Editing Clindamycin

{{Short description|Antibiotic}}
{{Use dmy dates|date=February 2024}}
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{{Drugbox
| Verifiedfields     = changed
| verifiedrevid      = 457629722
| image              = Clindamycin skeletal formula labelled.svg
| image_class        = skin-invert-image
| width              = 250
| alt                = 
| image2             = Clindamycin 3D 3jz0.png
| width2             = 250
| alt2               = 
| caption            = 

<!-- Clinical data -->
| pronounce          = {{IPAc-en|k|l|ɪ|n|d|ə|ˈ|m|aɪ|s|ᵻ|n}}
| tradename          = Cleocin, Clinacin, Dalacin, others
| Drugs.com          = {{drugs.com|monograph|clindamycin-systemic}}
| MedlinePlus        = a682399
| DailyMedID         = Clindamycin
| pregnancy_AU       = A
| pregnancy_AU_comment = <ref name="Drugs.com Pregnancy">{{drugs.com|pregnancy|clindamycin}}</ref>
| pregnancy_category = 
| routes_of_administration = [[Oral administration|By mouth]], [[Topical administration|topical]], [[intravenous therapy|intravenous]], [[pessary|intravaginal]]
| class              = [[Lincosamides|Lincosamide antibiotic]]
| ATC_prefix         = J01
| ATC_suffix         = FF01
| ATC_supplemental   = {{ATC|D10|AF01}} {{ATC|G01|AA10}} {{ATC|D10|AF51}}

<!-- Legal status -->
| legal_AU           = S4
| legal_AU_comment   = 
| legal_BR           = <!-- OTC, A1, A2, A3, B1, B2, C1, C2, C3, C4, C5, D1, D2, E, F -->
| legal_BR_comment   = 
| legal_CA           = Rx-only
| legal_CA_comment   = <ref>{{cite web | title=Product monograph brand safety updates | website=[[Health Canada]] | date=6 June 2024 | url=https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/drug-product-database/label-safety-assessment-update/product-monograph-brand-safety-updates.html | access-date=8 June 2024}}</ref>
| legal_DE           = <!-- Anlage I, II, III or Unscheduled -->
| legal_DE_comment   = 
| legal_NZ           = <!-- Class A, B, C -->
| legal_NZ_comment   = 
| legal_UK           = POM
| legal_UK_comment   = 
| legal_US           = Rx-only
| legal_US_comment   = <ref name="Xaciato FDA label" />
| legal_EU           = 
| legal_EU_comment   = 
| legal_UN           = <!-- N I, II, III, IV / P I, II, III, IV -->
| legal_UN_comment   = 
| legal_status       = <!-- For countries not listed above -->

<!-- Pharmacokinetic data -->| bioavailability    = 90% (by mouth)<br />4–5% (topical)
| protein_bound      = 95%
| metabolism         = [[Liver]]
| metabolites        = 
| onset              = 
| elimination_half-life = 2–3 hour
| duration_of_action = 
| excretion          = [[Bile duct]] and [[kidney]] (around 20%)

<!-- Identifiers -->
| index2_label       = as HCl
| CAS_number_Ref     = {{cascite|correct|??}}
| CAS_number         = 18323-44-9
| CAS_supplemental   = 
| PubChem            = 446598
| IUPHAR_ligand      = 
| DrugBank_Ref       = {{drugbankcite|correct|drugbank}}
| DrugBank           = DB01190
| ChemSpiderID_Ref   = {{chemspidercite|correct|chemspider}}
| ChemSpiderID       = 393915
| UNII_Ref           = {{fdacite|correct|FDA}}
| UNII               = 3U02EL437C
| KEGG_Ref           = {{keggcite|correct|kegg}}
| KEGG               = D00277
| KEGG2_Ref          = {{keggcite|correct|kegg}}
| KEGG2              = D02132
| ChEBI_Ref          = {{ebicite|changed|EBI}}
| ChEBI              = 3745
| ChEMBL_Ref         = {{ebicite|changed|EBI}}
| ChEMBL             = 1753
| NIAID_ChemDB       = 
| PDB_ligand         = CLY
| synonyms           = 7-chloro-lincomycin<br />7-chloro-7-deoxylincomycin, DARE-BV1

<!-- Chemical and physical data -->
| IUPAC_name         = <nowiki>methyl 7-chloro-6,7,8-trideoxy-6-{[(4</nowiki>''R'')-1-methyl-4-propyl-<small>L</small>-prolyl]amino}-1-thio-<small>L</small>-threo-α-<small>D</small>-galacto-octopyranoside
| C                  = 18
| H                  = 33
| Cl                 = 1
| N                  = 2
| O                  = 5
| S                  = 1
| SMILES             = Cl[C@@H](C)[C@@H](NC(=O)[C@H]1N(C)C[C@H](CCC)C1)[C@H]2O[C@H](SC)[C@H](O)[C@@H](O)[C@H]2O
| StdInChI_Ref       = {{stdinchicite|correct|chemspider}}
| StdInChI           = 1S/C18H33ClN2O5S/c1-5-6-10-7-11(21(3)8-10)17(25)20-12(9(2)19)16-14(23)13(22)15(24)18(26-16)27-4/h9-16,18,22-24H,5-8H2,1-4H3,(H,20,25)/t9-,10+,11-,12+,13-,14+,15+,16+,18+/m0/s1
| StdInChI_comment   = 
| StdInChIKey_Ref    = {{stdinchicite|correct|chemspider}}
| StdInChIKey        = KDLRVYVGXIQJDK-AWPVFWJPSA-N
| density            = 
| density_notes      = 
| melting_point      = 
| melting_high       = 
| melting_notes      = 
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| solubility         = 
| sol_units          = 
| specific_rotation  = 
}}

<!-- Definition and medical uses -->
'''Clindamycin''' is a [[Lincosamides|lincosamide]] [[antibiotic]] medication used for the treatment of a number of [[bacterial infection]]s, including [[osteomyelitis]] (bone) or [[joint infection]]s, [[pelvic inflammatory disease]], [[strep throat]], [[pneumonia]], [[acute otitis media]] (middle ear infections), and [[endocarditis]].<ref name=AHFS2015>{{cite web |title=Clindamycin (Systemic) |url=https://www.drugs.com/monograph/clindamycin-systemic.html |publisher=The American Society of Health-System Pharmacists |access-date=19 December 2021 |url-status=live |archive-url=https://web.archive.org/web/20210812002904/https://www.drugs.com/monograph/clindamycin-systemic.html |archive-date=12 August 2021 }}</ref> It can also be used to treat [[acne vulgaris|acne]],<ref name=AHFS2015/><ref name=Ley2006/> and some cases of [[methicillin-resistant Staphylococcus aureus|methicillin-resistant ''Staphylococcus aureus'']] (MRSA).<ref name=Daum2007>{{cite journal |vauthors=Daum RS |title=Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus |journal=N. Engl. J. Med. |volume=357 |issue=4 |pages=380–90 |date=July 2007 |pmid=17652653 |doi=10.1056/NEJMcp070747}}</ref> In combination with [[quinine]], it can be used to treat [[malaria]].<ref name=AHFS2015/><ref name=Ley2006/> It is available by mouth, by [[intravenously|injection into a vein]], and as a cream or a gel to be applied to the skin or in the vagina.<ref name="Xaciato FDA label">{{cite web | title=Xaciato- clindamycin phosphate gel | website=DailyMed | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1f55f371-a27d-4331-815b-d8a90874223a | access-date=24 December 2021}}</ref><ref name=AHFS2015/><ref name=Ley2006>{{cite book | vauthors = Leyden JJ |title=Hidradenitis suppurativa |date=2006 |publisher=Springer |location=Berlin |isbn=9783540331018 |page=152 |url= https://books.google.com/books?id=hpKFsXwcKlgC&pg=PA152 |url-status=live |archive-url= https://web.archive.org/web/20170908162632/https://books.google.com/books?id=hpKFsXwcKlgC&pg=PA152 |archive-date=8 September 2017 }}</ref><ref>{{cite web | title=Clindamycin phosphate- clindamycin phosphate gel usp, 1% gel | website=DailyMed | url=https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=ac21d7ad-f94e-4d57-95e3-1648add7ad0b | access-date=19 December 2021}}</ref><ref>{{cite press release | title=Daré Announces FDA Approval of Xaciato (clindamycin phosphate) Vaginal Gel as a Treatment for Bacterial Vaginosis | website=Daré Bioscience | date=7 December 2021 | url=https://darebioscience.gcs-web.com/news-releases/news-release-details/dare-announces-fda-approval-xaciatotm-clindamycin-phosphate | access-date=19 December 2021}}</ref>

<!-- Side effects and mechanism -->
Common side effects include nausea and vomiting, diarrhea, skin rashes, and pain at the site of injection.<ref name=AHFS2015/> It increases the risk of hospital-acquired [[Clostridioides difficile infection|''Clostridioides difficile'' colitis]] about fourfold and thus is only recommended for use when other antibiotics are not appropriate.<ref name=Thomas>{{cite journal |vauthors=Thomas C, Stevenson M, Riley TV |title=Antibiotics and hospital-acquired Clostridium difficile-associated diarrhoea: a systematic review |journal=J Antimicrob Chemother |volume=51 |issue=6 |pages=1339–50 |year=2003 |pmid=12746372 |doi=10.1093/jac/dkg254 |doi-access=free | title-link=doi }}</ref><ref name=AHFS2015/> It appears to be generally safe in pregnancy.<ref name=AHFS2015/> It is of the [[lincosamides|lincosamide class]] and works by blocking bacteria from making protein.<ref name=AHFS2015/>

<!-- History, society and culture -->
Clindamycin was first made in 1966 from [[lincomycin]].<ref name=Sm1998>{{cite journal|vauthors=Smieja M |date=January 1998|title=Current indications for the use of clindamycin: A critical review|journal=The Canadian Journal of Infectious Diseases|volume=9|issue=1|pages=22–8|pmc=3250868|pmid=22346533|doi=10.1155/1998/538090|doi-access=free | title-link=doi }}</ref><ref>{{cite book|title=Neonatal Formulary: Drug Use in Pregnancy and the First Year of Life|date=2014|publisher=John Wiley & Sons|isbn=9781118819517|page=162|edition= 7|url=https://books.google.com/books?id=EORvBAAAQBAJ&pg=PA162|url-status=live|archive-url=https://web.archive.org/web/20170908162632/https://books.google.com/books?id=EORvBAAAQBAJ&pg=PA162|archive-date=8 September 2017}}</ref> It is on the [[WHO Model List of Essential Medicines|World Health Organization's List of Essential Medicines]].<ref name="WHO22nd">{{cite book | vauthors = ((World Health Organization)) | title = World Health Organization model list of essential medicines: 22nd list (2021) | year = 2021 | hdl = 10665/345533 | author-link = World Health Organization | publisher = World Health Organization | location = Geneva | id = WHO/MHP/HPS/EML/2021.02 | hdl-access=free }}</ref> It is available as a [[generic medication]].<ref name=Ric2015>{{cite book | vauthors = Hamilton R |title=Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition |date=2015 |publisher=Jones & Bartlett Learning |isbn=9781284057560 |page=108 }}</ref><ref>{{cite web | title=Competitive Generic Therapy Approvals | website=U.S. [[Food and Drug Administration]] (FDA) | date=29 June 2023 | url=https://www.fda.gov/drugs/generic-drugs/competitive-generic-therapy-approvals | access-date=29 June 2023 | archive-date=29 June 2023 | archive-url=https://web.archive.org/web/20230629233651/https://www.fda.gov/drugs/generic-drugs/competitive-generic-therapy-approvals | url-status=dead }}</ref> In 2022, it was the 147th most commonly prescribed medication in the United States, with more than 3{{nbsp}}million prescriptions.<ref>{{cite web | title=The Top 300 of 2022 | url=https://clincalc.com/DrugStats/Top300Drugs.aspx | website=ClinCalc | access-date=30 August 2024 | archive-date=30 August 2024 | archive-url=https://web.archive.org/web/20240830202410/https://clincalc.com/DrugStats/Top300Drugs.aspx | url-status=live }}</ref><ref>{{cite web | title = Clindamycin Drug Usage Statistics, United States, 2013 - 2022 | website = ClinCalc | url = https://clincalc.com/DrugStats/Drugs/Clindamycin | access-date = 30 August 2024 }}</ref>

== Medical uses ==
Clindamycin is used primarily to treat [[anaerobic infection]]s caused by susceptible [[anaerobic organism|anaerobic]] [[bacteria]], including dental infections,<ref>{{cite journal |vauthors=Brook I, Lewis MA, Sándor GK, Jeffcoat M, Samaranayake LP, Vera Rojas J |title=Clindamycin in dentistry: more than just effective prophylaxis for endocarditis? |journal=Oral Surg Oral Med Oral Pathol Oral Radiol Endod |volume=100 |issue=5 |pages=550–8 |date=November 2005 |pmid=16243239 |doi=10.1016/j.tripleo.2005.02.086 }}</ref> and infections of the [[respiratory tract]], skin, and [[soft tissue]], and [[peritonitis]].<ref name=RxList1>{{cite web |url = http://www.rxlist.com/cgi/generic/clindamyciniv_ids.htm |title = Cleocin I.V. Indications & Dosage |year = 2007 |access-date = 1 December 2007 |publisher = RxList.com |url-status = dead |archive-url = https://web.archive.org/web/20071127021156/http://www.rxlist.com/cgi/generic/clindamyciniv_ids.htm |archive-date = 27 November 2007 }}</ref> In people with [[hypersensitivity]] to [[penicillin]]s, clindamycin may be used to treat infections caused by susceptible [[aerobic organism|aerobic]] bacteria, as well. It is also used to treat bone and joint infections, particularly those caused by ''[[Staphylococcus aureus]]''.<ref name=RxList1/><ref name="Darley">{{cite journal |vauthors=Darley ES, MacGowan AP |title=Antibiotic treatment of gram-positive bone and joint infections |journal=J Antimicrob Chemother |volume=53 |issue=6 |pages=928–35 |year=2004 |pmid=15117932 |doi=10.1093/jac/dkh191 |doi-access=free | title-link=doi }}</ref> [[Topical administration|Topical]] application of clindamycin phosphate can be used to treat mild to moderate acne.<ref name="Feldman">{{cite journal |vauthors=Feldman S, Careccia RE, Barham KL, Hancox J |title=Diagnosis and treatment of acne |journal=Am Fam Physician |volume=69 |issue=9 |pages=2123–30 |date=May 2004 |pmid=15152959 |url=https://www.aafp.org/afp/2004/0501/p2123.html |url-status=live |archive-url=https://web.archive.org/web/20110727113218/http://www.aafp.org/afp/2004/0501/p2123.pdf |archive-date=27 July 2011 }}</ref><ref name="pmid31613567">{{cite journal |vauthors=Oge' LK, Broussard A, Marshall MD |title=Acne Vulgaris: Diagnosis and Treatment |journal=Am Fam Physician |volume=100 |issue=8 |pages=475–84 |date=October 2019 |pmid=31613567 |doi= |url=https://www.aafp.org/afp/2019/1015/p475.html }}</ref>

=== Acne ===
[[File:Clindamycin**.jpg|thumb|Clindamycin phosphate topical solution]]

For the treatment of acne, in the long term, the combined use of topical clindamycin and [[benzoyl peroxide]] was similar to [[salicylic acid]] plus benzoyl peroxide.<ref name="pmid31613567" /><ref name=Sei2010/> Topical clindamycin plus topical benzoyl peroxide is more effective than topical clindamycin alone.<ref name="pmid31613567" /><ref name=Sei2010>{{cite journal |vauthors=Seidler EM, Kimball AB |title=Meta-analysis comparing efficacy of benzoyl peroxide, clindamycin, benzoyl peroxide with salicylic acid, and combination benzoyl peroxide/clindamycin in acne |journal=J. Am. Acad. Dermatol. |volume=63 |issue=1 |pages=52–62 |date=July 2010 |pmid=20488582 |doi=10.1016/j.jaad.2009.07.052 }}</ref>

=== Susceptible bacteria ===
It is most effective against infections involving the following types of organisms:

* Aerobic [[Gram-positive]] [[cocci]], including some members of the ''[[Staphylococcus]]'' and ''[[Streptococcus]]'' (''e.g.'' [[pneumococcus]]) [[genus|genera]], but not [[Enterococcus|enterococci]].<ref name="Merck" />
* Anaerobic, [[Gram-negative]] [[Bacteria Morphology|rod-shaped bacteria]], including some ''[[Bacteroides]]'', ''[[Fusobacterium]]'', and ''[[Prevotella]]'', although resistance is increasing in ''[[Bacteroides fragilis]]''.<ref>{{cite journal | vauthors = Di Bella S, Antonello RM, Sanson G, Maraolo AE, Giacobbe DR, Sepulcri C, Ambretti S, Aschbacher R, Bartolini L, Bernardo M, Bielli A, Busetti M, Carcione D, Camarlinghi G, Carretto E, Cassetti T, Chilleri C, De Rosa FG, Dodaro S, Gargiulo R, Greco F, Knezevich A, Intra J, Lupia T, Concialdi E, Bianco G, Luzzaro F, Mauri C, Morroni G, Mosca A, Pagani E, Parisio EM, Ucciferri C, Vismara C, Luzzati R, Principe L | title = Anaerobic bloodstream infections in Italy (ITANAEROBY): A 5-year retrospective nationwide survey | journal = Anaerobe | volume = 75 | pages = 102583 | date = June 2022 | pmid = 35568274 | doi = 10.1016/j.anaerobe.2022.102583 | hdl = 11368/3020691 | s2cid = 248736289 | hdl-access = free }}</ref>

Most aerobic Gram-negative bacteria (such as ''[[Pseudomonas]]'', ''[[Legionella]]'', ''[[Haemophilus influenzae]]'' and ''[[Moraxella]]'') are resistant to clindamycin,<ref name="Merck" /><ref name="Bell">{{cite web|url=http://www.pediatricsupersite.com/view.aspx?rid=35957 |title=Clindamycin: new look at an old drug |vauthors=Bell EA |date=January 2005 |access-date=1 December 2007 |work=Infectious Diseases in Children |url-status=dead |archive-url=https://web.archive.org/web/20111008040952/http://www.pediatricsupersite.com/view.aspx?rid=35957 |archive-date=8 October 2011 }}</ref> as are the [[facultative anaerobic organism|facultative anaerobic]] [[Enterobacteriaceae]].<ref name="Gold">{{cite book | vauthors = Gold HS, Moellering RC |chapter=Macrolides and clindamycin |chapter-url=https://books.google.com/books?id=zvCOpighJggC&pg=PA294 | veditors = Root RE, Waldvogel F, Corey L, Stamm WE |title=Clinical infectious diseases: a practical approach |publisher=Oxford University Press |location=Oxford |year=1999 |pages=291–7 |isbn=978-0-19-508103-9 |archive-url=https://web.archive.org/web/20180513203552/https://books.google.com/books?id=zvCOpighJggC&pg=PA294 |archive-date=13 May 2018 }} {{Retrieved|access-date=19 January 2009}}through [[Google Book Search]].</ref> A notable exception is ''[[Capnocytophaga canimorsus]]'', for which clindamycin is a first-line drug of choice.<ref>{{cite journal |vauthors=Jolivet-Gougeon A, Sixou JL, Tamanai-Shacoori Z, Bonnaure-Mallet M |title=Antimicrobial treatment of ''Capnocytophaga'' infections |journal=Int J Antimicrob Agents |volume=29 |issue=4 |pages=367–73 |date=April 2007 |pmid=17250994 |doi=10.1016/j.ijantimicag.2006.10.005}}</ref>

The following represents [[Minimum inhibitory concentration|MIC]] susceptibility data for a few medically significant pathogens.<ref>{{cite web |url=https://www.toku-e.com/content/product-documents/MIC_Clindamycin%20Phosphate.pdf |title=Clindamycin Phosphate Susceptibility and Minimum Inhibitory Concentration (MIC) Data |date=1 June 2020 |website=toku-e.com}}</ref>

*''Staphylococcus aureus'': 0.016&nbsp;μg/mL – >256&nbsp;μg/mL
*''Streptococcus pneumoniae'': 0.002&nbsp;μg/mL – >256&nbsp;μg/mL
*''Streptococcus pyogenes'': <0.015&nbsp;μg/mL – >64&nbsp;μg/mL

=== D-test ===
[[File:D test.jpg|thumb|upright=1.2|D-test]]

When testing a gram-positive culture for sensitivity to clindamycin, it is common to perform a "D-test" to determine if there is a sub-population of [[bacteria]] present with the [[phenotype]] known as {{not a typo|iMLS<sub>B</sub>}}. This phenotype of bacteria are resistant to the [[macrolide]]-[[lincosamide]]-[[streptogramin B]] group of antibiotics; however, the resistance mechanism is only induced by the presence of 14-membered ring macrolides, such as [[erythromycin]]. During a D-test, bacteria of the {{not a typo|iMLS<sub>B</sub>}} phenotype demonstrate ''in vitro'' erythromycin-induced ''in vitro'' resistance to clindamycin. This is because of the activity of the macrolide-inducible [[plasmid]]-encoded ''erm'' gene.<ref>{{cite journal |vauthors=Leclerq R |title=Mechanisms of Resistance to Macrolides and Lincosamides: Nature of the Resistance Elements and Their Clinical Implications |journal=Clinical Infectious Diseases |date=February 2002 |volume=34 |issue=4 |pages=482–92 |doi=10.1086/324626 |pmid=11797175 | doi-access=free | title-link=doi }}</ref>

To perform a D-test, an [[agar]] plate is inoculated with the bacteria in question and two drug-impregnated disks (one with [[erythromycin]], one with clindamycin) are placed 15–20&nbsp;mm apart on the plate. If the area of inhibition around the clindamycin disk is D-shaped, the test result is positive. Despite the apparent susceptibility to clindamycin in the absence of erythromycin, a positive D-test precludes therapeutic use of clindamycin. This is because the erythromycin-inducible ''erm'' gene is prone to [[mutations]] causing the inducible activity to switch to constitutive (permanently switched on).<ref name="Macrolide-inducible resistance to c">{{cite journal |vauthors=Woods CR |title=Macrolide-inducible resistance to clindamycin and the D-test |journal=The Pediatric Infectious Disease Journal |date=December 2009 |volume=28 |issue=12 |pages=1115–8 |doi=10.1097/INF.0b013e3181c35cc5 |pmid=19935273 | doi-access= | title-link=doi }}</ref> This, in turn, may lead to the therapeutic failure of clindamycin.

If the area of inhibition around the clindamycin disk is circular, the test result is negative and clindamycin can be used.<ref name="Macrolide-inducible resistance to c"/>

=== Malaria ===
Given with [[chloroquine]] or [[quinine]], clindamycin is effective and well tolerated in treating ''[[Plasmodium falciparum]]'' malaria; the latter combination is particularly useful for children, and is the treatment of choice for pregnant women who become infected in areas where [[drug resistance|resistance]] to chloroquine is common.<ref name=Lell2002>{{cite journal |vauthors=Lell B, Kremsner PG |title=Clindamycin as an antimalarial drug: review of clinical trials |journal=[[Antimicrobial Agents and Chemotherapy]] |issn=0066-4804 |volume=46 |issue=8 |pages=2315–20 |year=2002 |pmid=12121898 |doi=10.1128/AAC.46.8.2315-2320.2002 |pmc=127356 | doi-access=free | title-link=doi }}</ref><ref name="Griffith">{{cite journal |vauthors=Griffith KS, Lewis LS, Mali S, Parise ME |title=Treatment of malaria in the United States: a systematic review |journal=JAMA |volume=297 |issue=20 |pages=2264–77 |year=2007 |pmid=17519416 |doi=10.1001/jama.297.20.2264 |doi-access=free | title-link=doi }}</ref> Clindamycin should not be used as an antimalarial by itself, although it appears to be very effective as such, because of its slow action.<ref name=Lell2002 /><ref name="Griffith" /> Patient-derived isolates of ''[[Plasmodium falciparum]]'' from the [[Peruvian Amazonia|Peruvian Amazon]] have been reported to be resistant to clindamycin as evidenced by ''in vitro'' drug susceptibility testing.<ref name="Dharia">{{cite journal |vauthors=Dharia NV, Plouffe D, Bopp SE, González-Páez GE, Lucas C, Salas C, Soberon V, Bursulaya B, Kochel TJ, Bacon DJ, Winzeler EA |title=Genome scanning of Amazonian Plasmodium falciparum shows subtelomeric instability and clindamycin-resistant parasites |journal=[[Genome Research]] |volume=20 |issue=11 |pages=1534–44 |year=2010 |pmid=20829224 |doi=10.1101/gr.105163.110 |pmc=2963817 }}</ref>

=== Other ===
Clindamycin may be useful in skin and [[soft tissue]] infections caused by [[methicillin-resistant Staphylococcus aureus|methicillin-resistant ''Staphylococcus aureus'']] (MRSA).<ref name="Daum2007" /> Many strains of MRSA are still susceptible to clindamycin; however, in the United States spreading from the West Coast eastwards, MRSA is becoming increasingly resistant.{{medical citation needed|date=December 2019}}

While it has been used in [[intraabdominal infections]], such use is generally not recommended due to resistance.<ref name=AHFS2015/>

Clindamycin is used in cases of suspected [[toxic shock syndrome]],<ref name="Annane">{{cite journal |vauthors=Annane D, Clair B, Salomon J |title=Managing toxic shock syndrome with antibiotics |journal=Expert Opin Pharmacother |volume=5 |issue=8 |pages=1701–10 |year=2004 |pmid=15264985 |doi=10.1517/14656566.5.8.1701|s2cid=24494787 }}</ref> often in combination with a [[bactericidal]] agent such as [[vancomycin]]. The rationale for this approach is a presumed synergy between vancomycin, which causes the death of the bacteria by [[lysis|breakdown of the cell wall]], and clindamycin, which is a powerful inhibitor of [[toxin]] synthesis. Both ''[[in vitro]]'' and ''[[in vivo]]'' studies have shown clindamycin reduces the production of [[exotoxin]]s by staphylococci;<ref>{{cite journal |vauthors=Coyle EA |title=Targeting bacterial virulence: the role of protein synthesis inhibitors in severe infections. Insights from the Society of Infectious Diseases Pharmacists |journal=Pharmacotherapy |volume=23 |issue=5 |pages=638–42 |date=May 2003 |pmid=12741438 |doi=10.1592/phco.23.5.638.32191 |s2cid=29061418 }}</ref> it may also induce changes in the surface structure of bacteria that make them more sensitive to [[immune system]] attack ([[opsonin|opsonization]] and [[phagocytosis]]).<ref>{{cite journal |vauthors=Gemmell CG, O'Dowd A |title=Regulation of protein A biosynthesis in Staphylococcus aureus by certain antibiotics: its effect on phagocytosis by leukocytes |journal=J Antimicrob Chemother |volume=12 |issue=6 |pages=587–97 |year=1983 |pmid=6662837|doi=10.1093/jac/12.6.587}}</ref><ref>{{cite journal |vauthors=Gemmell CG, Peterson PK, Schmeling D, Kim Y, Mathews J, Wannamaker L, Quie PG |title=Potentiation of opsonization and phagocytosis of Streptococcus pyogenes following growth in the presence of clindamycin |journal=[[Journal of Clinical Investigation|J Clin Invest]] |volume=67 |issue=5 |pages=1249–56 |date=May 1981 |pmid=7014632 |doi=10.1172/JCI110152 |pmc=370690}}</ref>

Clindamycin has been proven to decrease the risk of [[premature birth]]s in women diagnosed with [[bacterial vaginosis]] during early pregnancy to about a third of the risk of untreated women.<ref name="Lamont">{{cite journal |vauthors=Lamont RF |title=Can antibiotics prevent preterm birth—the pro and con debate |journal=BJOG |volume=112 |issue= Suppl 1 |pages=67–73 |year=2005 |pmid=15715599 |doi=10.1111/j.1471-0528.2005.00589.x|s2cid=25572794 }}</ref>

The combination of clindamycin and quinine is the standard treatment for severe [[babesiosis]].<ref name="Homer">{{cite journal |vauthors=Homer MJ, Aguilar-Delfin I, Telford SR, Krause PJ, Persing DH |title=Babesiosis |journal=Clin Microbiol Rev |volume=13 |issue=3 |pages=451–69 |date=July 2000 |pmid=10885987 |doi=10.1128/CMR.13.3.451-469.2000 |pmc=88943 |doi-access=free | title-link=doi }}</ref>

Clindamycin may also be used to treat [[toxoplasmosis]],<ref name="Merck" /><ref name="Pleyer">{{cite journal |vauthors=Pleyer U, Torun N, Liesenfeld O | title = Okuläre Toxoplasmose |trans-title=Ocular toxoplasmosis |language=de |journal=Ophthalmologe |volume=104 |issue=7 |pages=603–16 |year=2007 |pmid=17530262 |doi=10.1007/s00347-007-1535-8| s2cid = 36696180 }}</ref><ref name="Jeddi">{{cite journal |vauthors=Jeddi A, Azaiez A, Bouguila H, Kaoueche M, Malouche S, Daghfous F, Ayed S | title = Intérêt de la clindamycine dans le traitement de la toxoplasmose oculaire |trans-title=Value of clindamycin in the treatment of ocular toxoplasmosis |language=fr |journal=Journal Français d'Ophtalmologie |volume=20 |issue=6 |pages=418–22 |year=1997 |pmid=9296037 | issn = 0181-5512 }}</ref> and, in combination with [[primaquine]], is effective in treating mild to moderate [[Pneumocystis pneumonia|''Pneumocystis jirovecii'' pneumonia]].<ref>{{cite journal |vauthors=Fishman JA |title=Treatment of infection due to Pneumocystis carinii |journal=[[Antimicrobial Agents and Chemotherapy]] |volume=42 |issue=6 |pages=1309–14 |date=June 1998 |pmid=9624465 |doi= 10.1128/AAC.42.6.1309|pmc=105593 | doi-access=free | title-link=doi }}</ref>

Clindamycin, either applied to skin or taken by mouth, may also be used in [[hidradenitis suppurativa]].<ref>{{cite journal|vauthors=Saunte DM, Jemec GB |date=November 2017|title=Hidradenitis Suppurativa: Advances in Diagnosis and Treatment|journal=JAMA|volume=318|issue=20|pages=2019–32|doi=10.1001/jama.2017.16691|pmid=29183082|s2cid=5017318 }}</ref>

== Side effects ==
Common [[adverse drug reaction]]s associated with systemic clindamycin therapy{{snd}}found in over 1% of people{{snd}}include: diarrhea, [[pseudomembranous colitis]], [[nausea]], [[vomiting]], [[abdomen|abdominal]] pain or [[cramp]]s and/or [[rash]]. High doses (both intravenous and oral) may cause a [[metallic taste]]. Common adverse drug reactions associated with topical formulations{{snd}}found in over 10% of people{{snd}}include: dryness, burning, itching, scaliness, or peeling of skin (lotion, solution); erythema (foam, lotion, solution); oiliness (gel, lotion). Additional side effects include [[contact dermatitis]].<ref name="Rossi">{{cite book | veditors = Rossi S | title =  [[Australian Medicines Handbook]] | date = 2006 | location = Adelaide | publisher = AMH Pty Ltd }}</ref><ref name="xl">{{cite journal |vauthors=de Groot MC, van Puijenbroek EP |doi = 10.1111/j.1365-2125.2007.02908.x | title = Clindamycin and taste disorders |journal = British Journal of Clinical Pharmacology |volume = 64 |issue = 4 |pages = 542–5 |date=October 2007 |pmid = 17635503 |pmc =2048568 }}</ref> Common side effects{{snd}}found in over 10% of people{{snd}}in vaginal applications include fungal infection.{{medical citation needed|date=December 2019}}

Rarely{{snd}} in less than 0.1% of people{{snd}} clindamycin therapy has been associated with [[anaphylaxis]], blood [[dyscrasia]]s, [[polyarthritis]], [[jaundice]], [[elevated transaminases|raised liver enzyme levels]], renal dysfunction, cardiac arrest, and/or [[hepatotoxicity]].<ref name="Rossi" />

=== ''Clostridioides difficile'' ===

[[Pseudomembranous colitis]] is a potentially lethal condition commonly associated with clindamycin, but which also occurs with other antibiotics.<ref name="Thomas" /><ref name="Starr">{{cite journal |vauthors=Starr J |title=Clostridium difficile associated diarrhoea: diagnosis and treatment |journal=BMJ |volume=331 |issue=7515 |pages=498–501 |year=2005 |pmid=16141157 |doi=10.1136/bmj.331.7515.498 |pmc=1199032 }}</ref> Overgrowth of ''[[Clostridioides difficile (bacteria)|Clostridioides difficile]]'', which is inherently [[antibiotic resistance|resistant]] to clindamycin, results in the production of a toxin that causes a range of adverse effects, from diarrhea to colitis and [[toxic megacolon]].<ref name="Rossi" /><ref>{{cite journal |vauthors=Kelly CP, Pothoulakis C, LaMont JT |date=January 1994|title=Clostridium difficile colitis |journal=New England Journal of Medicine|volume=330|issue=4|pages=257–62|doi=10.1056/NEJM199401273300406|pmid=8043060 }}</ref>

=== Pregnancy and breastfeeding ===
Use of clindamycin during pregnancy is generally considered safe.<ref>{{cite journal |vauthors=Lell B, Kremsner PG |date=August 2002|title=Clindamycin as an antimalarial drug: review of clinical trials |journal=Antimicrobial Agents and Chemotherapy|volume=46|issue=8|pages=2315–20|doi=10.1128/AAC.46.8.2315-2320.2002|pmid=12121898|pmc=127356 }}</ref>

Clindamycin is classified as compatible with breastfeeding by the [[American Academy of Pediatrics]],<ref>{{cite journal |vauthors=((American Academy of Pediatrics Committee on Drugs)) |title=Transfer of drugs and other chemicals into human milk |journal=Pediatrics |volume=108 |issue=3 |pages=776–89 |date=September 2001 |pmid=11533352 |doi=10.1542/peds.108.3.776 |doi-access=free | title-link=doi }}</ref> however, the WHO categorizes it as "avoid if possible".<ref>{{cite book |title=Breastfeeding and maternal medication : recommendations for drugs in the Eleventh WHO Model List of Essential Drugs |date=2002|hdl=10665/62435 | location = Geneva, Switzerland | work = Department of Child and Adolescent Health and Development |publisher=World Health Organization |last1=Organization |first1=World Health }}</ref> It is classified as [[Breastfeeding and medications#Lactation risk categories|L2 probably compatible]] with breastfeeding according to ''Medications and Mothers' Milk''.<ref>{{cite book |title=Medications & mothers' milk | vauthors = Hale TW |publisher=Springer |others=Rowe, Hilary E. |year=2017 |isbn=9780826128584 |edition= Seventeenth |location=New York, NY |pages= |oclc=959873270 }}</ref> A 2009 review found it was likely safe in breastfeeding mothers, but did find one complication ([[hematochezia]]) in a breastfed infant which might be attributable to clindamycin.<ref>{{cite journal |vauthors=Mitrano JA, Spooner LM, Belliveau P |date=September 2009 |title=Excretion of antimicrobials used to treat methicillin-resistant Staphylococcus aureus infections during lactation: safety in breastfeeding infants |journal=Pharmacotherapy |volume=29 |issue=9 |pages=1103–9 |doi=10.1592/phco.29.9.1103 |pmid=19698015 |s2cid=2594769 }}</ref> LactMed lists potentially negative gastrointestinal effects in babies whose mothers take it while breastfeeding but did not see that as justification to stop breastfeeding.<ref>{{cite journal|title=Clindamycin|date=2006|url=https://www.ncbi.nlm.nih.gov/books/NBK501208/|journal=Drugs and Lactation Database (LactMed)|publisher=National Library of Medicine (US)|pmid=30000267|id=Bookshelf ID: NBK501208}}</ref>

== Interactions ==
Clindamycin may prolong the effects of [[neuromuscular-blocking drugs]], such as [[succinylcholine]] and [[vecuronium]].<ref name="Fogdall">{{cite journal |vauthors=Fogdall RP, Miller RD |title=Prolongation of a pancuronium-induced neuromuscular blockade by clindamycin |journal=Anesthesiology |volume=41 |issue=4 |pages=407–8 |year=1974 |pmid=4415332|doi=10.1097/00000542-197410000-00023}}</ref><ref name="al_Ahdal">{{cite journal |vauthors=al Ahdal O, Bevan DR |title=Clindamycin-induced neuromuscular blockade |journal=Can J Anaesth |volume=42 |issue=7 |pages=614–7 |year=1995 |pmid=7553999 |doi=10.1007/BF03011880|doi-access=free | title-link=doi }}</ref><ref name="Sloan">{{cite journal |vauthors=Sloan PA, Rasul M |title=Prolongation of rapacuronium neuromuscular blockade by clindamycin and magnesium |journal=Anesth Analg |volume=94 |issue=1 |pages=123–4, table of contents |year=2002 |pmid=11772813 |doi=10.1097/00000539-200201000-00023 | doi-access=free | title-link=doi }}</ref> Its similarity to the mechanism of action of [[macrolide]]s and [[chloramphenicol]] means they should not be given simultaneously, as this causes antagonism<ref name=Bell/> and possible [[cross-resistance]].{{medical citation needed|date=December 2019}}

== Chemistry ==
[[File:Clindamycin phosphate Structural Formula V2.svg|class=skin-invert-image|thumb|Clindamycin phosphate<ref name="RxList">{{cite web|url=https://www.rxlist.com/clindamycin-phosphate-topical-solution-drug.htm|website=RxList|title=Clindamycin Phosphate Topical Solution|access-date=27 January 2017|url-status=live|archive-url=https://web.archive.org/web/20170202040857/http://www.rxlist.com/clindamycin-phosphate-topical-solution-drug.htm|archive-date=2 February 2017}}</ref>]]

Clindamycin is a [[semisynthesis|semisynthetic]] derivative of [[lincomycin]], a natural antibiotic produced by the [[Actinomycetota|actinobacterium]] ''[[Streptomyces lincolnensis]]''. It is obtained by 7(''S'')-[[chloro]]-[[substitution (chemistry)|substitution]] of the 7(''R'')-[[hydroxyl]] group of lincomycin.<ref>{{cite journal |vauthors=Birkenmeyer RD, Kagan F |doi = 10.1021/jm00298a007 |title = Lincomycin. XI. Synthesis and structure of clindamycin, a potent antibacterial agent |journal = Journal of Medicinal Chemistry |volume = 13 |issue = 4 |pages = 616–19 |date=July 1970 |pmid = 4916317 }}</ref><ref name=Meyers>{{cite journal |vauthors=Meyers BR, Kaplan K, Weinstein L |title=Microbiological and Pharmacological Behavior of 7-Chlorolincomycin |journal=Appl Microbiol |volume=17 |issue=5 |pages=653–7 |year=1969 |pmid=4389137 |doi= 10.1128/AEM.17.5.653-657.1969|pmc=377774}}</ref> The synthesis of clindamycin was first announced by BJ Magerlein, RD Birkenmeyer, and F Kagan on the fifth Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in 1966.<ref>{{cite journal |vauthors=Magerlein BJ, Birkenmeyer RD, Kagan F |title = Chemical modification of lincomycin | journal = Antimicrobial Agents and Chemotherapy |volume = 6 |pages = 727–36 |year = 1966 |pmid = 5985307 }}</ref> It has been on the market since 1968.<ref name="xl" />

Clindamycin is white or yellow powder that is very soluble in water.<ref name=":1">{{cite journal |vauthors=Spízek J, Rezanka T |date=May 2004|title=Lincomycin, clindamycin and their applications|journal=Applied Microbiology and Biotechnology|volume=64|issue=4|pages=455–64|doi=10.1007/s00253-003-1545-7|pmid=14762701|s2cid=7870760 }}</ref> The topically used clindamycin phosphate is a phosphate-[[ester]] prodrug of clindamycin.<ref name="RxList" />

== Mechanism of action ==
[[File:Clindamycin mechanism.png|thumb|377x377px|Clindamycin mechanism]]

Clindamycin has a primarily [[bacteriostatic]] effect. At higher concentrations, it may be bactericidal.<ref name=":1" /> It is a bacterial [[protein synthesis inhibitor]] by inhibiting ribosomal translocation,<ref>[https://archive.today/20120718035925/http://sitemaker.umich.edu/mc3/clindamycin Clindamycin] University of Michigan. Retrieved 31 July 2009</ref> in a similar way to [[macrolide]]s. It does so by binding to the rRNA of the bacterial [[50S]] [[ribosome]] subunit, overlapping with the binding sites of the [[oxazolidinone]], [[pleuromutilin]], and [[macrolide]] antibiotics, among others.<ref name=Merck>{{cite web |url = https://www.merckmanuals.com/professional/infectious-diseases/bacteria-and-antibacterial-drugs/lincosamides,-oxazolidinones,-and-streptogramins |title = Lincosamides, Oxazolidinones, and Streptogramins |date = May 2020 |access-date = 19 December 2021 |publisher = [[Merck & Co.]] |work = [[Merck Manual of Diagnosis and Therapy]] |url-status = live |archive-url = https://web.archive.org/web/20071202164507/http://www.merck.com/mmpe/print/sec14/ch170/ch170g.html |archive-date = 2 December 2007 }}</ref><ref>{{cite journal |vauthors=Wilson DN |title=Ribosome-targeting antibiotics and mechanisms of bacterial resistance |journal=Nature Reviews Microbiology |volume=12 |issue=1 |pages=35–48 |doi=10.1038/nrmicro3155 |pmid=24336183 |date=January 2014 |s2cid=9264620 }}</ref> The binding is reversible.<ref>Beauduy CE, Winston LG. Tetracyclines, Macrolides, Clindamycin, Chloramphenicol, Streptogramins, & Oxazolidinones. In: Katzung BG. eds. Basic & Clinical Pharmacology, 14e New York, NY: McGraw-Hill; .</ref> Clindamycin is more effective than lincomycin.<ref name=":1" />

The X-ray crystal structures of clindamycin bound to ribosomes (or ribosomal subunits) derived from ''[[Escherichia coli]]'',<ref>{{cite journal |vauthors=Dunkle JA, Xiong L, Mankin AS, Cate JH |date=October 2010 |title=Structures of the Escherichia coli ribosome with antibiotics bound near the peptidyl transferase center explain spectra of drug action |journal=Proceedings of the National Academy of Sciences |volume=107 |issue=40 |pages=17152–57 |doi=10.1073/pnas.1007988107 |pmid=20876128 |pmc=2951456|bibcode=2010PNAS..10717152D |doi-access=free | title-link=doi }}</ref> ''[[Deinococcus radiodurans]]'',<ref>{{cite journal |vauthors=Schlünzen F, Zarivach R, Harms J, Bashan A, Tocilj A, Albrecht R, Yonath A, Franceschi F |title=Structural basis for the interaction of antibiotics with the peptidyl transferase centre in eubacteria |journal=Nature |volume=413 |issue=6858 |pages=814–21 |doi=10.1038/35101544 |pmid=11677599 |date=October 2001|bibcode=2001Natur.413..814S |s2cid=205022511 }}</ref> and ''[[Haloarcula marismortui|Haloarcula marismortui]]''<ref>{{cite journal |vauthors=Tu D, Blaha G, Moore PB, Steitz TA |title=Structures of MLSBK antibiotics bound to mutated large ribosomal subunits provide a structural explanation for resistance |journal=Cell |volume=121 |issue=2 |pages=257–70 |doi=10.1016/j.cell.2005.02.005 |pmid=15851032 |date=April 2005|s2cid=7086043 |doi-access=free | title-link=doi }}</ref> have been determined; the structure of the closely related antibiotic [[lincomycin]] bound to the 50S ribosomal subunit of ''[[Staphylococcus aureus]]'' has also been reported.<ref>{{cite journal |vauthors=Matzov D, Eyal Z, Benhamou RI, Shalev-Benami M, Halfon Y, Krupkin M, Zimmerman E, Rozenberg H, Bashan A, Fridman M, Yonath A |title=Structural insights of lincosamides targeting the ribosome of Staphylococcus aureus |journal=Nucleic Acids Research |doi=10.1093/nar/gkx658 |pmid=28973455 |pmc=5622323 |volume=45 |issue=17 |date=September 2017 |pages=10284–92 }}</ref>

== Society and culture ==
=== Economics ===
Clindamycin is available as a [[generic medication]] and is relatively inexpensive.<ref name=Ric2015/><ref name=Cun2009>{{cite book | vauthors = Cunha BA |title=Infectious Diseases in Critical Care Medicine |date=2009 |publisher=CRC Press |isbn=978-1-4200-9241-7 |page=506 |url=https://books.google.com/books?id=syasCQAAQBAJ&dq=Cephalexin+inexpensive&pg=PA506 }}</ref>

=== Available forms ===
<!-- Please do not include international trade names and dosages without discussion. -->
[[File:Clindamycin.jpg|thumb|Clindamycin capsules]]
Clindamycin preparations that are taken by mouth include [[Capsule (pharmacy)|capsule]]s (containing clindamycin [[hydrochloride]]) and oral suspensions (containing clindamycin [[palmitate]] hydrochloride).<ref name=Lell2002 /> Oral suspension is not favored for administration of clindamycin to children, due to its extremely foul taste and odor. Clindamycin is formulated in a vaginal cream and as [[Suppository#Vaginal suppositories|vaginal ovules]] for treatment of [[bacterial vaginosis]].<ref name=Lamont/> It is also available for topical administration in [[gel]] form, as a lotion, and in a foam delivery system (each containing clindamycin [[phosphate]]) and a solution in ethanol (containing clindamycin hydrochloride) and is used primarily as a prescription acne treatment.<ref name="Cunliffe">{{cite journal |vauthors=Cunliffe WJ, Holland KT, Bojar R, Levy SF |title=A randomized, double-blind comparison of a clindamycin phosphate/benzoyl peroxide gel formulation and a matching clindamycin gel with respect to microbiologic activity and clinical efficacy in the topical treatment of acne vulgaris |journal=Clin Ther |volume=24 |issue=7 |pages=1117–33 |year=2002 |pmid=12182256|doi=10.1016/S0149-2918(02)80023-6}}</ref>

Several combination acne treatments containing clindamycin are also marketed, such as single-product formulations of clindamycin with [[benzoyl peroxide]]—sold as BenzaClin ([[Sanofi-Aventis]]), [[Duac]] (a [[gel]] form made by [[Stiefel Laboratories|Stiefel]]), and Acanya, among other trade names—and, in the United States, a combination of clindamycin and [[Clindamycin/tretinoin|tretinoin]], sold as [[Ziana]].<ref>{{cite web |url=https://www.medscape.com/viewarticle/548709 |title=FDA Approvals: Ziana, Kadian, Polyphenon E | vauthors = Waknine Y |date=1 December 2006 |access-date=1 December 2007 |website=[[Medscape|Medscape Medical News]] |url-status=live |archive-url=https://web.archive.org/web/20110206012932/http://www.medscape.com/viewarticle/548709 |archive-date=6 February 2011 }}</ref> In India, vaginal suppositories containing clindamycin in combination with [[clotrimazole]] are manufactured by Olive Health Care and sold as Clinsup-V. In Egypt, vaginal cream containing clindamycin produced by Biopharmgroup sold as Vagiclind indicated for vaginosis.{{citation needed|date=December 2019}}

Clindamycin is available as a [[generic drug]], for both systemic (oral and intravenous) and topical use.<ref name=Lell2002 /> (The exception is the vaginal suppository, which is not available as a generic in the US<ref>{{cite web | title=Generic Cleocin Vaginal Availability | website=Drugs.com | url=https://www.drugs.com/availability/generic-cleocin-vaginal.html | access-date=13 October 2019}}</ref>).

== Veterinary use ==
The [[veterinary medicine|veterinary]] uses of clindamycin are quite similar to its human indications, and include treatment of [[osteomyelitis]],<ref>(8 February 2005) [http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/91509.htm "Osteomyelitis"] {{webarchive|url=https://web.archive.org/web/20080107204544/http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm%2Fbc%2F91509.htm |date=7 January 2008 }}, in Kahn, Cynthia M., Line, Scott, Aiello, Susan E. (ed.): ''[[Merck Veterinary Manual|The Merck Veterinary Manual]]'', 9th ed., [[John Wiley & Sons]]. {{ISBN|0-911910-50-6}}. Retrieved 14 December 2007.</ref> skin infections, and [[toxoplasmosis]], for which it is the preferred drug in dogs and cats.<ref>(8 February 2005) [http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/52200.htm "Toxoplasmosis: Introduction"] {{webarchive |url=https://web.archive.org/web/20071220055127/http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm%2Fbc%2F52200.htm |date=20 December 2007}}, in Kahn, Cynthia M., Line, Scott, Aiello, Susan E. (ed.): ''[[Merck Veterinary Manual|The Merck Veterinary Manual]]'', 9th ed., [[John Wiley & Sons]]. {{ISBN|0-911910-50-6}}. Retrieved 14 December 2007.</ref> It can be used both by mouth and topically.<ref name=":1" /> A disadvantage is that bacterial resistance can develop fairly quickly.<ref name=":1" /> Gastrointestinal upset may also occur.<ref name=":1" /> Toxoplasmosis rarely causes symptoms in cats, but can do so in very young or [[immunocompromised]] kittens and cats.{{citation needed|date=December 2019}}

== References ==
{{Reflist}}

== External links ==
* {{ClinicalTrialsGov|NCT04370548|DARE-BV1 in the Treatment of Bacterial Vaginosis (DARE-BVFREE)}}

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