Chloramphenicol is an antibiotic useful for the treatment of a number of bacterial infections. This includes use as an eye ointment to treat conjunctivitis. By mouth or by injection into a vein, it is used to treat meningitis, plague, cholera, and typhoid fever. Its use by mouth or by injection is only recommended when safer antibiotics cannot be used. Monitoring both blood levels of the medication and blood cell levels every two days is recommended during treatment.
|Trade names||Pentamycetin, Chloromycetin, others|
|Topical (eye drops), by mouth, IV, IM|
|Elimination half-life||1.6–3.3 hours|
|Excretion||Kidney (5–15%), faeces (4%)|
|Chemical and physical data|
|Molar mass||323.1320 g/mol g·mol−1|
|3D model (JSmol)|
Common side effects include bone marrow suppression, nausea, and diarrhea. The bone marrow suppression may result in death. To reduce the risk of side effects treatment duration should be as short as possible. People with liver or kidney problems may need lower doses. In young children a condition known as gray baby syndrome may occur which results in a swollen stomach and low blood pressure. Its use near the end of pregnancy and during breastfeeding is typically not recommended. Chloramphenicol is a broad-spectrum antibiotic that typically stops bacterial growth by stopping the production of proteins.
Chloramphenicol was discovered after being isolated from Streptomyces venezuelae in 1947. Its chemical structure was identified and it was first artificially made in 1949, making it the first antibiotic to be made instead of extracted from a micro-organism.:26 It is on the World Health Organization's List of Essential Medicines, the most effective and safe medicines needed in a health system. It is available as a generic medication. The wholesale cost in the developing world of an intravenous dose is about US$0.40–1.90. In the United States an intravenous dose costs about $41.47.
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.
In low-income countries, the WHO no longer recommends oily chloramphenicol as first-line to treat meningitis, but recognises it may be used with caution if there are no available alternatives.
In the context of preventing endophthalmitis, a complication of cataract surgery, a 2017 systematic review found moderate evidence that using chloramphenicol eye drops in addition to an antibiotic injection (cefuroxime or penicillin) will likely lower the risk of endophthalmitis, compared to eye drops or antibiotic injections alone.
Chloramphenicol has a broad spectrum of activity and has been effective in treating ocular infections such as conjunctivitis, blepharitis etc. caused by a number of bacteria including Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli. It is not effective against Pseudomonas aeruginosa. The following susceptibility data represent the minimum inhibitory concentration for a few medically significant organisms.
- Escherichia coli: 0.015 – 10,000 μg/mL
- Staphylococcus aureus: 0.06 – 128 μg/mL
- Streptococcus pneumoniae: 2 – 16 μg/mL
Three mechanisms of resistance to chloramphenicol are known: 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 (also called R factors).
As of 2014 some Enterococcus faecium and Pseudomonas aeruginosa strains are resistant to chloramphenicol. Some Veillonella spp. and Staphylococcus capitis strains have also developed resistance to chloramphenicol to varying degrees.
The most serious side effect of chloramphenicol treatment is aplastic anaemia. This effect is rare and sometimes fatal. The risk of AA is high enough that alternatives should be strongly considered. Treatments are available but expensive. No way exists to predict who may or may not get this side effect. The effect usually occurs weeks or months after treatment has been stopped, and a genetic predisposition may be involved. 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 baseline blood count with a repeat blood count every few days while on treatment. Chloramphenicol should be discontinued if the complete blood count drops. 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 one 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, but is not approved for use in humans.
Bone marrow suppressionEdit
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 existing marrow damage may compound any marrow damage resulting from the toxic effects of chloramphenicol.
Leukemia, a cancer of the blood or bone marrow, is characterized by an abnormal increase of immature white blood cells. The risk of childhood leukemia is increased, as demonstrated in a Chinese case–control study, and the risk increases with length of treatment.
Gray baby syndromeEdit
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.
Fever, macular and vesicular rashes, angioedema, urticaria, and anaphylaxis may occur. Herxheimer's reactions have occurred during therapy for typhoid fever.
Headache, mild depression, mental confusion, and delirium have been described in patients receiving chloramphenicol. Optic and peripheral neuritis have been reported, usually following long-term therapy. If this occurs, the drug should be promptly withdrawn.
Chloramphenicol is extremely lipid-soluble; it remains relatively unbound to protein and is a small molecule. It has a large apparent volume of distribution and penetrates effectively into all tissues of the body, including the brain. Distribution is not uniform, with highest concentrations found in the liver and kidney, with lowest in the brain and cerebrospinal fluid. The concentration achieved in brain and cerebrospinal fluid is around 30 to 50% of the overall average body concentration, even when the meninges are not inflamed; this increases to as high as 89% when the meninges are inflamed.
Use in special populationsEdit
Chloramphenicol is metabolized by the liver to chloramphenicol glucuronate (which is inactive). In liver impairment, the dose of chloramphenicol must therefore be reduced. No standard dose reduction exists 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.
Plasma levels of chloramphenicol must be monitored in neonates and 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. Because efficacy and toxicity of chloramphenicol are associated with a maximum serum concentration, peak levels (one hour after the intravenous dose is given) should be 10–20 µg/ml with toxicity > 40 µg/ml; trough levels (taken immediately before a dose) should be 5–10 µg/ml.
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, proton-pump inhibitors, and anticoagulants 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, cardiac antiarrhythmics, antivirals, anticoagulants, and PDE5 inhibitors.
Mechanism of actionEdit
Chloramphenicol is a bacteriostatic by inhibiting protein synthesis. It 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. Chloramphenicol directly interferes with substrate binding in the ribosome, as compared to macrolides, which sterically block the progression of the growing peptide.
Chloramphenicol was first isolated from Streptomyces venezuelae in 1947 and in 1949 a team of scientists at Parke-Davis including Mildred Rebstock published their identification of the chemical structure and their synthesis, making it the first antibiotic to be made instead of extracted from a micro-organism.:26
In 2007, the accumulation of reports associating aplastic anemia and blood dyscrasia with chloramphenicol eye drops lead to the classification of “probable human carcinogen” according to World Health Organization criteria, based on the known published case reports and the spontaneous reports submitted to the National Registry of Drug-Induced Ocular Side Effects.
Society and cultureEdit
In many areas of the world an intravenous dose is about US$0.40–1.90. In the United States it costs about $3.60 per dose in oral tablet form at wholesale.
Chloramphenicol is available as a generic worldwide under many brandnames and also under various generic names in eastern Europe and Russia, including chlornitromycin, levomycetin, and chloromycetin; the racemate is known as synthomycetin.
Chloramphenicol is available as a capsule or as a liquid. In some countries, it is sold as chloramphenicol palmitate ester (CPE). CPE is inactive, and is hydrolysed to active chloramphenicol in the small intestine. No difference in bioavailability is noted 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. No oral formulation of chloramphenicol is now available in the U.S.
In molecular biology, chloramphenicol is prepared in ethanol.
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 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.
Oily chloramphenicol was first used to treat meningitis in 1975 and numerous studies since have demonstrated its efficacy. It is the cheapest treatment available for meningitis (US$5 per treatment course, compared to US$30 for ampicillin and US$15 for five days of ceftriaxone). It has the great advantage of requiring only a single injection, whereas ceftriaxone is traditionally given daily for five days. This recommendation may yet change, now that a single dose of ceftriaxone (cost US$3) has been shown to be equivalent to one dose of oily chloramphenicol.
Chloramphenicol is still used occasionally 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 of the order of less than one in 224,716 prescriptions. In Mexico, this is the treatment used prophylactically in newborns.
Although its use in veterinary medicine is highly restricted, chloramphenicol still has some important veterinary uses. It is currently considered the most useful treatment of chlamydial disease in koalas. The pharmacokinetics of chloramphenicol have been investigated in koalas.
Although unpublished, recent research suggests chloramphenicol could also be applied to frogs to prevent their widespread destruction from fungal infections. It 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.
- Woods, Adrienne L. (2008). Delmar nurse's drug handbook (2009 ed.). Clifton Park, N.Y.: Delmar. p. 296. ISBN 9781428361065. Archived from the original on 2016-03-05.
- "Chloramphenicol". PubChem. Archived from the original on 2016-11-15.
- "Chloramphenicol". The American Society of Health-System Pharmacists. Archived from the original on 2015-06-24. Retrieved Aug 1, 2015.
- Edwards, Keith H. (2009). Optometry: Science, Techniques and Clinical Management. Elsevier Health Sciences. p. 102. ISBN 978-0750687782. Archived from the original on 2017-03-07.
- "Chloramphenicol Pregnancy and Breastfeeding Warnings". Multum Information Services. Archived from the original on 8 September 2015. Retrieved 26 August 2015.
- Pongs, O. (1979). "Chapter 3: Chloramphenicol". In Hahn, eFred E. Mechanism of Action of Antibacterial Agents. Antibiotics Volume V Part 1. Berlin, Heidelberg: Springer Berlin Heidelberg. pp. 26–42. ISBN 978-3-642-46403-4.
- "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. Retrieved 8 December 2016.
- "Chloramphenicol". International Drug Price Indicator Guide. Retrieved 26 August 2015.
- "Chloramphenicol Prices, Coupons & Patient Assistance Programs - Drugs.com". Drugs.com. Archived from the original on 2017-03-08.
- "WHO meningitis epidemic guidelines Africa". Archived from the original on 5 March 2016. Retrieved 29 February 2016.
- Gower EW, Lindsley K, Tulenko SE, Nanji AA, Leyngold I, McDonnell PJ (2017). "Perioperative antibiotics for prevention of acute endophthalmitis after cataract surgery". Cochrane Database Syst Rev. 2 (2): CD006364. doi:10.1002/14651858.CD006364.pub3. PMC 5375161. PMID 28192644.
- "Archived copy". Archived from the original on 2014-04-23. Retrieved 2014-04-21.CS1 maint: Archived copy as title (link)
- Carone, BR; Xu, T; Murphy, KC; Marinus, MG (Jan 2014). "High incidence of multiple antibiotic resistant cells in cultures of in enterohemorrhagic Escherichia coli O157:H7". Mutation Research. 759: 1–8. doi:10.1016/j.mrfmmm.2013.11.008. PMC 3913999. PMID 24361397.
- Moore, AM; Patel, S; Forsberg, KJ; Wang, B; Bentley, G; Razia, Y; Qin, X; Tarr, PI; Dantas, G (2013). "Pediatric fecal microbiota harbor diverse and novel antibiotic resistance genes". PLoS ONE. 8 (11): e78822. Bibcode:2013PLoSO...878822M. doi:10.1371/journal.pone.0078822. PMC 3827270. PMID 24236055.
- "Chloramphenicol spectrum of bacterial susceptibility and Resistance" (PDF). Archived (PDF) from the original on 11 February 2014. Retrieved 15 May 2012.
- Hammett-Stabler, C.; Johns, T. (May 1988). "Laboratory guidelines for monitoring of antimicrobial drugs". Clinical Chemistry. 44 (5): 1129–1140. PMID 9590397.
- Wallerstein, R.; Condit, P.; Kasper, C.; Brown, J.; Morrison, F. (June 1969). "Statewide study of chloramphenicol therapy and fatal aplastic anemia". JAMA. 208 (11): 2045–2050. doi:10.1001/jama.208.11.2045. PMID 5818983.
- Lancaster, T.; Stewart, A. M.; Jick, H. (1998). "Risk of serious haematological toxicity with use of chloramphenicol eye drops in a British general practice database". British Medical Journal. 316 (7132): 667. doi:10.1136/bmj.316.7132.667. PMC 28473. PMID 9522792. Archived from the original on 2006-02-27.
- Yunis AA (September 1989). "Chloramphenicol toxicity: 25 years of research". Am. J. Med. 87 (3N): 44N–48N. PMID 2486534.
- Morley, Alec; Trainor, Kevin; Remes, Judith (1 April 1976). "Residual Marrow Damage: Possible Explanation for Idiosyncrasy to Chloramphenicol". British Journal of Haematology. 32 (4): 525–532. doi:10.1111/j.1365-2141.1976.tb00955.x.
- Shu, X.; Gao, Y.; Linet, M.; Brinton, L.; Gao, R.; Jin, F.; Fraumeni, J. (October 1987). "Chloramphenicol use and childhood leukaemia in Shanghai". Lancet. 2 (8565): 934–937. doi:10.1016/S0140-6736(87)91420-6. PMID 2889862.
- McIntyre, J.; Choonara, I. (2004). "Drug toxicity in the neonate". Biology of the Neonate. 86 (4): 218–221. doi:10.1159/000079656. PMID 15249753.
- Piñeiro-Carrero, V.; Piñeiro, E. (2004). "Liver" (PDF). Pediatrics. 113 (4 Supplement): 1097–1106. PMID 15060205.
- Feder, H. (1986). "Chloramphenicol: what we have learned in the last decade". Southern Medical Journal. 79 (9): 1129–1134. doi:10.1097/00007611-198609000-00022. PMID 3529436.
- Mulhall, A.; de Louvois J.; Hurley, R. (1983). "Chloramphenicol toxicity in neonates: its incidence and prevention". British Medical Journal (Clinical Research Edition). 287 (6403): 1424–1427. doi:10.1136/bmj.287.6403.1424. PMC 1549666. PMID 6416440.
- Forster, J.; Hufschmidt, C.; Niederhoff, H.; Künzer, W. (1985). "[Need for the determination of chloramphenicol levels in the treatment of bacterial-purulent meningitis with chloramphenicol succinate in infants and small children]". Monatsschrift Kinderheilkunde (in German). 133 (4): 209–213. PMID 4000136.
- "Drug Insert from DailyMed". Archived from the original on 19 April 2014. Retrieved 18 April 2014.
- Harold M. Silverman; Pharm.D. (-in-chief), eds. (2006). "Iron Supplements". Pill Book, The (12th revised ed.). New York: Bantam Dell. pp. 593–596. ISBN 978-0-553-58892-7.
- kidsgrowth.org --> Drugs and Other Substances in Breast Milk Archived 2007-06-23 at Archive.today Retrieved on June 19, 2009
- Hammett-Stabler, C; Johns, T. (May 1988). "Laboratory guidelines for monitoring of antimicrobial drugs". Clinical Chemistry. 44 (5): 1129–1140. PMID 9590397.
- "Chloramphenicol (Lexi-Drugs)". Lexi-Comp Online. Archived from the original on 26 July 2013. Retrieved 18 April 2014.
-  June 2005. Royal Pharmaceutical Society of Great Britain (RPSGB)
- Park, J. Y.; Kim, K. A.; Kim, S. L. (November 2003). "Chloramphenicol Is a Potent Inhibitor of Cytochrome P450 Isoforms CYP2C19 and CYP3A4 in Human Liver Microsomes". Antimicrobial Agents and Chemotherapy. 47 (11): 3464–3469. doi:10.1128/AAC.47.11.3464-3469.2003. PMC 253795. PMID 14576103.
- "Facts for prescribers (Fakta för förskrivare)" (in Swedish). FASS – Swedish National Drug Formulary. Archived from the original on 2002-06-11.
- "Antagonistic effect of chloramphenicol in combination with cefotaxime or ceftriaxone". Archived from the original on September 24, 2015. Retrieved August 25, 2014.
- Schifano JM, Edifor R, Sharp JD, et al. (May 2013). "Mycobacterial toxin MazF-mt6 inhibits translation through cleavage of 23S rRNA at the ribosomal A site". Proceedings of the National Academy of Sciences of the United States of America. 110 (21): 8501–6. Bibcode:2013PNAS..110.8501S. doi:10.1073/pnas.1222031110. PMC 3666664. PMID 23650345.
- "Chloramphenicol". The Merck Manual. Merck. Archived from the original on 2010-03-10.
- Jardetzky, O. (July 1963). "Studies on the Mechanism of Action of Chloramphenicol – The Conformation of Chloramphenicol in Solution" (PDF). The Journal of Biological Chemistry. 238 (7): 2498–2508. PMID 13957484. Archived (PDF) from the original on 2015-12-11.
- Wolfe, A. D.; Hahn, F. E. (1965). "Mode of Action of Chloramphenicol. IX. Effects of Chloramphenicol Upon a Ribosomal Amino Acid Polymerization System and Its Binding to Bacterial Ribosome". Biochimica et Biophysica Acta. 95: 146–155. doi:10.1016/0005-2787(65)90219-4. PMID 14289020.
- Hahn, F. E.; Wisseman, C. L. Jr.; Hopps, H. E. (1955). "Mode of Action of Chloramphenicol III. : Action of Chloramphenicol on Bacterial Energy Metabolism". Journal of Bacteriology. 69 (2): 215–223. PMC 357505. PMID 14353832.
- Rebstock, Mildred C.; Crooks, Harry M.; Controulis, John.; Bartz, Quentin R. (July 1949). "Chloramphenicol (Chloromycetin).IV.Chemical Studies". Journal of the American Chemical Society. 71 (7): 2458–2462. doi:10.1021/ja01175a065.
- Controulis, John.; Rebstock, Mildred C.; Crooks, Harry M. (July 1949). "Chloramphenicol (Chloromycetin). V. Synthesis". Journal of the American Chemical Society. 71 (7): 2463–2468. doi:10.1021/ja01175a066.
- Fraunfelder, F.; Fraunfelder, F (September 2013). "Restricting Topical Ocular Chloramphenicol Eye Drop Use in the United States. Did We Overreact?". American Journal of Ophthalmology. 156 (3): 420–422. doi:10.1016/j.ajo.2013.05.004. PMID 23953152.
- Drugs.com drugs.com international listings for chloramphenicol Archived 2015-07-11 at the Wayback Machine Page accessed July 9, 2015
- The Great Soviet Encyclopedia, 3rd Edition, 1970–1979 (3 ed.). The Gale Group, Inc. Retrieved 10 July 2015.
- Glazko, A. J.; Dill, W. A.; Kinkel, A. W. (1977). "Absorption and excretion of parenteral doses of chloramphenicol sodium succinate in comparison with per oral doses of chloramphenicol (abstract)". Clinical Pharmacological Therapy. 21: 104.
- Bhutta, Z.; Niazi, S.; Suria, A. (March–April 1992). "Chloramphenicol Clearance in Typhoid Fever: Implications for Therapy". Indian Journal of Pediatry. 59 (2): 213–219. doi:10.1007/BF02759987. PMID 1398851.
- Lewis, R. F.; Dorlencourt, F.; Pinel, J. (1998). "Long-acting oily Chloramphenicol for Meningococcal Meningitis". Lancet. 352 (9130): 823. doi:10.1016/S0140-6736(05)60723-4. PMID 9737323.
- Rey, M.; Ouedraogo, L.; Saliou, P.; Perino, L. (1976). "Traitement minute de la méningite cérébrospinale épidémique par injection intramusculaire unique de chloramphénicol (suspension huileuse)". Médecine et Maladies Infectieuses (in French). 6 (4): 120–124. doi:10.1016/S0399-077X(76)80134-5.
- Wali, S.; Macfarlane, J.; Weir, W.; Cleland, P.; Ball, P.; Hassan-King, M.; Whittle, H.; Greenwood, B. (1979). "Single injection treatment of meningococcal meningitis. 2. Long-acting chloramphenicol". Transactions of the Royal Society of Tropical Medicine and Hygiene. 73 (6): 698–702. doi:10.1016/0035-9203(79)90024-5. PMID 538813.
- Puddicombe, J.; Wali, S.; Greenwood, B. (1984). "A field trial of a single intramuscular injection of long-acting chloramphenicol in the treatment of meningococcal meningitis". Transactions of the Royal Society of Tropical Medicine and Hygiene. 78 (3): 399–403. doi:10.1016/0035-9203(84)90132-9. PMID 6464136.
- Pécoulm B.; Varaine, F.; Keita, M.; Soga, G.; Djibo, A.; Soula, G.; Abdou, A.; Etienne, J.; Rey, M. (October 1991). "Long-acting chloramphenicol versus intravenous ampicillin for treatment of bacterial meningitis". Lancet. 338 (8771): 862–866. doi:10.1016/0140-6736(91)91511-R. hdl:10144/19393. PMID 1681224.
- Nathan, N.; Borel, T.; Djibo, A. (2005). "Ceftriaxone as effective as long-acting chloramphenicol in short-course treatment of meningococcal meningitis during epidemics: a randomised non-inferiority study". Lancet. 366 (9482): 308–313. doi:10.1016/S0140-6736(05)66792-X. hdl:10144/23232. PMID 16039333.
- "Chloramphenicol and Congeners". Merck Manuals. Archived from the original on 31 October 2014. Retrieved 31 October 2014.
- Govendir, M (16 May 2011). "Plasma concentrations of chloramphenicol after subcutaneous administration to koalas (Phascolarctos cinereus) with chlamydiosis". Journal of Veterinary Pharmacology and Therapeutics. 35 (2): 147–154. doi:10.1111/j.1365-2885.2011.01307.x. PMID 21569052.
- Griffith, J. (2012). "Diagnosis, treatment and outcomes for koala chlamydiosis at a rehabilitation facility (1995–2005)". Australian Veterinary Journal. 90 (90): 457–463. doi:10.1111/j.1751-0813.2012.00963.x. PMID 23106328.
- Black, Lisa (2013). "Pharmacokinetics of chloramphenicol following administration of intravenous and subcutaneous chloramphenicol sodium succinate, and subcutaneous chloramphenicol, to koalas ( Phascolarctos cinereus )". Journal of Veterinary Pharmacology and Therapeutics. 36 (5): 478–485. doi:10.1111/jvp.12024. PMID 23157306.
- Griggs, K. (2007-10-30). "Frog killer fungus 'breakthrough'". BBC News. Archived from the original on 2007-10-30.
- Poulter RTM, Busby JN, Bishop PJ, Butler MI, Speare R. "Chloramphenicol cures chytridiomycosis" (PDF). NZ Frogs. Archived (PDF) from the original on 2008-05-15.
- Jardetzky, O. (1963). "Studies on the Mechanism of Action of Chloramphenicol". Journal of Biological Chemistry. 238 (7): 2498–2508.