Current indications for the use of clindamycin: A critical review Original paper

What Was Reviewed?

This critical review evaluates the current indications for clindamycin use, consolidating evidence-based guidelines across a range of infectious conditions. It synthesizes data from randomized clinical trials, cohort studies, and expert opinions published between 1966 and 1996, focusing on therapeutic efficacy and safety. The review categorizes evidence by clinical syndrome, discussing clindamycin’s roles in skin and soft tissue infections, necrotizing fasciitis, diabetic foot infections, osteomyelitis, head and neck infections, preoperative prophylaxis, pneumonia, intra-abdominal and pelvic infections, and select protozoal diseases. The review also highlights adverse effects, particularly the significant risk of Clostridium difficile-associated diarrhea​.

Who Was Reviewed?

This review encompasses a broad spectrum of patient populations with bacterial and protozoal infections treated with clindamycin. Key patient groups include individuals with skin and soft tissue infections, diabetic foot ulcers, osteomyelitis, necrotizing fasciitis, and recurrent group A streptococcal pharyngitis. The review also covers surgical patients requiring perioperative prophylaxis and those with anaerobic pulmonary infections or pelvic infections. Special attention is given to vulnerable populations such as diabetics and hospitalized patients at risk of C. difficile colonization, illustrating the intersection between microbial ecology and clinical outcomes​.

What Were the Most Important Findings?

The review confirms that clindamycin remains a vital alternative antibiotic, especially in patients allergic to beta-lactams or for infections involving toxin-producing pathogens like Streptococcus pyogenes. Notably, clindamycin’s efficacy in anaerobic lung infections, diabetic foot infections, and necrotizing fasciitis is well-supported, with its dual action of inhibiting bacterial protein synthesis and suppressing toxin production. However, the review underscores significant concerns over C. difficile-associated diarrhea, with inpatient colonization risks reaching up to 30%. While clindamycin demonstrates broad-spectrum anaerobic activity, its use in abdominal infections is increasingly challenged by cheaper, safer alternatives like metronidazole. From a microbiome standpoint, the paper emphasizes that clindamycin’s prolonged intestinal presence profoundly disrupts gut flora, increasing susceptibility to pathogenic colonization, especially in inpatient settings​.

What Are the Greatest Implications of This Review?

For clinicians, the key takeaway is the nuanced application of clindamycin: it should be reserved for cases with compelling evidence of benefit, such as invasive streptococcal infections or anaerobic lung abscesses. Stewardship is critical to limit microbiome disruption and resistance proliferation, particularly given the high incidence of C. difficile-related complications. The review calls for judicious prescribing practices, recommending metronidazole-based regimens where feasible and advocating for combination therapies in severe infections to optimize outcomes while minimizing adverse microbiome impacts​.