Surgery, Colds, and Chloramphenicol eye drops!
Dr Steve
Well, most of you will know that I have now arrived at time for my surgery, with 2 weeks off work following. Wayne is also having surgery, of course. We hope to only be in ICU/ITU for a night, and hospital for 2, but let's see...
We hope to be back on board from Tues 15th June- and whilst off I will probably catch up on some paperwork and promised care plans and DVA CVC ICCP plan paperwork, if I am well enough, but I will NOT be available for enquiries, scripts, referrals, or usual care.
Please don't message me or ask reception to message me for acute matters pre-my return to work. messages will be ignored. For matters that you do need to pass to reception to be deal with in the 2nd half of June, speakn to them directly, thank you.
Please remember Dr Raymond Gadd and the Morayfield Health Hub.
Please remember also that any symptoms of cough, cold, nasal issues, laryngitis, fevers, sore throat, mucus, sinuses, phlegm, etc., need the Morayfield Health Hub (COVID19) Respiratory Clinic.
Secondly- nothing has changed. I do not see patients in the surgery with cough, phlegm, sputum, wheezing, sore throat, tonsillitis, pussy throat, snotty nose, blocked nose, runny nose, sneezing, blocked sinuses, sinus pain, mucus dripping from the back of the nose, colds, flus, acute (<7d) diarrhoea and vomiting, acute red eye/conjunctivitis, gastro/diarrhoea/vomiting. Instead, call for advice, or go to Morayfield Health Hub COVID19 clinic, get tested, then d/w dr steve initially on the phone thereafter.
YOU STILL CAN'T COME INTO SYCAMORE HEALTH COUGHING AND SNEEZING AND SNOTTING *EVEN* WITH A MASK, AND EVEN IF COVID 19 NEGATIVE. Thank you for your understanding.
Finally, it seems that high levels of boron from chlorsig/chloramphenicol eye drops may impact fertilioty if given to kids under 2yo at the proper dose- BUT chlorsig/chloramphenicol eye ointment remains safe as 5x a day applications. `Just FYI :). -- see below for details --
Best wishes, see you in over 2 weeks!
Dr Steve and Wayne
From Dr Rob Walker, NB Medical Education (these peeps are excellent!):
Conjunctivitis in the under 2s: Eyeing up a problem with chloramphenicol
It would be fair to say that eyes are generally not my thing. Watching clamped eyes being operated on makes me squeamish and removing corneal foreign bodies with the help of a 21 gauge needle and a slit lamp was never my most favoured activity in A&E. And as a GP, assessment and management of eye problems remains an area with ‘room for improvement’! However, I thought I was pretty much OK with conjunctivitis. Or that was the case until this week, when information filtered into my sphere, culminating in an alert from my local medicines management team saying that chloramphenicol eye drops are now contra-indicated in children under 2 years old. Eh? So what on earth is this all about? Well, it’s all about boron, you see. I thought boron was a pretty inert substance, but apparently there have been concerns that boron may impair fertility if given above certain levels. It is used as a buffer agent in chloramphenicol eye drops and that is why we’re run into problems. Back in 2017 this was addressed by the EMA which made recommendations on thresholds of boron that were acceptable in medicines, and that for children under 2 years old the maximum exposure should be 1mg/day. As discussed in a very helpful DTB editorial this month this has all of a sudden got significant implications for us in General Practice, as the majority of chloramphenicol eye drop products are now not licensed for children under 2. Given that there has been no official communication from the MHRA, this has caught many of us on the hop, with the concern that the first some of us may hear about this is when a prescription is challenged at the dispensing stage. So what are the risks? The Royal College of Ophthalmologists have posted a useful safety alert putting this in context. It states that ‘Chloramphenicol eye preparations have been widely used in children of all ages for many years with no documented adverse effects on fertility. To our knowledge there is no new scientific data from human studies to support this change to the product license’. They go on to state that if given at a standard dose of 1 drop QDS the amount of boron absorbed will still be well below the 1mg/day threshold. Okay, so why don’t we just prescribe something else? And that, as discussed in the DTB and by the RCOphth, is the snag. We don’t really have any other suitable products. Fusidic acid has a much narrower spectrum of activity and may not give suitable cover (and is horribly expensive at £35/tube, making it black listed on many formularies). Quinolone and cephalosporin products obviously have real risks of driving resistance, and are specifically not recommended by the RCOphth for bacterial conjunctivitis as they should be reserved for severe eye disease e.g. keratitis. So that basically leaves us with chloramphenicol eye ointment (which does not contain boron), but trying to apply eye ointment to a wriggling toddler is likely to be well-nigh impossible. So while the the RCOphth state that ‘the benefits of chloramphenicol eyedrops in paediatric ophthalmic practice for appropriate indications and with courses of appropriate duration outweigh the possible risks posed by boron ingestion’, it will be very difficult for us in primary care to prescribe when the SPC for many products now states that ’This medicinal product must not be given to a child less than 2 years old as it contains boron and may impair fertility in the future.’ However, there could be a silver lining here. It is an opportunity for us to remind parents that conjunctivitis is not a serious condition, that it self resolves (whether viral or bacterial) in the majority of cases within 10 days, and indeed the NHS advice is not to see a GP unless conjunctivitis has not resolved by 2 weeks (unless for a child under 1 month old). It’s a reminder that the current first line treatment recommended by NICE/PHE is self care (e.g. cotton wool and cooled boiled water) and that exclusion from child care settings is not needed. And if time and self care really don’t sort the problem out, it appears a ‘trial by chloramphenicol eye ointment’ for the under 2s is probably all we have to offer - with a ‘good luck’ to the parents.
Dr Rob Walker 27th May 2021