Pseudomembraneous colitis clindamycin

Nausea vomiting diarrhea (clindamycin 3.4% to 30%) pseudomembranous colitis (clindamycin 0.01% to 10% 3 to 4 times more frequent with oral administration) neutropenia (sometimes transient) leukopenia agranulocytosis thrombocytopenic purpura skin rashes, urticaria, erythema multiforme anaphylaxis jaundice liver function test abnormalities (serum transaminase elevations). 

The use of lincomycin is avoided because there is a significant occurrence of pseudomembranous colitis. Clindamycin is the dmg of choice because it is safer and more effective than lincomycin. 

Besides being associated with pseudomembranous colitis, clindamycin can also cause an adverse interaction with antidiarrheals, chloramphenicol (Chloromycetin), and erythromycin. 

Clostridium dijficile, described in older texts as of little significance as a pathogen if present in the gut, may, after therapy with antibiotics such as clindamycin or ampicillin, remain uninhibited, grow and produce toxins which give rise to a serious condition known as pseudomembranous colitis. The organism will usually succumb to vancomycin. 

Employed as the hydrochloride and administered by dilute intravenous injection, vancomycin is indicated in potentially life-threatening infections that cannot be treated with other effective, less toxic, antibiotics. Oral vancomycin is the drug of choice in the treatment of antibiotic-induced pseudomembranous colitis associated with the administration of antibiotics such as clindamycin and lincomycin (section 9.3). 

Adverse effects are generally mild and include dryness, erythema, and itching.18 Although rare and seen most often with oral therapy, pseudomembranous colitis can occur with the use of topical clindamycin.19 As with any antibacterial agent, the possibility of resistance exists with the use of topical erythromycin. However, co-administration of erythromycin and benzoyl peroxide has been shown to decrease the incidence of resistance, as well as to improve symptoms of mild to moderate inflammatory acne.20... 

Although their effectiveness is similar to the tetracyclines, the use of erythromycin and clindamycin is often limited due to their potential adverse outcomes. Erythromycin has treatment failure due to resistance and a high incidence of gastrointestinal intolerance, while clindamycin causes diarrhea and carries a risk of developing pseudomembranous colitis with long-term use.3,8... 

Clindamycin Capsules 75, 1 50, 300 mg 1 50-300 mg daily Maintenance dose 1 50 mg daily Diarrhea, pseudomembranous colitis... 

Clindamycin use is limited by diarrhea and the risk of pseudomembranous colitis. 

Clindamycin can be administered orally with a high bioavailability. Also formulations for intravenous administration exist. Protein binding is about 90%. It is distributed throughout the body except the CNS. It shows excellent penetration in bone and in empyema and abscesses. It is metabolized in the liver and excreted in the bile. The elimination half-life is about 3 h. Adverse effects include gastrointestinal distress, skin rashes and decreased liver function. Pseudomembranous colitis is relatively frequently seen due to resistance of Clostridium difficile. 

Clindamycin has in vitro activity against Propionibacterium acnes this has been postulated as the mechanism of its beneficial effect in acne therapy. Approximately 10% of an applied dose is absorbed, and rare cases of bloody diarrhea and pseudomembranous colitis have been reported following topical application. The hydroalcoholic vehicle may cause drying and irritation of the skin, with complaints of burning and stinging. The water-based gel and lotion formulations are well tolerated and less likely to cause irritation. Allergic contact dermatitis is uncommon. Clindamycin is also available in a fixed-combination topical gel with benzoyl peroxide (BenzaClin). 

Doxycycline is commonly used for moderate to severe acne vulgaris. It is more effective and produces less resistance than tetracycline. The initial dose is 100 or 200 mg daily, followed by 50 mg daily as a maintenance dose after improvement is seen. Doxycycline maybe given with food, but it is more effective when taken 30 minutes before meals. / Minocycline is also commonly used for moderate to severe acne vulgaris. It is more effective than tetracycline. It is dosed similar to doxycycline (100 mg/day or 50 mg twice daily) and on an indefinite basis in selected patients. Minocycline has the most reported adverse effects of the tetracyclines, some of which may be serious. Trimethoprim-sulfamethoxazole (or trimethoprim alone) is a second-line oral agent that may be used for patients who do not tolerate tetracyclines and erythromycin or in cases of resistance to these antibiotics. The adult dose is usually 800 mg sulfamethoxazole and 160 mg trimethoprim twice daily. Clindamycin use is limited by diarrhea and the risk of pseudomembranous colitis. 

The most serious adverse effect is antibiotic-associated (pseudomembranous) colitis (see p. 210) usually due to opportunistic infection of the bowel with Clostridium difficile which produces an entero-toxin clindamycin should be stopped if any diarrhoea occurs. 

Pseudomembranous colitis was known before the introduction of antimicrobial agents and can still occur without previous antibiotic use, for example after antineoplastic chemotherapy (125) or even spontaneously. However, the number of cases has increased dramatically since antibiotics began to be used (126). Patients treated with lincomycin or clindamycin, cephalosporins, penicillinase-resistant penicillins, or combinations of several antibiotics... 

Although the first antibiotics reported to cause pseudomembranous colitis were lincomycin and clindamycin, the disease was later described with all other antimicrobial drugs, even topically applied (149). Vancomycin (150) and metronidazole (151), which may be used as specific treatments, have also been implicated. 

Milstone EB, McDonald AJ, Scholhamer CF Jr. Pseudomembranous colitis after topical application of clindamycin. Arch Dermatol 1981 117(3) 154-5. 

The most prominent adverse reaction of the lincosamides is diarrhea, which varies from mildly loose bowel movements to life-threatening pseudomembranous colitis (see monograph on Beta-lactam antibiotics). Almost all antimicrobial drugs have been associated with severe diarrhea and colitis however, lincomycin and clindamycin have been particularly incriminated. The incidence of clindamycin-induced diarrhea in hospital is 23%. Diarrhea resolves promptly after withdrawal in most cases. It seems to be dose-related and may result from a direct action on the intestinal mucosa. Severe colitis due to C. difficile is not dose-related and occurs in 0.01-10% of recipients. Clustering of cases in time and place suggests the possibility of cross-infection. Even low doses of clindamycin, in some cases after topical administration, can cause marked alterations in several intestinal functions related to bowel flora (23). There was reduced susceptibility of C. difficile to clindamycin in 80% of French isolates in 1997 (24). Lincomycin was among the antibiotics that were most often associated with the development of antibiotic-associated diarrhea in a Turkish study of 154 patients other associated antibiotics were azithromycin and ampicillin (25). 

Parry MF, Rha CK. Pseudomembranous colitis caused by topical clindamycin phosphate. Arch Dermatol 1986 122(5) 583-4. 

Vancomycin hydrochloride is always administered intravenously (never intramuscularly), either by slow injection or hy continuous infusion, for the treatment of systemic infections. In shott-term therapy, the toxic side reactions arc usually slight, hut continued u.sc may lead to impaired auditory acuity, renal damage, phlebitis, and rashes. Bccau.se it is nut assorted or signilicantly degraded in the gastrointc.stinal tract, vancomycin may he administered orally fur the treatment of staphylococcal enterocolitis and for pseudomembranous colitis associated with clindamycin therapy. Some conversion to aglucovancomycin likely (Kcurs in the low pH of the stomach. The latter retains about three-fourths of the activity of vancomycin. 

Chang T-W, Bartlett JG, Gorbach SL, etal. (1978) Clindamycin-induced enterocolitis in hamsters as a model of pseudomembranous colitis in patients. In Infect. Immun. 20 526—529. 

Lincomycin has generally been replaced by Clindamycin (Cleocin) because there are significant occurrences of pseudomembranous colitis in patients who use lincomycins. Clindamycin is a semisynthetic derivative of lincomycin that is safer and more effective than lincomycin. 

Topical clindamycin inhibits P. acnes and provides comedolytic as well as anti-inflammatory activity. It is available in gel, lotion, solution, and disposable pad formulations, and is usually applied twice daily. Combination with BPO increases efficacy. Though rare, diarrhea and pseudomembranous colitis may occur secondary to topical clindamycin. ... 

Clindamycin is very effective in the treatment of acne, but has disadvantages for long-term therapy due to the possible induction of pseudomembranous colitis. For this reason, its use in acne is uncom-... 

The reported incidence of diarrhea associated with the administration of clindamycin ranges from 2 to 20%. A number of patients (variously reported as 0.01 to 10%) have developed pseudomembranous colitis caused by the toxin from the organism C. difficile. This colitis is characterized by abdominal pain, diarrhea, fever, and mucus and blood in the stools. Proctoscopic examination reveals white-to-yellow... 

Although many infections with gram-positive cocci respond to clindamycin, the high incidence of diarrhea and the occurrence of pseudomembranous colitis limit its use to infections where it is clearly superior to other agents. Clindamycin is particularly valuable for anaerobic infections, especially those due to B. fragiUs. Clindamycin is not predictably useful for the treatment of bacterial brain abscesses metronidazole, in combination with penicillin or a third-generation cephalosporin, is preferred. 

Lincomycin is a natural product isolated from fermentations of Streptomyces lincolnensis var. lincolnensis. It is active against Gram-positive organisms, including some anaerobes. It is indicated for the treatment of serious infections caused by sensitive strains of streptococci, pneumococci, and staphylococci. It generally is reserved for patients who are allergic to penicillin because of the increased risk of pseudomembranous colitis (described below). It also serves as the starting material for the synthesis of clindamycin (by a Sn-2 reaction that inverts the R stereochemistry of the C-7 hydroxyl to a C-7 S-chloride). 

However, note that marked diarrhoea is an indication that lincomycin or clindamycin should be stopped immediately. This is because it may be a sign of pseudomembranous colitis, which can be fatal. 

Topical clindamycin is widely used in the treatment of acne vulgaris. Approximately 5% clindamycin hydrochloride is absorbed systemically (Barza et al. 1982). The degree of absorption largely depends on the vehicle, ranging from 0.13% (acetone) to 13.92% (DMSO) (Franz 1983). Several cases of topical-clindamycin-associated diarrhea have been reported (Becker et al. 1981). Pseudomembranous colitis is a side effect of systemic administration of clindamycin. A case of pseudomembranous colitis has been reported after topical administration by Milstone et al. (1981). 

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