When is clindamycin used for suppression in patients with recurrent infections?

Clindamycin for Suppression of Recurrent Infections

Clindamycin is recommended for suppression therapy in patients with recurrent staphylococcal skin infections who have had 3-4 episodes per year despite attempts to treat or control predisposing factors, typically at a dose of 150 mg daily for 3 months. 1, 2

Indications for Clindamycin Suppression

Primary Indications:

• Recurrent staphylococcal skin infections (furuncles, abscesses)
• Recurrent Group A Streptococcal pharyngotonsillitis

Patient Selection Criteria:

1. Frequency threshold: 3-4 episodes per year 1
2. Failed standard measures: Persistence despite addressing predisposing factors 1
3. Documented pathogen: Confirmed S. aureus or Group A Streptococcus 2, 3

Dosing Regimens for Suppression

For Recurrent Staphylococcal Skin Infections:

• Adult dose: 150 mg oral clindamycin once daily for 3 months 1, 2
• Efficacy: Reduces subsequent infections by approximately 80% 1

For Recurrent Streptococcal Pharyngitis:

• Adult dose: 600 mg/day in 2-4 divided doses for 10 days 1
• Pediatric dose: 20-30 mg/kg/day in 3 divided doses for 10 days 1

Implementation Algorithm

1. First attempt non-antibiotic approaches:

   • Personal hygiene measures (regular bathing, hand washing) 1
   • Environmental cleaning (high-touch surfaces, towels, sheets) 1
   • Treatment of predisposing conditions (edema, obesity, eczema, tinea pedis) 1

2. If infections recur despite above measures, consider:

   • Decolonization with mupirocin nasal ointment and chlorhexidine baths 1

3. If still experiencing recurrences (3-4 episodes/year):

   • Initiate clindamycin suppression therapy 1

Evidence Quality and Efficacy

• A double-blind controlled trial showed 82% of patients treated with low-dose clindamycin (150 mg daily) remained infection-free during the 3-month treatment period compared to only 36% in the placebo group 2

• Clindamycin appears more effective than trimethoprim-sulfamethoxazole in eradicating S. aureus colonization (44% vs 57% remained colonized) and preventing recurrent SSTI (31% vs 47% experienced recurrence) 4

• For streptococcal pharyngitis, clindamycin showed superior clinical cure rates compared to amoxicillin/clavulanate at 12 days (92.6% vs 85.2%) 5

Monitoring and Duration

• Continue suppression therapy as long as predisposing factors persist 1
• Many patients experience durable response, with 67% of responders remaining infection-free for at least 9 months after discontinuing clindamycin 2

Potential Adverse Effects and Cautions

• Diarrhea is the most common side effect (8.6% of patients) 5
• Risk of C. difficile colitis (approximately 1 per 1000 in outpatients) 6
• Monitor for rash and gastrointestinal symptoms 6

Key Clinical Pearls

• Clindamycin's efficacy for suppression likely relates to its ability to eradicate colonization in multiple body sites, not just the nares 4
• For recurrent skin infections, always perform incision and drainage of abscesses before considering suppression therapy 1
• Clindamycin is particularly valuable when there is concern for inducible clindamycin resistance in MRSA 1
• Surveillance cultures following decolonization regimens are not routinely recommended in the absence of active infection 1

Remember that clindamycin suppression is not a first-line approach but should be reserved for patients with truly recurrent infections who have failed other interventions aimed at addressing predisposing factors.