What is the recommended dose of clindamycin (antibiotic) for a pediatric patient with a positive oral throat swab for Methicillin-resistant Staphylococcus aureus (MRSA)?

Clindamycin Dosing for Pediatric MRSA Throat Colonization

For a pediatric patient with MRSA isolated from an oral throat swab, treatment is generally NOT indicated unless there is active infection (pharyngitis, abscess, or systemic symptoms), as throat colonization alone does not require antibiotic therapy. 1

When Treatment IS Indicated (Active Infection Present)

If the child has clinical evidence of active MRSA infection (not just colonization), the recommended clindamycin dosing is:

Oral Dosing

• 30-40 mg/kg/day divided into 3-4 doses (maximum 1800 mg/day total) 1, 2
• More specifically: 8-20 mg/kg/day divided into 3-4 equal doses for serious infections 2
• For severe infections: 16-20 mg/kg/day (8-10 mg/lb/day) divided into 3-4 equal doses 2

Intravenous Dosing (if severe infection)

• 40 mg/kg/day divided every 6-8 hours (or 10-13 mg/kg/dose every 6-8 hours, not exceeding 40 mg/kg/day total) 1

Critical Decision Points

Distinguish Colonization from Infection

• Throat colonization alone (positive swab without symptoms) does NOT require treatment 1
• Treatment is only indicated if there is:
  • Active pharyngitis with systemic symptoms 1
  • Peritonsillar or retropharyngeal abscess 1
  • Cervical lymphadenitis requiring drainage 1
  • Pneumonia or invasive disease 3, 4

Verify Clindamycin Susceptibility

• Only use clindamycin if local MRSA clindamycin resistance rates are <10% 5
• Check for inducible clindamycin resistance (D-test) if the isolate is erythromycin-resistant, as 38% of clindamycin-susceptible MRSA in children carry this mechanism 6
• If D-test positive, there is risk of developing clindamycin resistance during therapy 6, 7

Treatment Duration

• 7-10 days for most infections 1, 5
• At least 10 days for Group A Streptococcus co-infection 2
• Longer duration (7-21 days) for pneumonia or complicated infections 1

Important Caveats

Common Pitfalls to Avoid

• Do not treat asymptomatic colonization - this promotes resistance without clinical benefit 1
• Ensure adequate dosing - underdosing at <30 mg/kg/day risks treatment failure for serious infections 1
• Monitor for treatment failure - if erythromycin-resistant and D-test positive, clindamycin resistance can emerge during therapy 6
• Capsules must be swallowed whole with full glass of water to avoid esophageal irritation; use oral solution if child cannot swallow capsules 2

Alternative Agents if Clindamycin Inappropriate

• Trimethoprim-sulfamethoxazole if clindamycin resistance >10% or D-test positive 5
• Vancomycin IV for severe infections or clindamycin-resistant isolates 4

Clinical Outcomes Data

Clindamycin has demonstrated effectiveness for invasive MRSA infections in children, with median fever resolution of 3 days and successful outcomes in pneumonia, osteomyelitis, and bacteremia when the organism is susceptible 4. However, one case report documented emergence of clindamycin resistance during treatment of a D-test positive isolate causing pneumonia/empyema 6.