of 450 to 600 mg every 6 to 8 hours was chosen for mild to moderate infections because we thought it would be the maximum dose tolerated in HIV/AIDS patients. We chose 600 mg q 6 hours and 900 mg q 8 hours for smaller studies of severe disease based upon tolerance studies for other infections. As I recall, as much as 1200 mg q 8 hours was used in cerebral toxoplasmosis studies; again, an empiric choice based upon less-than-full CNS penetration.”

This discussion raises a larger question “about how decisions are made regarding the proper use of antibiotics,” said a member in Massachusetts. The member noted that recommended dosages are set by drug company-sponsored clinical trials, which examine drug usage under ideal circumstances. “There is a need for the continued review of the use of antibiotics in new settings, against changing pathogens,” the member said, but there is no financial incentive for drug manufacturers to do such studies. “Good studies are hard and expensive. The reality is that the lack of good studies is harder and more expensive. But who will fund the studies, and can they be done free of commercial bias?”

[Note: IDSA has been recommending the National Institute of Allergy and Infectious Diseases (NIAID) conduct these studies, and NIAID has begun funding some of them. See the June IDSA News for more information.]

Quinine Recommended for Malaria, but Hard to Find

The Centers for Disease Control and Prevention (CDC) has received several reports of patients with malaria who appear to have been treated only with doxycycline. CDC is cautioning physicians that doxycycline, tetracycline, or clindamycin should not be prescribed alone to treat malaria, but should be combined with quinine.

However, several EIN members reported difficulty obtaining quinine. The only quinine drug available in the United States is Qualaquin (quinine sulfate), manufactured by AR Scientific.

Cost can be an issue—one member reported that the prescription would cost about $200, which was more than the patient could afford. Two members reported obtaining it from Canada, where it is much cheaper.


The Emerging Infections Network (EIN) is a provider-based sentinel network designed to help the public-health community detect trends in emerging infectious diseases.

A joint project of IDSA and the Pediatric Infectious Diseases Society (PIDS) and supported by funding from the Centers for Disease Control and Prevention.

EIN tracks emerging infectious diseases and keeps the public-health community up to date with issues that are currently affecting or may soon affect members’ clinical practices.The Network provides a great opportunity for members to share knowledge quickly across large geographical distances. Both IDSA and PIDS members are eligible to join. The EIN listserve allows members to discuss new disease trends and difficult cases. Click here for more information or to join EIN.
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