Clindamycin and C. difficile Infection Risk
Clindamycin is associated with a 59% rate of C. difficile resistance and is one of the highest-risk antibiotics for developing C. difficile infection (CDI). 1
Epidemiology of Clindamycin-Associated CDI
Clindamycin has been consistently identified as one of the antibiotics most strongly associated with C. difficile infection development:
- Clindamycin has one of the highest odds ratios for causing CDI, with studies showing odds ratios ranging from 2.86 to 42 2
- C. difficile strains show a 59% weighted pooled resistance rate to clindamycin 1
- Clindamycin-resistant strains of C. difficile have been responsible for major hospital outbreaks 3
Mechanism of Risk
The high risk of CDI with clindamycin use is due to several factors:
- Profound alteration of intestinal microbiota following even a single dose of clindamycin 4
- Studies show clindamycin reduces gut microbial diversity by approximately 90% for at least 28 days 4
- This disruption creates an environment where C. difficile can flourish due to lack of competing normal flora
- Clindamycin resistance in C. difficile strains further increases the risk, as these strains can proliferate while other bacteria are suppressed 3
Clinical Impact of Clindamycin-Associated CDI
The consequences of clindamycin-associated CDI are significant:
- Patients who develop CDI have increased hospital length-of-stay, higher medical costs, more hospital readmissions, and higher mortality 2
- CDI can range from mild diarrhea to life-threatening fulminant colitis 2
- Symptomatic recurrent C. difficile infection occurs in approximately 20% of patients 2
- Mortality in fulminant C. difficile colitis remains high due to toxic megacolon, colonic perforation, peritonitis, and septic shock 2
Preventive Strategies
Hospital-based interventions to reduce clindamycin-associated CDI have proven effective:
- Hospital-wide restriction of clindamycin use has been shown to decrease CDI incidence significantly 5, 6
- In one study, restricting clindamycin reduced CDI cases from 11.5 cases/month to 3.33 cases/month (P < 0.001) 6
- Such restrictions have also led to increased clindamycin susceptibility among C. difficile isolates (from 9% to 61%) 6
Important Clinical Considerations
When prescribing clindamycin, clinicians should:
- Consider alternative antibiotics when possible, especially in high-risk patients
- Use the shortest effective duration of therapy
- Monitor patients for diarrhea during and after clindamycin therapy
- Promptly test for C. difficile in patients who develop diarrhea during or after clindamycin treatment
- Be aware that patients remain susceptible to CDI for weeks after clindamycin exposure 4
In summary, clindamycin is associated with a 59% C. difficile resistance rate and is one of the highest-risk antibiotics for CDI development. Hospital antimicrobial stewardship programs that restrict clindamycin use have demonstrated significant reductions in CDI rates.