Is clindamycin safe in patients with a history of allergy to penicillin and Clarithromycin (clarithromycin)?

From the Guidelines

Clindamycin is generally considered safe for patients with penicillin and clarithromycin allergies. Since clindamycin belongs to the lincosamide class of antibiotics, it has a different chemical structure than both penicillins (beta-lactams) and macrolides (like clarithromycin), making cross-reactivity unlikely 1.

Key Considerations

• The Dutch Working Party on Antibiotic Policy (SWAB) guideline for the approach to suspected antibiotic allergy does not specifically address the use of clindamycin in patients with penicillin and clarithromycin allergies, but it does provide guidance on the approach to none β-lactam antibiotic (NBLA) allergy, which includes lincosamides like clindamycin 1.
• According to the guideline, patients with a suspected non-severe, delayed-type allergy to a macrolide (like clarithromycin) can receive other NBLAs, including lincosamides, in a controlled setting 1.
• The guideline also suggests that any carbapenem can be used in patients with suspected a non-severe, delayed-type allergy to cephalosporins, irrespective of time since the index reaction, but this does not directly apply to the use of clindamycin in patients with penicillin and clarithromycin allergies 1.

Dosage and Administration

• For adults, typical dosing of clindamycin is 300-450 mg orally every 6-8 hours or 600-900 mg IV every 8 hours, depending on infection severity.
• For children, the usual dose is 8-25 mg/kg/day divided into 3-4 doses.
• Treatment duration typically ranges from 7-14 days based on the infection being treated.

Important Considerations

• Before starting clindamycin, inform your healthcare provider about all allergies and medications you're taking.
• Common side effects include diarrhea, nausea, and abdominal pain.
• It's essential to complete the full course as prescribed, even if symptoms improve.
• If severe diarrhea occurs during or after treatment, contact your healthcare provider immediately as this could indicate Clostridioides difficile infection, a serious potential complication of clindamycin therapy.

From the FDA Drug Label

CONTRAINDICATIONS Clindamycin hydrochloride capsules are contraindicated in individuals with a history of hypersensitivity to preparations containing clindamycin or lincomycin. Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate.

The safety of clindamycin in patients with a penicillin allergy is addressed in the label, suggesting it can be used in penicillin-allergic patients. However, there is no direct information regarding Clarithromycin allergy.

• Penicillin allergy: Clindamycin can be considered.
• Clarithromycin allergy: The FDA drug label does not provide direct information to answer this question. Given the lack of direct information about Clarithromycin allergy, a conservative clinical decision would be to exercise caution when prescribing clindamycin to patients with a Clarithromycin allergy, and consider alternative treatments or further evaluation 2, 2, 2.

From the Research

Clindamycin Safety in Penicillin and Clarithromycin Allergy

• Clindamycin is a bactericidal antibiotic that is effective against most nonenterococcal gram-positive aerobic bacteria and many anaerobic microorganisms 3.
• It is considered an excellent alternative to beta-lactam antibiotics for treatment of many staphylococcal infections, and it has therapeutic utility in anaerobic infections and in several protozoan infections in immunosuppressed patients 3.
• The use of clindamycin is associated with a risk of pseudomembranous colitis, which is a significant toxic effect 4, 3.

Penicillin Allergy and Cross-Reactivity

• Approximately 10% of the US population reports an allergy to penicillin, but clinically significant IgE-mediated or T lymphocyte-mediated penicillin hypersensitivity is uncommon (<5%) 5.
• Cross-reactivity between penicillin and other beta-lactams, such as cephalosporins, occurs in about 2% of cases, which is less than previously thought 5, 6.
• Patients with a history of penicillin allergy can be evaluated using penicillin skin testing, which carries a negative predictive value that exceeds 95% and approaches 100% when combined with amoxicillin challenge 5.

Antibiotic Selection in Penicillin-Allergic Patients

• Clinicians should be familiar with which antibiotics are safe to use for different types of penicillin-allergic reactions 7.
• For patients with unknown or possible penicillin allergy, beta-lactam antibiotics may be used safely, while penicillins or beta-lactams should not be used for patients with hives or anaphylactic reactions 7.
• Clindamycin can be considered as an alternative antibiotic for patients with penicillin allergy, especially for the treatment of anaerobic infections or staphylococcal infections 4, 3.

Clarithromycin Allergy

• There is no direct information available in the provided studies regarding the safety of clindamycin in patients with Clarithromycin allergy.
• However, clindamycin and clarithromycin are both used to treat various bacterial infections, and the decision to use clindamycin in a patient with a reported allergy to clarithromycin should be made on a case-by-case basis, considering the patient's medical history and the severity of the reported allergy.