What is the appropriate dosing of clindamycin (intravenous (IV) and oral (PO)) for a 42-year-old adult female with bilateral purulent otitis media, history (Hx) of multiple myeloma, and previous treatment-resistant ear infections?

From the Guidelines

For a 42-year-old female with bilateral purulent otitis media and history of multiple myeloma, I recommend starting with clindamycin 600 mg IV, followed by oral clindamycin 300 mg three times daily for 7-10 days. The patient's history of multiple myeloma and previous treatment-resistant ear infections suggests a need for broad-spectrum antibiotic coverage, and clindamycin is effective against a range of organisms, including anaerobes and resistant gram-positive bacteria, as noted in the guidelines by the Infectious Diseases Society of America 1.

Key Considerations

• The patient's immunocompromised state due to multiple myeloma increases the risk of severe infections, making it crucial to choose an antibiotic with a broad spectrum of activity.
• Clindamycin's good penetration into middle ear fluid, as well as its effectiveness against common pathogens in otitis media, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, makes it an appropriate choice for this patient.
• The recommended dosing of clindamycin 600 mg IV, followed by oral clindamycin 300 mg three times daily, is consistent with guidelines for the treatment of complicated skin and soft tissue infections, including those caused by MRSA 1.

Monitoring and Follow-Up

• Close follow-up within 48-72 hours is essential to ensure clinical improvement and to assess the need for continued or modified antibiotic therapy.
• If symptoms persist or worsen on oral therapy, the patient may need to return for reassessment and possibly IV therapy, as indicated in the guidelines for the management of skin and soft tissue infections 1.

Evidence Summary

The guidelines from the Infectious Diseases Society of America provide evidence-based recommendations for the treatment of skin and soft tissue infections, including those caused by MRSA 1. Clindamycin is listed as an option for empirical therapy for CA-MRSA, with a recommended dose of 600 mg IV or PO every 8 hours for adults, and 10-13 mg/kg/dose PO every 6-8 hours for children, as noted in the guidelines 1. The most recent guidelines from 2014 also support the use of clindamycin for the treatment of MRSA SSTI, with a recommended dose of 600 mg every 8 hours IV or 300-450 mg every 6 hours PO for adults, and 25-40 mg/kg/d in 3 divided doses IV or PO for children 1.

From the FDA Drug Label

Adults: Parenteral (IM or IV Administration): Serious infections due to aerobic gram-positive cocci and the more susceptible anaerobes (NOT generally including Bacteroides fragilis, Peptococcus species and Clostridium species other than Clostridium perfringens): 600 mg to 1,200 mg per day in 2,3 or 4 equal doses More severe infections, particularly those due to proven or suspected Bacteroides fragilis, Peptococcus species, or Clostridium species other than Clostridium perfringens: 1,200 mg to 2,700 mg per day in 2,3 or 4 equal doses.

The appropriate dosing of clindamycin for a 42-year-old adult female with bilateral purulent otitis media is 600 mg to 1,200 mg per day in 2,3, or 4 equal doses for serious infections due to aerobic gram-positive cocci and the more susceptible anaerobes. However, since the patient has a history of multiple myeloma and previous treatment-resistant ear infections, the dose may need to be increased to 1,200 mg to 2,700 mg per day in 2,3, or 4 equal doses for more severe infections. For oral administration, the dose is not explicitly stated in the provided label for adults, but it can be changed to oral clindamycin flavored granules (clindamycin palmitate hydrochloride) or clindamycin capsules (clindamycin hydrochloride) when the condition warrants and at the discretion of the physician 2.

From the Research

Appropriate Dosing of Clindamycin

The provided studies do not directly address the appropriate dosing of clindamycin for a 42-year-old adult female with bilateral purulent otitis media, history of multiple myeloma, and previous treatment-resistant ear infections. However, some information can be gathered from the available evidence:

• The study 3 mentions the use of clindamycin in combination with gentamicin for the treatment of chronic suppurative otitis media, but it does not provide specific dosing information.
• The other studies 4, 5, 6, 7 discuss the treatment of otitis media, but they do not mention clindamycin dosing.

Treatment of Otitis Media

Some general information about the treatment of otitis media can be found in the studies:

• The study 4 discusses the microbiology of otitis media and the importance of selecting the most appropriate treatment regimen.
• The study 5 proposes the use of combination therapy with antibacterial and antifungal drugs for the treatment of otitis media purulenta chronica.
• The study 6 recommends high-dose amoxicillin as first-line therapy for acute otitis media in children.
• The study 7 discusses the diagnosis and treatment of acute otitis media, including pain management and antibiotic therapy.

Clindamycin Use

Although the studies do not provide specific dosing information for clindamycin, they do mention its use in certain contexts:

• The study 3 compares the efficacy of clindamycin, metronidazole, and lincomycin, each in combination with gentamicin, for the treatment of chronic suppurative otitis media.
• The other studies do not mention clindamycin use specifically for otitis media treatment.

Key points to consider:

• The lack of direct evidence on clindamycin dosing for the specified condition.
• The importance of considering the patient's medical history, including multiple myeloma and previous treatment-resistant ear infections, when selecting a treatment regimen.
• The need for further research or consultation with a medical professional to determine the most appropriate treatment approach.