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.
Copyright © 2016 R Bhopal
