Adult pure red cell aplasia following topical ocular chloramphenicol

Topical Chloramphenicol in Ophthalmology: Old is Gold

PURPOSE

Topical chloramphenicol is one of the most ubiquitous antibiotics used in ophthalmology and oculoplastic surgery globally. It shows broad-spectrum activity against a variety of different pathogenic organisms, is well tolerated on the ocular surface and displays excellent topical pharmacokinetics. Chloramphenicol has been available for purchase over the counter in the United Kingdom since 2005. Despite this, the largest health economy in the world, The United States has had a de-facto moratorium on its use for the past 30 years. In this review, we aim to evaluate topical chloramphenicol in ophthalmology and oculoplastic surgery and to determine whether its reputation within the US is warranted and justified.

METHODS

We conducted a comprehensive literature review to evaluate the different facets of chloramphenicol, providing a detailed understanding of the drug, its historical context, the benefits and perceived risks, including safety concerns, and clinical perspectives of its use in clinical practice.

RESULTS

The mechanism of chloramphenicol, the context around which the drug's use in the US declined, and the drug's evidence base and safety data, including published case reports of serious adverse events, were analysed. The perceived benefits of the drug, particularly in light of antimicrobial resistance and its economic impact, were reviewed. Finally, perspectives on its use in clinical practice in ophthalmology and associated allied specialities were presented.

CONCLUSION

Chloramphenicol and its topical application have been misunderstood for many decades, particularly in the United States. Its demise across the Atlantic was due to an overzealous response to a dubious association with a weak evidence base. Numerous authors have since validated the safety profile of the and its safety has been borne out. The benefits of chloramphenicol, an effective broad-spectrum agent with a positive cost differential in the era of anti-microbial resistance and fiscal tightening, cannot be understated. Its likely effectiveness as a therapeutic topical agent in ophthalmic surgery makes it a valuable tool in the ophthalmic anti-microbial armoury. We would encourage the reinstatement of this valuable yet misunderstood drug as a first-line agent for simple ophthalmic infections.

Drug-induced and antibody-mediated pure red cell aplasia: a review of literature and current knowledge

Anti-erythropoietin (EPO)-induced pure red cell aplasia (PRCA) is an uncommon, potentially life-threatening condition in which the bone marrow stops manufacturing red blood cells. In the past few years, reports of drug-induced, anti-EPO antibody-mediated PRCA have increased substantially, with most cases attributed to the use of one erythropoiesis-stimulating protein, Eprex. A literature review was undertaken to document the reports of drug-induced PRCA, with all drugs and drug regimens. The sudden increase in reports of antibody-mediated PRCA is discussed.

Lack of evidence for systemic toxicity following topical chloramphenicol use

There has been considerable controversy regarding the safety of topical chloramphenicol in ophthalmic practice. The evidence for associated haematopoietic toxicity in idiosyncratic and dose-dependent forms was reviewed. The 7 cases of idiosyncratic haematopoietic reactions associated with topical chloramphenicol reported in the literature are refutable evidence for the existence of such a response. In Scotland, despite extensive prescription of topical chloramphenicol, the incidence of acquired aplastic anaemia was found to be low, as were associated reports of blood dyscrasias throughout the UK. The epidemiology of acquired aplastic anaemia failed to make an association with topical chloramphenicol use. High-performance liquid chromatography (minimum detection limit 1 mg/l) was used to investigate whether serum accumulation of chloramphenicol occurred after topical therapy in 40 patients. The mean dose of chloramphenicol eye drops used after 1 week of treatment was 8.0 mg, and after 2 weeks, 15.3 mg. As expected, chloramphenicol failed to accumulate to detectable levels. This supported the view that topical chloramphenicol was not a risk factor for inducing dose-related bone marrow toxicity. Calls for the abolition of treatment with topical chloramphenicol based on current data are not supported.

Possible association between ocular chloramphenicol and aplastic anaemia--the absolute risk is very low

AIMS

To determine whether topical ocular chloramphenicol increases the risk of aplastic anaemia and to estimate the magnitude of this risk, if any.

METHODS

Population-based prospective case-control surveillance of aplastic anaemia in a community of 4.2 million inhabitants from 1980 to 1995 (67.2 million person-years) plus case-population estimate of the risk, based on sales figures of ocular chloramphenicol in the study area during the study period.

RESULTS

One hundred and forty-five patients with aplastic anaemia and 1,226 controls were included in the analysis. Three cases (2.1%) and 5 controls (0.4%) had been exposed to ocular chloramphenicol during the relevant etiological period. The adjusted odds ratio was 3.77 (95% confidence interval, 0.84-16.90). Two cases had also been exposed to other known causes of aplastic anaemia. The incidence of aplastic anaemia among users of ocular chloramphenicol was 0.36 cases per million weeks of treatment. The incidence among non users was 0.04 cases per million weeks.

CONCLUSIONS

An association between ocular chloramphenicol and aplastic anaemia cannot be excluded. However, the risk is less than one per million treatment courses.

Ocular chloramphenicol and aplastic anaemia. Is there a link?

The question of a link between the use of topical ocular chloramphenicol and the incidence of aplastic anaemia continues to be a controversial issue in ophthalmological spheres. At present topical ocular chloramphenicol is widely used in the UK for the treatment of conjunctivitis, whereas it is very rarely prescribed for this indication in the U.S. Individual policies vary around the rest of the world. The evidence for and against any association between topical and ocular chloramphenicol and an increased risk of aplastic anaemia is reviewed, and the reasons behind the current prescribing policies are clarified. The discussion generated in the literature over the past 2 years over this issue is considered, along with the published debate from the past 3 decades. The debate is not conclusive, but by presenting or referencing the specific case reports and the published opinions of various experts, we hope to enable the reader to make his or her own informed decision as to whether use of the topical preparation of chloramphenicol should be considered by the ophthalmological community.