Is clindamycin (antibiotic) suitable for surgical prophylaxis in patients with a penicillin (antibiotic) allergy?

From the Guidelines

Clindamycin is a suitable antibiotic prophylaxis option for surgical procedures in patients with penicillin allergies, with a recommended dosage of 600-900 mg IV administered within 60 minutes before surgical incision, as supported by recent guidelines 1. When considering antibiotic prophylaxis for surgical procedures, it is essential to weigh the benefits and risks of each option. Clindamycin provides good coverage against gram-positive organisms, including Staphylococcus aureus and streptococci, which are common surgical wound pathogens. It also has activity against anaerobes, making it suitable for procedures involving the gastrointestinal tract. However, clindamycin lacks coverage against gram-negative organisms, so for procedures with high risk of gram-negative infection, consider adding gentamicin (1.5 mg/kg IV) or aztreonam (2g IV) 1.

Some key points to consider when using clindamycin for antibiotic prophylaxis include:

• Clindamycin works by binding to the 50S ribosomal subunit, inhibiting bacterial protein synthesis.
• It achieves good tissue penetration, including bone, which makes it particularly useful for orthopedic procedures.
• Be aware that clindamycin can cause Clostridioides difficile-associated diarrhea, so patients should be monitored for this potential complication post-surgery.
• Recent studies have highlighted the importance of delabeling penicillin allergy whenever possible, as it can lead to improved antibiotic selection and decreased use of broad-spectrum antibiotics 1.

In terms of specific procedures, clindamycin may be used as an alternative to other antibiotics in patients with penicillin allergies. For example, in vascular surgery, clindamycin + gentamicin may be used as an alternative to cefazolin in patients with penicillin allergies 1. Similarly, in obstetrical procedures, clindamycin may be used as an alternative to other antibiotics in patients with penicillin allergies 1.

Overall, clindamycin is a viable option for antibiotic prophylaxis in surgical procedures for patients with penicillin allergies, but it is essential to consider the specific procedure, potential risks, and benefits, as well as alternative options, to ensure the best possible outcome for the patient.

From the FDA Drug Label

Clindamycin Injection, USP is also indicated in the treatment of serious infections due to susceptible strains of streptococci, pneumococci, and staphylococci Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. Indicated surgical procedures should be performed in conjunction with antibiotic therapy

Clindamycin antibiotic prophylaxis can be used for surgery in penicillin-allergic patients. The decision to use clindamycin should be based on the judgment of the physician, considering the nature of the infection and the suitability of less toxic alternatives.

• Key points to consider:
  • Penicillin allergy: Clindamycin can be used as an alternative in penicillin-allergic patients.
  • Surgical procedures: Clindamycin can be used in conjunction with surgical procedures to prevent infections.
  • Physician judgment: The decision to use clindamycin should be based on the physician's judgment, considering the individual patient's needs and the potential risks and benefits of treatment 2.

From the Research

Clindamycin Antibiotic Prophylaxis for Surgery in Penicillin Allergy

• Clindamycin is often used as an alternative antibiotic prophylaxis in patients with penicillin or cephalosporin allergy labels 3.
• However, studies have shown that the use of clindamycin is associated with higher incidences of surgical site infections (SSIs) compared to the use of cephalosporins 4, 5.
• A study found that clindamycin was largely administered in patients with non-severe hypersensitivity reactions, low-risk history, or unknown reactions to penicillin or cephalosporin, whom cefazolin could have been administered safely 3.
• The use of clindamycin as a substitute for cephalosporins in penicillin-allergic patients has been shown to result in a higher adverse event rate, with a reported adverse reaction rate of 1.5% 4.

Penicillin Allergy and Cross-Reactivity

• Penicillin allergies are reported by 8% to 15% of the US population, but up to 95% of these allergies do not correspond to a true allergy when tested 5.
• Cross-reactivity between penicillin and cephalosporin drugs occurs in about 2% of cases, less than the 8% reported previously 6.
• A study found that having a penicillin allergy label results in a 50% increased odds of surgical site infection among patients reporting a penicillin allergy, entirely attributable to the use of a beta-lactam alternative antibiotic (primarily clindamycin or vancomycin) 5.

Management of Penicillin Allergy

• Preoperative penicillin allergy testing has been demonstrated to be a cost-effective measure in the prevention of prosthetic joint infection and is suggested for all penicillin-allergic patients in the peri-operative setting 7.
• Evaluation of penicillin allergy before deciding not to use penicillin or other β-lactam antibiotics is an important tool for antimicrobial stewardship 6.
• Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories, while moderate-risk patients can be evaluated with penicillin skin testing 6.