Pharmaceutical
Microbiology (Note 3)
MCB 525
500 Level
Chloramphenicol
Chloramphenicol,
also known as chlornitromycin, is effective against a wide variety of Gram-positive and Gram-negative bacteria, including most anaerobic organisms. Due to resistance and safety
concerns, it is no longer a first-line agent for any infection in developed nations, with the notable
exception of topical treatment of bacterial conjunctivitis. Nevertheless, the global problem of advancing bacterial resistance
to newer drugs has led to renewed interest in its use. In low-income countries,
chloramphenicol is still widely used because it is inexpensive and readily
available.
Pure
chloramphenicol
History
Chloramphenicol
was originally derived from the bacterium Streptomyces
venezuelae,
isolated by David Gottlieb, and introduced into clinical
practice in 1949, under the trade name Chloromycetin. It was the first
antibiotic to be manufactured synthetically on a large scale.
Spectrum of activity
Chloramphenicol
has a broad spectrum of activity and has been effective in treating ocular
infections caused by a number of bacteria including Staphylococcus aureus,
Streptococcus pneumoniae, and Escherichia coli. Chloramphenicol is
not effective against Pseudomonas aeruginosa. The following represents MIC
susceptibility data for a few medically significant organisms.
- Escherichia
coli:
0.015 μg/mL - 10,000 μg/mL
- Staphylococcus
aureus:
0.06 μg/mL - >128 μg/mL
- Streptococcus
pneumoniae:
2 μg/mL - 16 μg/mL
Therapeutic uses
The original indication of
chloramphenicol was in the treatment of typhoid, but the now almost universal presence of multiple
drug-resistant Salmonella typhi has meant it is seldom used for
this indication except when the organism is known to be sensitive.
Chloramphenicol may be used as a second-line agent in the treatment of tetracycline-resistant cholera.
Because
of its excellent blood-brain barrier penetration (far superior to any of
the cephalosporins), chloramphenicol remains the first
choice treatment for staphylococcal brain abscesses. It is also useful in the treatment of brain abscesses due
to mixed organisms or when the causative organism is not known.
Although
unpublished, recent research suggests chloramphenicol could also be applied to
frogs to prevent their widespread destruction from fungal infections. Chloramphenicol has recently been discovered to be a
life-saving cure for chytridiomycosis in amphibians. Chytridiomycosis is a fungal disease, blamed for the
extinction of one-third of the 120 frog species lost since 1980.
Adverse effects
Aplastic anemia
The
most serious side effect of chloramphenicol treatment is aplastic anaemia. This effect is rare and is generally fatal: there is no
treatment and no way of predicting who may or may not get this side effect. The
effect usually occurs weeks or months after chloramphenicol treatment has been
stopped, and there may be a genetic predisposition. It is not known whether
monitoring the blood counts of patients can prevent the
development of aplastic anaemia, but patients are recommended to have a blood
count check twice weekly while on treatment. The highest risk is with oral
chloramphenicol (affecting 1 in 24,000–40,000) and the lowest risk occurs with
eye drops (affecting less than 1 in 224,716 prescriptions).
Thiamphenicol, a related compound with a similar spectrum of activity, is
available in Italy and China for human use, and has never been associated with
aplastic anaemia. Thiamphenicol is available in the U.S. and Europe
as a veterinary antibiotic, and is not approved for use in humans.
Bone marrow suppression
Chloramphenicol
may cause bone marrow
suppression
during treatment; this is a direct toxic effect of the drug on human mitochondria. This effect manifests first as a fall in hemoglobin levels, which occurs quite predictably once a cumulative
dose of 20 g has been given. The anaemia is fully reversible once the drug is
stopped and does not predict future development of aplastic anaemia. Studies in
mice have suggested that existing marrow damage may compound any marrow damage
resulting from the toxic effects of chloramphenicol.
Leukemia
Leukemia
is a type of cancer of the blood or bone marrow characterized by an abnormal
increase of immature white blood cells. There is an increased risk of childhood
leukemia, as demonstrated in a Chinese case-controlled
study, and the
risk increases with length of treatment.
Gray baby syndrome
Intravenous
chloramphenicol use has been associated with the so-called gray baby syndrome. This phenomenon occurs in newborn
infants because they do not yet have fully functional liver enzymes (i.e.
UDP-glucuronyl transferase), so chloramphenicol remains unmetabolized in the
body. This causes several adverse effects, including hypotension and cyanosis. The condition can be prevented by using the drug at the
recommended doses, and monitoring blood levels.
Pharmacokinetics
Chloramphenicol
is extremely lipid soluble; it remains relatively unbound to protein and is a small molecule. It has a
large apparent volume of
distribution
of 100 litres, and penetrates effectively into all tissues of the body,
including the brain. The concentration achieved in brain and cerebrospinal fluid (CSF) is around 30 to 50%, even
when the meninges are not inflamed; this increases to as high as 89% when the
meninges are inflamed.
Chloramphenicol
increases the absorption of iron.
Use in special populations
Chloramphenicol
is metabolized by the liver to chloramphenicol glucuronate (which is inactive). In liver impairment, the dose of
chloramphenicol must therefore be reduced. There is no standard dose reduction
for chloramphenicol in liver impairment, and the dose should be adjusted
according to measured plasma concentrations.
The
majority of the chloramphenicol dose is excreted by the kidneys as the inactive
metabolite, chloramphenicol glucuronate. Only a tiny fraction of the
chloramphenicol is excreted by the kidneys unchanged. Plasma levels should be monitored
in patients with renal impairment, but this is not mandatory. Chloramphenicol
succinate ester (an intravenous prodrug form) is readily excreted unchanged by the kidneys, more so
than chloramphenicol base, and this is the major reason why levels of
chloramphenicol in the blood are much lower when given intravenously than
orally.
Chloramphenicol
passes into breast milk, so should therefore be avoided
during breast feeding, if possible.
Dose monitoring
Plasma levels of chloramphenicol must be monitored in neonates and
in patients with abnormal liver function. Plasma levels should be monitored in
all children under the age of four, the elderly and patients with renal
failure. Peak levels (one hour after the dose is given) should be 15–25 mg/l; trough levels (taken immediately
before a dose) should be less than 15 mg/l.
Drug interactions
Administration
of chloramphenicol concomitantly with bone marrow depressant drugs is
contraindicated, although concerns over aplastic anaemia associated with ocular chloramphenicol have largely been
discounted.
Chloramphenicol
is a potent inhibitor of the cytochrome P450 isoforms CYP2C19 and CYP3A4 in the liver. Inhibition of CYP2C19 causes decreased
metabolism and therefore increased levels of, for example, antidepressants, antiepileptics and proton pump
inhibitors if they
are given concomitantly. Inhibition of CYP3A4 causes increased levels of, for
example, calcium channel
blockers, immunosuppressants, chemotherapeutic
drugs, benzodiazepines, azole antifungals, tricyclic
antidepressants,
macrolide antibiotics, SSRIs, statins and PDE5 inhibitors.
Mechanism of action
Chloramphenicol
is a bacteriostatic drug that stops bacterial growth by
inhibiting protein
synthesis.
Chloramphenicol prevents protein chain elongation by inhibiting the peptidyl transferase activity of the bacterial ribosome. It specifically binds to A2451 and A2452 residues in the 23S rRNA of the 50S ribosomal subunit, preventing peptide bond
formation. While chloramphenicol and the macrolide class of antibiotics both interact with ribosomes,
chloramphenicol is not a macrolide. It directly interferes with substrate
binding, whereas macrolides sterically block the progression of the growing
peptide.
Resistance
There
are three mechanisms of resistance to chloramphenicol: reduced
membrane permeability, mutation of the 50S ribosomal subunit and elaboration of
chloramphenicol acetyltransferase. It is easy to select for reduced membrane
permeability to chloramphenicol in vitro by serial passage of bacteria,
and this is the most common mechanism of low-level chloramphenicol resistance.
High-level resistance is conferred by the cat-gene; this gene codes for an enzyme called chloramphenicol
acetyltransferase,
which inactivates chloramphenicol by covalently linking one or two acetyl groups, derived from
acetyl-S-coenzyme A, to the hydroxyl groups on the chloramphenicol molecule. The acetylation
prevents chloramphenicol from binding to the ribosome. Resistance-conferring
mutations of the 50S ribosomal subunit are rare.
Chloramphenicol
resistance may be carried on a plasmid that also codes for resistance to other
drugs. One example is the ACCoT plasmid (A=ampicillin, C=chloramphenicol, Co=co-trimoxazole, T=tetracycline), which mediates multiple-drug resistance in typhoid.
Formulations
Chloramphenicol
is available as 250 mg capsules or as a liquid (125 mg/5 mL). In
some countries, it is sold as chloramphenicol palmitate ester (CPE). CPE is inactive, and is hydrolysed to active chloramphenicol in the small intestine. There is no difference in bioavailability between chloramphenicol and CPE.
Manufacture
of oral chloramphenicol in the U.S. stopped in 1991, because the vast majority
of chloramphenicol-associated cases of aplastic anaemia are associated with the oral preparation. There is now no
oral formulation of chloramphenicol available in the U.S.
In
molecular biology, chloramphenicol is prepared as 25–50 mg/mL stock in
ethanol.
Intravenous
The
intravenous (IV) preparation of chloramphenicol is the succinate ester, because pure chloramphenicol does not dissolve in water.
This creates a problem: Chloramphenicol succinate ester is an inactive prodrug and must first be hydrolysed to chloramphenicol; however,
the hydrolysis process is often incomplete, and 30% of the dose is lost and
removed in the urine. Serum concentrations of IV chloramphenicol are only 70%
of those achieved when chloramphenicol is given orally. For this reason, the
dose needs to be increased to 75 mg/kg/day when administered IV to achieve
levels equivalent to the oral dose.
Oily
Oily
chloramphenicol (or chloramphenicol oil suspension) is a long-acting preparation
of chloramphenicol first introduced by Roussel in 1954; marketed as Tifomycine,
it was originally used as a treatment for typhoid. Roussel stopped production of oily chloramphenicol in
1995; the International Dispensary Association has manufactured it since 1998,
first in Malta and then in India from December 2004.
Eye drops
In
the West, chloramphenicol is still widely
used in topical preparations (ointments and eye drops) for the treatment of bacterial conjunctivitis. Isolated case reports of aplastic anaemia following use of chloramphenicol eyedrops exist, but the
risk is estimated to be less than 1 in 224,716 prescriptions. In Mexico, this is the treatment used
prophylactically in newborns.
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