the pitfalls of topical chloramphenicol use

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Rickesh Bhopal OMFS SHO, Tun Wildan OMFS StR, Anne Hicks OMFS Sister, Phillip Ameerally OMFS Consultant. Northampton General Hospital, Northampton, ...
THE  PITFALLS  OF  TOPICAL  CHLORAMPHENICOL  USE  

Rickesh  Bhopal  OMFS  SHO,  Tun  Wildan  OMFS  StR,  Anne  Hicks  OMFS  Sister,  Phillip  Ameerally  OMFS  Consultant.     Northampton  General  Hospital,  Northampton,  UK  

Figure 1.

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INTRODUCTION   Chloramphenicol   is   a   bacteriosta+c   an+bio+c   that   exerts   its   mechanism  of  ac+on  through  the  inhibi+on  of  protein  synthesis.   It  has  a  broad  spectrum  of  ac+vity  against  Gram  posi+ve  and  Gram   nega+ve  bacteria,  including  Staphylococcus  aureus.1   The  primary  use  of  topical  chloramphenicol  ointment  is  treatment   of  bacterial  conjunc+vi+s.   Chloramphenicol   is   commonly   used   amongst   as   a   prophylaxis   against  wound  infec+ons  on  suture  lines  and  skin  gra]s.     Chloramphenicol  may  cause  contact  derma++s,  anaphylac+c  shock   and  aplas+c  anaemia.   Topical   chloramphenicol   is   very   rarely   prescribed   in   the   United   States,  compared  to  its  widespread  use  in  the  United  Kingdom  and   Australia.2  

CASE  1   A   62   year   old   female   had   an   excision   of   a   basal   cell   carcinoma   (BCC)   from   her   right   anterior   scalp   with   a   full   thickness   skin   gra].   Chloramphenicol   ointment   was   applied   to   the   wound   sites   post-­‐ opera+vely,   and   con+nued   three   +mes   a   day.   48   hours   later,   she   presented  with  both  excision  and  donor  sites  being  extremely  pruri+c   and  erythematous  (Figure  2  and  3).  Swabs  were  taken  for  culture  and   sensi+vity.   She   was   started   on   oral   penicillin   and   flucloxacillin   and   prescribed  an+histamines.  Chloramphenicol  ointment  was  halted.  At  2   week  review,  all  symptoms  had  resolved.                                     Figure 2.   CASE  2   A   33   year   old   male   sustained   +ssue   loss   on   the   nasal   +p   from   a   dog   bite   and   the   area   reconstructed   with   a   paramedian   forehead   flap.   Chloramphenicol   was   applied   over   a   three-­‐month   period   during   the   course  of  treatment.  The  wound  sites  became  erythematous  and  both   eyes   swollen.   A   clinical   diagnosis   of   bilateral   periorbital   celluli+s   was   made   and   he   was   treated   accordingly   with   IV   an+bio+cs   with   liele   success.   Chloramphenicol   was   then   stopped   and   the   pa+ent’s   symptoms    seeled.       REFERENCEES  

1.  2.  3.  4.  5.  6.   

Therapeu+c  guidelines:  an+bio+c.  Version  13.  North  Melbourne,  Victoria:  Therapeu+c  Guidelines,  2006.   Rayner  SA,  Buckley  RJ.  Ocular  chloramphenicol  and  aplas+c  anaemia:  is  there  a  link?  Drug  Saf1996;14:273-­‐6.   Schewach-­‐Millet  M,  Shapiro  D,  "Ur+caria  and  angioedema  due  to  topically  applied  chloramphenicol  ointment",  Arch.  Dermatol.,  1985  ;  121:  587.   Marks  JG,  Belsiion  DV,  DeLeo  VA,  Fowler  JF,  Fransway  AF,  Maibach  HI,  et  al.  North  American  contact  derma++s  group  patch  test  results  for  the  detec+on  of   delayed-­‐type  hypersensi+vity  to  topical  allergens.  J  Am  Acad  Dermatol1998;38:911-­‐8.   Blondeel  A,  Oleffe  J,  Achten  G.  Contact  allergy  in  330  dermatological  pa+ents.  Contact  Derma++s1978;4:270-­‐6.   Heal  CF  et  al.  Does  single  applica+on  of  topical  chloramphenicol  to  high  risk  sutured  wounds  reduce  incidence  of  wound  infec+on  a]er  minor  surgery?  Prospec+ve   randomised  placebo  controlled  double  blind  trial  BMJ  2009;338:a2812    

Figure 3. CASE  3   A   53   year   old   female   had   excision   of   a   BCC   from   the   le]   cheek   and   repair   with   a   rhomboid   transposi+on   flap.   15   days   post-­‐opera+vely   she   presented   with   an   erythematous   and   weeping   wound   from   the   le]  cheek.  Flucloxacillin  was  prescribed  and  chloramphenicol  ointment   use  was  ceased.  At  one  month  review,  her  symptoms  had  completely   resolved.   §  §  §  §  §  §  §  § 

                                 

DISCUSSION   The  pa+ents  in  our  cases  developed  a  delayed-­‐type  hypersensi+vity   derma++s  following  topical  chloramphenicol  ointment  use   This   could   be   confirmed   with   cutaneous   tes+ng   with   a   posi+ve   scratch  and  patch  test  to  chloramphenicol.     The  dichloroacetamide  ring  (Figure  1)  is  probably  the  major  an+genic   determinant.3     The   delayed   onset   complicated   the   possible   diagnoses   and   it   was   only   when   an+bio+c   therapy   was   unsuccessful   that   allergic   reac+ons   were  considered.     The   incidence   of   allergic   contact   derma++s   with   use   of   topical   an+bio+cs  can  be  as  high  as  11%,  especially  for  topical  neomycin.4     Incidence  is  thought  to  be  very  uncommon  with  chloramphenicol.5     A  protocol  for  24-­‐72  hour  post-­‐opera+ve  erythema  and  swelling  has   now  been  proposed  by  our  department  (Figure  4).     We   have   now   implemented   using   a   single   applica+on   of   chloramphenicol  to  high  risk  sutured  wounds.  It  has  been  suggested   that   this   can   reduce   infec+on   by   40%   and   prevent   con+nued   exposure   to   this   medica+on.6     We   have   had   no   reac+ons   since   employing  this  method  at  Northampton  General  Hospital.  

Figure 4.

CONCLUSION   Vigilance   is   essen+al   in   pa+ents   that   display   the   symptoms   reported   within   this   case   series.   Appropriate   management   of   delayed-­‐type   hypersensi+vity   to   chloramphenicol   is   key   to   prevent   further   poten+ally   serious  health  consequences.    

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