Topical chloramphenicol for minor surgical wounds: - First do no harm?

Chloramphenicol ointment (chloramphenicol 10 mg g-1 in white soft paraffin and liquid paraffin) is a broad-spectrum antibiotic used in the prophylaxis of or treatment for wound infections in the belief that this reduces the risk of bacterial infection and optimizes healing. We report a 36-year-old woman who was referred to the patch testing service with erythema, scaling and fissuring around the insertion site of a surgical drain on the right breast following a silicone breast implant. The rash commenced 14 days after drain removal. The resulting scar had been allowed to heal by secondary intention and at presentation had been treated solely with chloramphenicol 1% w/w eye ointment (Martindale Pharma, Romford, Essex, U.K.) once a day for 35 days with a primary dressing (Tegaderm) applied over the wound. Patch testing to the British Society for Cutaneous Allergy baseline series and leg ulcer series were performed according to the International Contact Dermatitis Research Group guidelines. These revealed a relevant 2+ positive reaction to Chloramphenicol 5% in petrolatum. A 2+ positive reaction to Sodium Fusidate 2% in petrolatum and 1+ positive reaction to Amerchol L101 50% in petrolatum were also noted but were not relevant to her current presentation. Our patient's wound was recovering well immediately after surgery; however, allergic contact dermatitis (ACD) to chloramphenicol impaired wound healing. Her wound rapidly improved after stopping chloramphenicol. There are concerns about both antibiotic resistance and ACD to topical antibiotics at wound sites. ACD to chloramphenicol is rare and the exact incidence is not known. The incidence of ACD to topical neomycin to patients referred for patch testing has been shown to be as high as 11% (Marks JG, Belsito DV, DeLeo VA et al. North American contact dermatitis group patch test results for the detection of delayed-type hypersensitivity to topical allergens. J Am Acad Dermatol 1998; 38: 911-8). Results from a randomized placebo-controlled trial reveal that a single dose of topical chloramphenicol to high risk sutured wounds after minor surgery does not produce a clinically significant reduction in infection rates (Heal CF, Buettner PG, Cruickshank R et al. Does single application of topical chloramphenicol to high risk sutured wounds reduce incidence of wound infection after minor surgery? Prospective randomized placebo controlled double blind trial. BMJ 2009; 338: a2812). Our case highlights the importance of restricting the use of topical antibiotics to high risk wounds, for careful wound monitoring and to consider ACD in a nonhealing surgical wound.