Management of chloramphenicol intoxication in infancy by charcoal hemoperfusion

Chloramphenicol toxicity revisited: a 12-year-old patient with a brain abscess

Chloramphenicol, a broad-spectrum antibiotic, is rarely used in the United States due to its well-described adverse effects. Because of its limited use, many clinicians are unfamiliar with its indications, spectrum of activity, and potential adverse drug effects. We describe a 12-year-old patient who presented after two craniotomies for a persistent brain abscess complicated by long-term chloramphenicol administration. Findings for this patient were consistent with many of the adverse drug effects associated with chloramphenicol, including elevated chloramphenicol serum concentrations, anemia, thrombocytopenia, reticulocytopenia, and severe metabolic acidosis. Rare manifestations of chloramphenicol toxicity that developed in this patient included neutropenia, visual field changes, and peripheral neuropathy. Chloramphenicol administration was discontinued, and hemodialysis was initiated for severe metabolic acidosis. The patient recovered with severe visual field deficits. Although chloramphenicol is rarely indicated, it remains an effective antibiotic. Healthcare providers should become familiar with the pharmacology, toxicology, and monitoring parameters for appropriate use of this antibiotic.

Chloramphenicol toxicity associated with severe cardiac dysfunction

A 9-month-old infant experienced severe chloramphenicol toxicity associated with high serum levels (313 micrograms/ml). Cardiovascular collapse with cardiomyopathic changes and impaired left ventricular function was documented by echocardiography. Serial echocardiographic evaluation showed resolution of the cardiomyopathic findings as the chloramphenicol levels were spontaneously cleared. Clinical course was complicated by the development of liver disease and coagulopathy compatible with disseminated intravascular consumption. Patient's recovery was complete and uneventful, nevertheless, chloramphenicol toxicity in childhood is associated with a significant mortality rate of 40%. The related impaired cardiac function, although reversible, appears to play a major role in the pathogenesis and eventual outcome in this syndrome.

Antimicrobial therapy for pediatric patients

New antimicrobial agents are being introduced for clinical use at an increasingly rapid rate. This has required physicians continually to review relevant data and determine unique properties that might guide selection among any new antibiotics as well as older ones. Efficacy, potential toxicity, and comparative cost (in that order) generally guide selection. The present comprehensive review examines currently available antibiotics along with some under investigation, emphasizing these three basic areas of consideration.

The new black magic: activated charcoal and new therapeutic uses

Activated charcoal has been used for centuries as antidotal therapy for poisonings. New variations of charcoal therapy have developed over the last two decades. These modifications include multiple-dose activated charcoal (MDAC) therapy, charcoal hemoperfusion, and a new "superactive" charcoal (SAC). Recent literature suggests using initial charcoal therapy instead of ipecac as a first-line antidotal agent for many acute poisonings. The palatability of charcoal slurries has been enhanced by the addition of carboxymethylcellulose, sucrose, saccharin, chocolate syrup, or sorbitol. The new SAC has shown to adsorb 1.7 to 4 times the amount of substance tested compared with other activated charcoal preparations. Multiple-dose activated charcoal therapy has been shown effective in treating phenobarbital, digoxin, digitoxin, theophylline, and dapsone intoxications, among others. The problems associated with charcoal hemoperfusion therapy have been partially alleviated, and it is now alternative therapy for the seriously intoxicated patient.

Acidosis as a presenting feature of chloramphenicol toxicity

Metabolic acidosis has previously been described in the gray baby syndrome, but has not been documented as a presenting feature. Four seriously ill children (bronchiolitis, hypoaldosteronism, dysautonomia, Reye syndrome), ages 4 months to 11 years, received chloramphenicol (CAP) intravenously. After initial stabilization, unexplained metabolic acidosis occurred 40 to 81 hours after beginning CAP. Serum CAP concentrations were 84, 62, 80, and 30 micrograms/ml, respectively, when acidosis was recognized. Hypotension, hypothermia, and abdominal distension occurred a mean of 23 hours after the onset of acidosis. Acidosis resolved and signs of the gray baby syndrome cleared with the decrease in serum CAP concentrations. Metabolic acidosis should be considered an early sign of CAP toxicity, and CAP should be used in reduced doses in severely ill patients, especially those with liver dysfunction.