Use of Clindamycin in Pediatric Infections

Marcia L. Buck, Pharm.D., FCCP

Disclosures

Pediatr Pharm. 2008;14(2) 

In This Article

Clinical Studies in Children

Clindamycin has been used for many years in the treatment of infections in children. It has traditionally been a component of empiric antibiotic regimens for dental, bone and joint infections where anaerobes were likely causes, as well as in the treatment of serious skin and soft tissue infections.[1,2,3] Clindamycin has a particular niche in the treatment of beta-lactam resistant infections. In 1952, Eagle first demonstrated the failure of penicillin to eradicate Streptococcus pyogenes myositis in a murine model when the antibiotic was given late in the course or in the presence of a high bacterial load.[7] This did not appear to be related to bacterial resistance, but was associated with a decreased concentration of penicillin-binding proteins in the stationary phase of growth. Subsequent research of the “Eagle effect” by Stevens and colleagues in 1988 and Zimbelman, Palmer, and Todd in 1999 showed that clindamycin was more efficacious in this setting, likely as a result of its ability to inhibit bacterial protein synthesis independent of bacterial load or the stage of bacterial growth.[8,9]

In recent years, clindamycin has emerged as a primary therapy in the management of children with CA-MRSA infections. The incidence of CA-MRSA has increased dramatically over the past decade. In a study from 1998, Herold and colleagues reported a 25-fold increase in hospitalizations for MRSA infections in previously healthy children without known risk factors.[10] Several reports have demonstrated the efficacy of clindamycin as part of combination treatment regimens in a variety of pediatric CAMRSA infections, including cellulitis and abscesses, pneumonia, and osteomyelitis.[11,12,13,14,15]

In 2002, Martinez-Aguilar and colleagues at Texas Children’s Hospital evaluated the records of 99 children with community-acquired invasive Staph aureus infections.[11] They identified CAMRSA in 46 children and community-acquired methicillin-sensitive Staph aureus (CA-MSSA) in another 53. In the MRSA group, 39 received clindamycin as primary therapy, including 20 patients who received it as the sole initial drug. The other drugs used included vancomycin or a beta-lactam antibiotic. Clindamycin was used as initial therapy in 24 of the MSSA patients. The remaining patients received beta-lactam antibiotics. The median number of febrile days was 3 for the MRSA patients and 2 for the MSSA patients (p=0.07) and the median number of days with a positive blood culture was 2 for the MRSA group and 1 for the MSSA group (p=0.04). The authors concluded that clindamycin was an effective therapy for community-acquired Staph aureus infections in children.

Arnold and colleagues conducted a retrospective study in 2006 of 158 pediatric osteomyelitis infections between 2000 and 2004 at LeBonheur Children’s Medical Center.[13] The proportion of infections caused by MSSA strains remained constant over the evaluation period (10-13%), but the incidence of MRSA rose from 4% to 40%. There were more subperiosteal abscesses in the MRSA patients than in the MSSA group (71% versus 38%, p=0.02). Ninety-one percent of the MRSA patients required surgical procedures, compared to 62% of the MSSA patients (p<0.001). Length of stay was also significantly longer in the MRSA group (10 days versus 7 days in the MSSA group, p=0.0001). Clindamycin was not routinely used in treating osteomyelitis prior to the increase in MRSA infections, but was rapidly incorporated into the institution’s empiric regimen. Of the 47 MRSA isolates, 46 were susceptible to clindamycin.

Guss and Kazahaya reported a similar increase in the number of cases of MRSA lymphadenitis.[14] They conducted a retrospective study of children who underwent trans-cervical surgical drainage of lymph node abscesses between 2000 and 2006. Of the 62 children identified, 49 had positive bacterial cultures. Of the Staph aureus cultures, 27% were MRSA. All of the MRSA isolates were susceptible to clindamycin. The MRSA isolates all came from the second half of the study; the authors found no cases of CAMRSA in their patient sample prior to 2003.

Clindamycin has also been found to be an effective treatment for neonates with CA-MRSA infections. In November 2007, Fortunov and colleagues published a retrospective review of community-acquired Staph aureus infections in previously healthy term and late-preterm neonates at Texas Children’s Hospital.[15]The patients were admitted over a 5-year period between August 2001 and July 2006. Of the 126 infections, 84 were methicillin-resistant. A total of 68 patients presented with cellulitis or an abscess, 43 had pustules, and 15 had invasive disease. Empiric treatment with clindamycin was prescribed in 75% of the patients with pustules, 58% of the patients with cellulitis or abscess, and 15% of the patients with invasive infections. In the patients with proven CA-MRSA, clindamycin was used as a definitive treatment in 51%. Forty-nine neonates received oral therapy after initial intravenous (IV) treatment. Clindamycin was the most commonly used oral antibiotic in both the methicillin-resistant and methicillin-sensitive groups. There was only one treatment failure.

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