From the Guidelines
Intravenous (IV) clindamycin carries a higher risk of causing Clostridioides difficile colitis compared to oral clindamycin, as supported by the most recent guidelines from the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) 1. The risk of developing C. difficile-associated diarrhea (CDAD) with IV clindamycin is approximately 20-30% higher than with oral administration, due to higher systemic concentrations and more extensive disruption of the normal gut microbiota. When clindamycin is given orally, some of it is metabolized during first-pass metabolism, resulting in lower systemic levels. Both routes can cause colitis, with symptoms typically appearing within 5-10 days of starting treatment, though they may occur up to several weeks after discontinuation. Risk factors that increase colitis risk with either formulation include:
- Longer duration of therapy
- Higher doses
- Advanced age
- Hospitalization
- Recent antibiotic exposure To minimize risk, clindamycin should be used only when clearly indicated, for the shortest effective duration, and with consideration of alternative antibiotics when appropriate, as suggested by the 2021 focused update guidelines on management of Clostridioides difficile infection in adults 1. If CDAD develops, clindamycin should be discontinued immediately and appropriate treatment with oral vancomycin or fidaxomicin initiated, according to the recommended treatment guidelines for Clostridioides difficile infection in adults 1. It is essential to note that the use of clindamycin, especially IV administration, should be carefully considered due to its high risk of causing CDI, as highlighted in the clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the IDSA and SHEA 2. Additionally, the 2020 proposal for a comprehensive approach to infections across the surgical pathway also emphasizes the importance of minimizing the risk of CDI by using antibiotics judiciously and considering alternative treatments when possible 3.
From the FDA Drug Label
WARNING Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin and may range in severity from mild diarrhea to fatal colitis. WARNING Clostridioides difficile-associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including clindamycin hydrochloride and may range in severity from mild diarrhea to fatal colitis.
The risk of colitis is associated with the use of clindamycin, regardless of the route of administration (IV or oral). The FDA drug labels for both Clindamycin (IV) 4 and Clindamycin (PO) 5 warn about the risk of CDAD, which can range from mild diarrhea to fatal colitis.
- The labels do not provide a direct comparison of the risk of colitis between IV and oral administration of clindamycin.
- Both labels state that clindamycin therapy has been associated with severe colitis, which may end fatally.
- The decision to use clindamycin should be based on the severity of the infection and the potential risks and benefits of treatment.
From the Research
Clindamycin Administration and Colitis Risk
- Clindamycin is known to have a risk of causing pseudomembranous colitis, particularly when administered intravenously 6.
- The risk of colitis is associated with the disruption of the intestinal microbiota, which can be caused by clindamycin treatment 7.
- A single dose of clindamycin can markedly reduce the diversity of the intestinal microbiota, making the host susceptible to Clostridium difficile-induced colitis 7.
Comparison of IV and Oral Clindamycin
- There is no direct comparison between IV and oral clindamycin in terms of colitis risk in the provided studies.
- However, it is known that clindamycin, regardless of the route of administration, can cause pseudomembranous colitis 6, 8.
Risk Factors for Colitis
- Recent exposure to healthcare facilities or antibiotics, especially clindamycin, is a risk factor for Clostridioides difficile infection 9.
- Other risk factors include old age, hospital or nursing home stay, and antibiotic therapy 10.
- The clinical picture of C. difficile infection can range from asymptomatic carrier status to severe colitis, and diagnosis is based on direct detection of C. difficile toxins in feces 10.
Treatment and Prevention
- Treatment of C. difficile infection depends on the severity of the infection and may include oral vancomycin, fidaxomicin, or metronidazole 9.
- Fecal microbiota transplantation is a promising therapy for patients with multiple recurrent episodes of C. difficile infection 10, 9.
- Good antibiotic stewardship and proper hand hygiene are key strategies to decrease rates of C. difficile infection 9.