Chloromycetin (Chloramphenicol)

Chloramphenicol Antibiotic

Chloramphenicol is a synthetic antibiotic that is active in vitro against many Gram-positive and Gram-negative aerobic bacteria.

Uses

Chloramphenicol should be used only for the treatment of serious infections caused by susceptible bacteria or rickettsiae when potentially less toxic drugs are ineffective or contraindicated. The drug must not be used for the treatment of trivial infections, as a prophylactic agent to prevent bacterial infections, or when it is not indicated (e.g., for colds, influenza, or sore throat). Prior to initiation of chloramphenicol therapy, appropriate specimens should be collected for identification of the causative organism and in vitro susceptibility tests. Chloramphenicol therapy may be started pending results of susceptibility tests, but the drug should be discontinued if tests show the causative organism to be resistant to chloramphenicol or if the organism is found to be susceptible to potentially less toxic drugs.

Typhoid Fever and Other Salmonella Infections

Chloramphenicol is used in the treatment of typhoid fever (enteric fever) caused by susceptible Salmonella Typhi. Various anti-infectives have been used for the treatment of typhoid fever, including chloramphenicol, ampicillin, amoxicillin, co-trimoxazole, cefotaxime, ceftriaxone, fluoroquinolones, and azithromycin.

Multidrug-resistant strains of S. Typhi (i.e., strains resistant to ampicillin, chloramphenicol, and/or co-trimoxazole) have been reported with increasing frequency, and a third-generation cephalosporin (e.g., ceftriaxone, cefotaxime) or a fluoroquinolone (e.g., ciprofloxacin, ofloxacin) are considered the drugs of first choice for the treatment of typhoid fever or other severe infections known or suspected to be caused by these strains. Although the time to defervescence in typhoid fever reportedly is faster with chloramphenicol therapy than with ampicillin therapy, results of a few controlled studies indicate that response time is slower with chloramphenicol than with amoxicillin.

There is some evidence that up to 10% of patients who receive chloramphenicol for the treatment of typhoid fever become temporary or permanent carriers of S. Typhi. Amoxicillin, co-trimoxazole, or a fluoroquinolone (e.g., ciprofloxacin) generally are the drugs of choice to treat the typhoid carrier state; chloramphenicol should not be used to treat S. Typhi carriers.

Meningitis

Chloramphenicol is used for the treatment of meningitis caused by susceptible bacteria, including susceptible strains of Neisseria meningitidis, Haemophilus influenzae, or Streptococcus pneumoniae. However, chloramphenicol is not considered a drug of first choice for meningitis and generally is used only when penicillins and cephalosporins are contraindicated or ineffective.

Chloramphenicol should not be used for the treatment of meningitis caused by Gram-negative bacilli and, despite evidence of in vitro activity against Listeria monocytogenes, the drug usually is ineffective for meningitis caused by this organism.

While IV ampicillin used in conjunction with IV chloramphenicol previously was considered a regimen of choice for empiric treatment of meningitis in children and infants 1 month of age or older, most clinicians now recommend an empiric regimen of IV ampicillin and either IV ceftriaxone or IV cefotaxime in this age group.

Pending results of CSF culture and in vitro susceptibility testing, the most appropriate empiric anti-infective regimen for suspected bacterial meningitis should be selected based on results of CSF Gram stain and antigen tests, patient age, the most likely pathogen(s) and source of infection, and current patterns of bacterial resistance within the hospital and local community.

When results of culture and susceptibility tests become available and the pathogen is identified, the empiric regimen should be modified (if necessary) to ensure that the most effective regimen is being administered.

Chloramphenicol is used as an alternative to penicillins and cephalosporins for meningitis caused by penicillin-susceptible S. pneumoniae. However, treatment failures have been reported when chloramphenicol was used for infections caused by penicillin-resistant S. pneumoniae, despite in vitro susceptibility.

It has been suggested that chloramphenicol may have had only bacteriostatic activity in these patients, and the drug probably should be used for meningitis caused by penicillin-resistant S. pneumoniae only if in vitro tests indicate that the minimum bactericidal concentration (MBC) is 4 mcg/mL or less. Because there are insufficient data regarding efficacy of chloramphenicol given in conjunction with other anti-infectives for meningitis caused by penicillin-resistant S. pneumoniae, the American Academy of Pediatrics (AAP) states that such regimens cannot be recommended for these infections.

For information on treatment of meningitis caused by S. pneumoniae, including strains with reduced susceptibility to penicillins and/or cephalosporins, see Meningitis Caused by Streptococcus pneumoniae under Uses: Meningitis and Other CNS Infections in Ceftriaxone 8:12.06.

Chloramphenicol can be used as an alternative to penicillins and cephalosporins for meningitis caused by beta-lactamase-producing or non-beta-lactamase-producing H. influenzae. While chloramphenicol-resistant H. influenzae have been reported in some areas of the world, these strains are relatively rare in the US. While many clinicians suggest ceftriaxone or cefotaxime for initial treatment of meningitis caused by H. influenzae, the AAP suggests that children with meningitis possibly caused by H. influenzae also could receive an initial regimen of ampicillin given in conjunction with chloramphenicol.

The incidence of H. influenzae meningitis in the US has decreased considerably since H. influenzae type b conjugate vaccines became available. Although IV penicillin G is considered the drug of choice for meningitis caused by N. meningitidis and ceftriaxone or cefotaxime the preferred alternatives (especially for penicillin-resistant strains), chloramphenicol is considered an alternative to penicillins and cephalosporins for N. meningitidis meningitis. Strains of N. meningitidis resistant to chloramphenicol have been isolated from some meningitis patients in certain regions (e.g., Vietnam, France) and may be a concern in developing countries where chloramphenicol is routinely used for meningococcal meningitis.

Anthrax

Chloramphenicol is used as an alternative agent in the treatment of anthrax. Parenteral penicillins generally have been considered the drugs of choice for naturally occurring or endemic anthrax caused by susceptible Bacillus anthracis, including clinically apparent GI, inhalational, or meningeal anthrax and anthrax septicemia, although IV ciprofloxacin or IV doxycycline also are recommended.

Chloramphenicol is suggested as an alternative to penicillin G for use in patients hypersensitive to penicillins, especially for anthrax meningoencephalitis. For inhalational anthrax resulting from exposure to B. anthracis spores in the context of biologic warfare or bioterrorism, the US Centers for Disease Control and Prevention (CDC) and the US Working Group on Civilian Biodefense recommend initiating a multiple-drug parenteral regimen that includes ciprofloxacin or doxycycline and 1 or 2 additional anti-infective agents predicted to be effective.

Based on in vitro data, drugs suggested as possibilities to augment ciprofloxacin or doxycycline include chloramphenicol, clindamycin, rifampin, vancomycin, clarithromycin, imipenem, penicillin, or ampicillin. If meningitis is established or suspected, some clinicians suggest a multiple-drug regimen that includes ciprofloxacin (rather than doxycycline) and chloramphenicol, rifampin, or penicillin.

There is evidence that chloramphenicol has in vitro activity against B. anthracis; however, limited or no clinical data exist regarding its use in anthrax, and efficacy has not been evaluated in human or animal studies. IV anti-infective therapy is recommended for the initial treatment of clinically apparent GI, inhalational, or meningeal anthrax and anthrax septicemia and also is indicated for cutaneous anthrax when there are signs of systemic involvement, extensive edema, or head and neck lesions. For additional information on treatment of anthrax and recommendations for prophylaxis following exposure to anthrax spores, see Uses: Anthrax, in Ciprofloxacin 8:12.18.

Rickettsial Infections

Although tetracyclines generally are the drugs of choice for Rocky Mountain spotted fever and other rickettsial infections, chloramphenicol is used when tetracyclines cannot be used. Chloramphenicol generally is considered the drug of choice for rickettsial infections in children younger than 8 years of age and in pregnant women (see Cautions: Pregnancy and Lactation) since tetracyclines should be avoided in these patients; however, some clinicians suggest weighing the risk of serious, sometimes fatal, adverse effects associated with chloramphenicol against the risks of tetracyclines (e.g., tooth discoloration) in these patients.

Anaerobic and Mixed Aerobic-Anaerobic Bacterial Infections

Chloramphenicol has been used for orofacial, intra-abdominal, or soft-tissue anaerobic bacterial infections, but generally is used only when other appropriate anti-infectives (e.g., metronidazole, clindamycin) are contraindicated or ineffective. Some clinicians suggest that chloramphenicol can be used as an alternative for infections caused by Clostridium perfringens, Fusobacterium, or Bacteroides when first-choice drugs and other less toxic alternatives cannot be used.

Cholera

Chloramphenicol has been used as an adjunct to fluid and electrolyte replacement in cholera (Vibrio cholerae). While tetracyclines are considered the drugs of choice, fluoroquinolones, furazolidone, co-trimoxazole, or chloramphenicol are considered alternative agents.

Burkholderia Infections: Melioidosis

Chloramphenicol is used in conjunction with doxycycline and co-trimoxazole for melioidosis, a life-threatening disease caused by Burkholderia pseudomallei (formerly Pseudomonas pseudomallei). B. pseudomallei is an aerobic, nonfermentative Gram-negative bacillus resistant to many anti-infective agents. Ceftazidime monotherapy is considered by many clinicians to be the drug of choice for severe melioidosis and has been associated with a lower mortality rate than a three-drug regimen of IV chloramphenicol, oral doxycycline, and oral co-trimoxazole.

Other drugs recommended as alternatives include amoxicillin/clavulanate, imipenem, or meropenem. B. pseudomallei is difficult to eradicate, and relapse is common. Therefore, therapy usually is continued for 6 weeks to 6 months or, alternatively, a parenteral agent (e.g., ceftazidime) is given for at least 1-2 weeks followed by an oral agent (e.g., amoxicillin/clavulanate) for at least 3-6 months.

Glanders

Some clinicians suggest that chloramphenicol and streptomycin can be used as an alternative to tetracycline and streptomycin for glanders caused by B. mallei (formerly Pseudomonas mallei).

Burkholderia cepacia Infections

Some clinicians suggest that chloramphenicol can be used for infections caused by Burkholderia cepacia (formerly Pseudomonas cepacia). Patients with cystic fibrosis often are colonized with B. cepacia (with or without Pseudomonas aeruginosa colonization). In addition, B. cepacia has been recognized as a cause of nosocomial pneumonia in immunocompromised patients. B. cepacia is an aerobic, nonfermentative Gram-negative bacillus resistant to many anti-infectives, and no regimen has been identified that reliably eradicates the organism in colonized cystic fibrosis patients. Some clinicians consider co-trimoxazole the drug of choice and ceftazidime, chloramphenicol, and imipenem alternative agents.

Plague

Chloramphenicol is used as an alternative agent for plague caused by Yersinia pestis. Streptomycin (or gentamicin) generally is considered the drug of choice. Alternatives when aminoglycosides are not used include doxycycline (or tetracycline), chloramphenicol, or co-trimoxazole (which may be less effective than other alternatives); based on in vitro and animal testing, ciprofloxacin (or another fluoroquinolone) also is recommended as an alternative. Chloramphenicol generally is considered the drug of choice for plague meningitis. Regimens recommended for naturally occurring bubonic, septicemic, or pneumonic plague also are recommended for plague following exposure in the context of biologic warfare or bioterrorism.

Such exposures would most likely result in primary pneumonic plague. Prompt initiation of therapy (within 18-24 hours of symptom onset) is essential. Some experts recommend initiating parenteral therapy with streptomycin (or gentamicin) or, alternatively, doxycycline, ciprofloxacin, or chloramphenicol, with a switch to oral therapy (doxycycline, ciprofloxacin) when the patient improves or if parenteral therapy is unavailable.

Postexposure prophylaxis is recommended after high-risk exposures. An oral regimen of doxycycline or ciprofloxacin usually is recommended for prophylaxis. Although some experts suggest oral chloramphenicol as an alternative, oral chloramphenicol is no longer commercially available in the US.

Tularemia

Chloramphenicol is used as an alternative to streptomycin (or gentamicin) for tularemia caused by Francisella tularensis. Other alternatives include tetracyclines (doxycycline) or ciprofloxacin. Gentamicin may be as effective as streptomycin, but clinical relapse occurs more frequently with tetracyclines or chloramphenicol.

Regimens recommended for endemic tularemia also are recommended for tularemia following exposure in the context of biologic warfare or bioterrorism; however, development of streptomycin-resistant strains in such contexts should be considered.

Exposures would most likely result in inhalational tularemia with pleuropneumonitis, although infection also can occur via skin, mucous membranes, and the GI tract. For postexposure prophylaxis, see Uses: Tularemia, in the Tetracyclines General Statement 8:12.

Brucellosis

For brucellosis, some clinicians suggest chloramphenicol (with or without streptomycin) as an alternative to tetracyclines when tetracyclines cannot be used; however, the AAP suggests co-trimoxazole (with or without rifampin) for children younger than 8 years of age who cannot receive a tetracycline.

Ehrlichiosis

Chloramphenicol has been used in some patients for ehrlichiosis caused by Ehrlichia chaffeensis or E. canis. While some clinicians suggest chloramphenicol as an alternative when tetracyclines are contraindicated, others note that efficacy has not been established. The AAP states that, in children younger than 8 years of age, the benefits and risks of a short course of doxycycline generally justify its use, especially since oral chloramphenicol is no longer commercially available in the US.

The manufacturer states that the usual IV dosage for neonates and children with suspected immature hepatic and/or renal function is 25 mg/kg daily. The AAP recommends 50-100 mg/kg daily in 4 divided doses for severe infections in children and infants 1 month of age or older. If chloramphenicol is used for meningitis or other severe infection caused by Streptococcus pneumoniae, the AAP recommends 75-100 mg/kg daily in divided doses every 6 hours. For ophthalmic uses, see 52:04.04.

Dosage and Administration

Reconstitution and Administration

Chloramphenicol sodium succinate is administered IV. Although it has been administered IM, most clinicians recommend avoiding IM administration because it may be less effective via this route.

Chloramphenicol has been administered orally as the base or as chloramphenicol palmitate; however, oral preparations are no longer commercially available in the US. For IV administration, chloramphenicol sodium succinate is reconstituted by adding 10 mL of an aqueous diluent (e.g., sterile water for injection, 5% dextrose injection) to a vial labeled as containing 1 g to provide a solution containing 100 mg/mL (expressed as chloramphenicol). The calculated dose should be injected over at least 1 minute.

Dosage

Dosage of chloramphenicol sodium succinate is expressed in terms of chloramphenicol. Because the difference between therapeutic and toxic plasma concentrations is narrow and because of interindividual differences in metabolism and elimination, many clinicians recommend monitoring plasma concentrations in all patients receiving the drug. In general, dosage should be adjusted to maintain plasma concentrations at 5-20 mcg/mL.

Chloramphenicol should be administered no longer than necessary to eradicate the infection with little or no risk of relapse, and repeated courses should be avoided if possible.

General Dosage

The usual IV dosage for adults and children with normal renal and hepatic function is 50 mg/kg daily in equally divided doses every 6 hours. In infections caused by less susceptible organisms, or when necessary to achieve adequate CSF concentrations, up to 100 mg/kg daily may be required; however, because toxic plasma concentrations may occur at 100 mg/kg daily, some clinicians suggest 75 mg/kg daily initially. Dosage should be reduced to 50 mg/kg daily as soon as possible.

Typhoid Fever

For typhoid fever in adults and children, chloramphenicol usually is given as 50 mg/kg daily in divided doses every 6 hours for 14-15 days.

Anthrax

When used as an alternative for anthrax, some clinicians suggest 50-100 mg/kg daily IV in 4 divided doses for adults and 50-75 mg/kg daily in 4 divided doses for children for clinically apparent GI, inhalational, or meningeal anthrax or anthrax septicemia. For anthrax meningoencephalitis, some clinicians suggest 1 g IV every 4 hours. Duration is typically at least 2 weeks after symptoms abate; some clinicians suggest 60 days for inhalational or cutaneous anthrax following spore exposure in the context of biologic warfare or bioterrorism.

Plague

For pneumonic plague following exposure in the context of biologic warfare or bioterrorism, some experts recommend 25 mg/kg IV 4 times daily for 10 days for adults and children 2 years of age or older. For plague meningitis, some experts recommend an IV loading dose of 25 mg/kg followed by 15 mg/kg IV 4 times daily for 10-14 days.

Tularemia

If used for tularemia following exposure in the context of biologic warfare or bioterrorism, some experts recommend 15 mg/kg IV 4 times daily for 14-21 days.

Dosage in Renal and Hepatic Impairment

In patients with impaired renal and/or hepatic function, dosage must be reduced in proportion to the degree of impairment and should be guided by plasma chloramphenicol concentrations.

Cautions

Hematologic Effects

One of the most serious adverse effects of chloramphenicol is bone marrow depression. Although rare, blood dyscrasias such as aplastic anemia, hypoplastic anemia, thrombocytopenia, and granulocytopenia have occurred during or following both short-term and prolonged therapy.

Hemolytic anemia has occurred rarely with chloramphenicol, and paroxysmal nocturnal hemoglobinuria has also been reported. In addition, there have been reports of aplastic anemia that later terminated in leukemia. Two forms of bone marrow depression may occur.

The first type is nondose-related, irreversible bone marrow depression leading to aplastic anemia with a mortality rate of 50% or greater, generally resulting from hemorrhage or infection. Bone marrow aplasia or hypoplasia may occur after a single dose but more often develops weeks or months after discontinuation. Pancytopenia is frequently observed peripherally, but in some cases only 1 or 2 major cell lines may be depressed.

The second (more common) type is dose-related and usually reversible upon discontinuation. It is characterized by anemia, vacuolation of erythroid cells, reticulocytopenia, leukopenia, thrombocytopenia, increased serum iron, and increased serum iron-binding capacity.

Reversible bone marrow depression occurs regularly when plasma concentrations are 25 mcg/mL or greater or when adult dosage exceeds 4 g daily.

Gray Syndrome

A type of circulatory collapse (gray syndrome) has occurred in premature and newborn infants receiving chloramphenicol. In most cases, therapy was instituted within the first 48 hours of life; however, gray syndrome has occurred in children as old as 2 years and in infants born to mothers who received chloramphenicol during late pregnancy or labor.

Symptoms usually develop 2-9 days after initiation and include failure to feed, abdominal distention with or without vomiting, progressive pallid cyanosis, and vasomotor collapse which may be accompanied by irregular respiration. Death may occur within a few hours. If chloramphenicol is discontinued when early symptoms appear, the process may be reversible with complete recovery. Gray syndrome has been attributed to high drug concentrations due to impaired conjugation and excretion in infants.

Nervous System Effects

Optic neuritis (rarely resulting in blindness) has been reported following long-term high-dose therapy. Ocular symptoms usually include bilateral decreased visual acuity and central scotomas. Peripheral neuritis also has occurred. If optic or peripheral neuritis occurs, chloramphenicol should be discontinued immediately. Other neurotoxic reactions reported occasionally include headache, mental depression, confusion, and delirium.

GI and Hepatic Effects

Adverse GI effects (nausea, vomiting, diarrhea, unpleasant taste, glossitis, stomatitis, pruritus ani, enterocolitis) occur infrequently. Rarely, jaundice has been reported.

Sensitivity Reactions

Hypersensitivity reactions may occur and can include fever; macular or vesicular rashes; angioedema; urticaria; hemorrhage of skin and mucosal and serosal surfaces of the intestine, bladder, and mouth; and anaphylactoid reactions. Herxheimer-like reactions have occurred in typhoid fever patients and may be due to release of bacterial endotoxins.

Precautions and Contraindications

Serious, sometimes fatal, reactions have been reported. Patients should be hospitalized during therapy so that appropriate laboratory studies and clinical observations can be performed.

Because of the narrow margin between effective and toxic dosages and wide variability in bioavailability and metabolism, many clinicians recommend monitoring plasma concentrations in all patients. In general, maintain 5-20 mcg/mL to ensure efficacy and avoid toxicity.

Hematologic studies should be performed prior to and approximately every 2 days during therapy. The drug should be discontinued if reticulocytopenia, leukopenia, thrombocytopenia, anemia, or other hematologic abnormalities attributable to chloramphenicol occur. Peripheral blood studies cannot reliably predict irreversible bone marrow depression and aplastic anemia. If optic or peripheral neuritis occurs, discontinue immediately. As with other antibiotics, chloramphenicol may result in overgrowth of nonsusceptible organisms, including fungi.

If superinfection occurs, institute appropriate therapy. Use with caution in patients with impaired renal and/or hepatic function and in neonates and infants with immature metabolic processes; monitor plasma concentrations closely and reduce dosage accordingly. Chloramphenicol is contraindicated in patients with a history of hypersensitivity and/or toxic reactions to the drug.

Pregnancy and Lactation

Safe use during pregnancy has not been established. Since the drug crosses the placenta and is distributed into milk, chloramphenicol should be used with extreme caution in pregnant women at term or during labor and in nursing women because of potential toxic effects (e.g., gray syndrome) on the fetus or child.

Drug Interactions

Effects on Hepatic Clearance of Drugs

Chloramphenicol may interfere with the biotransformation of chlorpropamide, dicumarol, phenytoin, and tolbutamide by inhibiting microsomal enzymes. Consider prolonged half-lives and potentiation of effects of these and other hepatically metabolized drugs; adjust dosages accordingly. In addition, chloramphenicol may prolong prothrombin time in patients receiving anticoagulants by interfering with vitamin K production by intestinal bacteria.

Phenobarbital

Concurrent administration may decrease plasma concentrations of chloramphenicol; monitor levels in patients receiving both drugs.

Antianemia Drugs

When administered concurrently with iron, vitamin B12, or folic acid, chloramphenicol may delay response. Avoid chloramphenicol therapy if possible in anemic patients receiving these agents.

Anti-infective Agents

Chloramphenicol has been reported to antagonize bactericidal activity of penicillins and aminoglycosides in vitro, and some clinicians recommend not using them concomitantly. However, in vivo antagonism has not been demonstrated, and chloramphenicol has been used successfully with ampicillin, penicillin G, or aminoglycosides without apparent loss of activity.

Although some in vitro studies showed additive or synergistic activity with chloramphenicol and certain cephalosporins, more recent in vitro evidence suggests antagonism (e.g., with cefoperazone, cefotaxime, ceftazidime, ceftriaxone), particularly when chloramphenicol was added before the beta-lactam. At least one case of in vivo antagonism has been reported in an infant with Salmonella enteritidis meningitis.

Therefore, combined therapy with chloramphenicol and a cephalosporin is generally discouraged, particularly when bactericidal activity is important. Chloramphenicol also may antagonize aztreonam bactericidal activity in vitro; some suggest administering chloramphenicol a few hours after aztreonam if concomitant use is necessary, although the necessity of this precaution has not been established. Rifampin may decrease plasma concentrations of chloramphenicol by inducing hepatic microsomal enzymes involved in its metabolism.

Myelosuppressive Agents

Avoid concomitant administration with other drugs that may cause bone marrow depression.

Mechanism of Action

Chloramphenicol usually is bacteriostatic, but may be bactericidal at high concentrations or against highly susceptible organisms. Chloramphenicol sodium succinate is inactive until hydrolyzed to free chloramphenicol; hydrolysis occurs rapidly in vivo.

Chloramphenicol inhibits protein synthesis in susceptible organisms by binding to 50S ribosomal subunits, primarily inhibiting peptide bond formation. The site of action appears to overlap with that of erythromycin, clindamycin, lincomycin, oleandomycin, and troleandomycin. Chloramphenicol also may inhibit protein synthesis in rapidly proliferating mammalian cells; reversible bone marrow depression may result from inhibition of mitochondrial protein synthesis in bone marrow cells.

Chloramphenicol has shown immunosuppressive activity when administered prior to an antigenic stimulus; antibody response may be less affected when administered after antigen exposure.

Spectrum

Chloramphenicol is active in vitro against many Gram-positive aerobic bacteria (including Streptococcus pneumoniae and other streptococci) and many Gram-negative aerobic bacteria (including Haemophilus influenzae, Neisseria meningitidis, Salmonella, Proteus mirabilis, Burkholderia mallei, B. cepacia, Vibrio cholerae, Francisella tularensis, Yersinia pestis, Brucella, and Shigella). Chloramphenicol has in vitro activity against some vancomycin-resistant enterococci, but experience is limited and clinical results have been variable. Chloramphenicol has in vitro activity against Bacillus anthracis.

Anti-infectives are active against the germinated form of B. anthracis but not against spores. Susceptible bacteria generally are inhibited by chloramphenicol concentrations of 0.1-20 mcg/mL; concentrations of 0.1-5 mcg/mL inhibit most susceptible strains of Salmonella, H. influenzae, S. pneumoniae, and Neisseria. Susceptible anaerobes generally are inhibited by 8 mcg/mL.

In Vitro Susceptibility Testing

The National Committee for Clinical Laboratory Standards (NCCLS) states that, if results indicate an isolate is susceptible, the infection may be appropriately treated with recommended dosages unless otherwise contraindicated. If intermediate, the MIC approaches attainable concentrations and response rates may be lower; this category may still be clinically useful in sites where drug concentrates physiologically or when higher dosages can be used. If resistant, the strain is not inhibited by achievable systemic concentrations and/or MICs suggest resistance mechanisms and efficacy has not been reliable in clinical studies.

Disk Susceptibility Tests

When disk diffusion is used, a disk containing 30 mcg of chloramphenicol should be used. Using NCCLS criteria, Staphylococcus, Enterococcus, Enterobacteriaceae, Pseudomonas aeruginosa, or Acinetobacter with zones of 18 mm or greater are susceptible, 13-17 mm intermediate, and 12 mm or less resistant. Using Haemophilus test medium (HTM), Haemophilus with zones of 29 mm or greater are susceptible, 26-28 mm intermediate, and 25 mm or less resistant. Using Mueller-Hinton agar with 5% sheep blood, S. pneumoniae with zones of 21 mm or greater are susceptible and 20 mm or less resistant. For streptococci other than S. pneumoniae, zones of 21 mm or greater are susceptible, 18-20 mm intermediate, and 17 mm or less resistant.

Dilution Susceptibility Tests

Using NCCLS criteria, Staphylococcus, Enterococcus, Enterobacteriaceae, P. aeruginosa, and other non-Enterobacteriaceae Gram-negative bacilli (e.g., other Pseudomonas spp., Acinetobacter, Stenotrophomonas maltophilia) with MICs of 8 mcg/mL or less are susceptible, 16 mcg/mL intermediate, and 32 mcg/mL or greater resistant. Using HTM, Haemophilus with MICs of 2 mcg/mL or less are susceptible, 4 mcg/mL intermediate, and 8 mcg/mL or greater resistant. Using cation-adjusted Mueller-Hinton broth with lysed horse blood, S. pneumoniae with MICs of 4 mcg/mL or less are susceptible and 8 mcg/mL or greater resistant. Streptococci other than S. pneumoniae with MICs of 4 mcg/mL or less are susceptible, 8 mcg/mL intermediate, and 16 mcg/mL or greater resistant.

Resistance

Natural and acquired resistance to chloramphenicol have been demonstrated in vitro and in vivo in strains of staphylococci, Salmonella, Shigella, and Escherichia coli. Chloramphenicol-resistant strains of H. influenzae, S. pneumoniae, or N. meningitidis have been reported rarely. In vitro, resistance can be induced stepwise. Resistance is caused in part by a plasmid-mediated factor acquired by conjugation that enables acetylation (inactivation) of chloramphenicol; resistance to other agents (e.g., aminoglycosides, sulfonamides, tetracyclines) may be transferred on the same plasmid.

Results of an in vitro study of chloramphenicol-resistant clinical isolates of N. meningitidis suggest resistance was due to production of chloramphenicol acetyltransferase (CAT). These strains also were resistant to streptomycin and sulfonamides but susceptible to penicillins, cephalosporins, tetracyclines, macrolides, rifampin, and quinolones.

Pharmacokinetics

Absorption

Following IV administration of chloramphenicol sodium succinate, there is considerable interindividual variation in plasma concentrations in adults, children, and neonates.

Chloramphenicol sodium succinate is hydrolyzed in vivo to active chloramphenicol, presumably by esterases in the liver, kidneys, and lungs. The rate and extent of hydrolysis are highly variable.

Bioavailability following IV administration also depends on renal clearance of the succinate ester, which is highly variable. In one study, after a single 1 g IV dose in healthy adults, plasma chloramphenicol ranged from 4.9-12 mcg/mL at 1 hour and 0-5 mcg/mL at 4 hours.

Distribution

Chloramphenicol is widely distributed into most tissues and fluids including saliva, ascitic fluid, pleural fluid, synovial fluid, and aqueous and vitreous humor. Highest concentrations occur in the liver and kidneys.

CSF concentrations are reported to be 21-50% of concurrent plasma concentrations in patients with uninflamed meninges and 45-89% in those with inflamed meninges.

Chloramphenicol crosses the placenta; fetal plasma concentrations may be 30-80% of concurrent maternal concentrations. The drug is distributed into milk.

Chloramphenicol is approximately 60% bound to plasma proteins.

Elimination

The plasma half-life in adults with normal renal and hepatic function is 1.5-4 hours. Because premature and newborn infants have immature mechanisms for glucuronide conjugation and renal excretion, usual doses can produce high and prolonged plasma concentrations in neonates.

The half-life is 24 hours or longer in infants 1-2 days of age and approximately 10 hours in infants 10-16 days of age. The half-life is prolonged in patients with markedly reduced hepatic function. In renal impairment, the half-life of parent drug is not significantly prolonged, although inactive conjugates may have prolonged half-lives.

Plasma concentrations may be increased in renal impairment following IV chloramphenicol sodium succinate because renal excretion of the succinate ester is reduced. Chloramphenicol is inactivated primarily in the liver by glucuronyl transferase. In adults with normal renal and hepatic function, approximately 68-99% of a single oral dose is excreted in urine over 3 days; 5-15% is excreted unchanged by glomerular filtration and the remainder as inactive metabolites (primarily the glucuronide).

After IV chloramphenicol sodium succinate in adults with normal renal and hepatic function, approximately 30% of the dose is excreted unchanged in urine; the fraction varies considerably and may range from 6-80% in neonates and children. Probenecid has no effect on chloramphenicol excretion.

Small amounts are excreted unchanged in bile and feces. Plasma concentrations are not affected by peritoneal dialysis; only small amounts are removed by hemodialysis. The drug appears to be removed by charcoal hemoperfusion.

Chemistry and Stability

Chemistry

Chloramphenicol, originally isolated from Streptomyces venezuelae, is now produced synthetically. It occurs as fine white to grayish or yellowish-white crystals, has a solubility of approximately 2.5 mg/mL in water at 77°F (25°C), and is freely soluble in alcohol. The pKa is 5.5. Chloramphenicol sodium succinate occurs as a white to light yellow powder and is freely soluble in water and alcohol. Chloramphenicol sodium succinate contains approximately 2.3 mEq of sodium per gram of chloramphenicol.

Stability

Chloramphenicol sodium succinate sterile powder for injection should be stored at 59-77°F (15-25°C). Following reconstitution with sterile water for injection, a solution containing 100 mg/mL has a pH of 6.4-7.0 and is stable for 30 days at room temperature. Cloudy solutions should not be used.

Chloramphenicol has been reported to be physically incompatible with many drugs; compatibility depends on factors such as concentrations, diluents, pH, and temperature. Consult specialized references for compatibility information.