Decision-making process

You’ll need to use your professional judgement when dealing with requests (see our professional judgement guide).

It’s important to share information about the process of supply with the person requesting. Explain that you’ll need to ask some questions to make sure the medicine is suitable for them, and that you may need to refer them to a prescriber if you identify contraindications or if investigations are required. 

You may want to use the following questions to support diagnosis, prescreening, education and supply. Explore the person’s situation by considering and asking the following: 

• Who’s requesting a supply? Is it the person who needs the medicine or a representative?
  • Supply to the person needing the medicine – is the person needing the medicine an adult or a child aged two years and over?
  • Ensure you are supplying the medicine within the marketing authorisation.
  • Supply to the person’s representative  – see section on supplying to a person’s representative.
• Does the person have signs and symptoms of acute bacterial conjunctivitis, and how long have they had them?
  • Are there any other symptoms that may indicate a differential diagnosis or require referral for further investigation?
• Is the person hypersensitive to any of the active ingredients or excipients in chloramphenicol OTC?
  • Chloramphenicol eye drops and ointment are contraindicated if there is hypersensitivity to the active substance or any excipients listed
• Do they have any health or medical conditions, and are they taking any medicines?
  • Check for contraindications, interactions and any reason for referral.
• Certain medications can affect a person’s susceptibility to eye conditions and cause visual disturbances.
• Do they wear contact lenses?
• Eye infections in lens wearers are often caused by other organisms and can be serious (see practical advice for contact lens wearers). 
• Have they been supplied chloramphenicol OTC before?
  • Check if they experienced any side/adverse effects that would require referral to the prescriber .
• Have they requested chloramphenicol in the past and been refused, or had to stop treatment for any reason?
  • Find out why and use your professional judgement to decide if that’s a reason for referral.  
• Have they already been prescribed chloramphenicol?
  • Chloramphenicol can still be purchased OTC if more practical (e.g. they are unable to get a suitable appointment with their prescriber). Consider if an emergency supply of the person’s prescribed medicine is more appropriate (e.g. if they are being prescribed off-licence or are taking an alternative dose or strength).
• Are they aware of all the other options available to them?
  • See the section on alternative treatment options and practical advice.
• Use your professional judgement to decide on suitable action:
  • If you feel the supply is suitable and the person requesting the medicine is happy to continue, provide counselling and any other relevant information.
  • If you feel the supply isn’t suitable, if in doubt of suitability or if medical attention, investigations or a referral is required, then refer to a prescriber. 

See the relevant product SPC and PIL, found under further information.

Decision-making flowchart

Use our short and easy-to-follow flowchart to help you assess the suitability of supply.

The flowchart is designed to be used with the following sections in this guide to support you in developing your own consultation skills:

• Decision-making process for supply – for further information and questions
• Summary of product information
• Counselling
• Confidence in consultation skills

Quantity to supply and repeat requests

You should use your professional judgement on a case-by-case basis to decide if multiple pack or repeat supply to the same person are appropriate. 

Remember:

• There is potential for resistance from frequent and recurrent use of chloramphenicol.
• Prolonged or frequent intermittent use should be avoided.
• The treatment course for both preparations is five days.
• Referral is recommended if symptoms don’t improve after 48 hours of treatment with chloramphenicol.
• Referral is recommended if symptoms worsen within two days or at any time.

You’ll need to be satisfied that the medicine is still clinically appropriate and suitable on each occasion and check if anything has changed since the last supply. This will determine if a repeat supply is suitable.

Possible questions you may consider appropriate to assess continued suitability:

• How old are they?
• How long have they been using this product and has there been any improvement?
• Have there been any changes in their health or medical conditions or medicines (including prescribed, OTC, herbal products, complementary, vitamins, dietary supplements, recreational, alcohol and tobacco) since their last supply?
• See when to refer.
• See interactions.
• Have they been experiencing any side effects or signs and symptoms of adverse effects?
• Serious side/adverse effects may require immediate withdrawal and referral to the prescriber.

If you feel the supply is no longer suitable, if in doubt of suitability or if medical attention, investigations or referral is required, then refer to a prescriber.

If you feel the supply is suitable, then provide counselling.

Supply to the person’s representative 

Chloramphenicol can be supplied to a representative. However, it’s important that you only supply the product: 

• Within the marketing authorisation.
• If you’re satisfied that it’s a genuine request.
• If the treatment is clinically appropriate for the person.

You will need to use your professional judgement with requests from representatives. 

Consider the following: 

• Who is requesting on the person’s behalf and why? 
• How will you ensure that the treatment is clinically appropriate for the person needing the medicine?  Check contraindications, referrals, previous medical history and existing medicines.
• How can you get in touch with the person to assess suitability and determine whether the request is appropriate and genuine? (e.g. by telephone).
• Be careful not to disclose to the representative what was previously discussed, unless you have consent from the person needing the medicine.
• Are you supplying the medicine within the marketing authorisation (e.g. ensure that the person is aged two or over and it’s used for the treatment of acute bacterial conjunctivitis)?

Counselling

Advise the person to read the PIL and packaging as a reminder of key safety messages.

Discuss the following:

• The condition – explain the condition and what causes it to empower the person to understand their condition.
• Alternative treatment options – provide information on alternative treatment options.
• Provide practical advice. 
• Provide advice for contact lens wearers (where appropriate).   
• The medicine – what it is, how it works, and how to use it.
• Importance of adherence – make sure the person is aware they need to complete the course for five days, even if they feel better and symptoms disappear.
• Side/adverse effects and risks:
  • Make sure the person is aware what signs and symptoms to look out for and when to seek medical attention and advice.
  • Blurred vision – make sure the person is aware that chloramphenicol drops and ointment may cause blurred vision following administration, so it is important not to drive or operate machinery until vision is clear.
• Interactions – make sure the person knows to check interactions with a pharmacist before starting any new medicines.
• Referrals – make sure the person is aware when to see a prescriber.
• Health promotion – provide lifestyle and wellbeing advice where appropriate, including on diet, exercise, smoking cessation, weight and blood pressure management.

For further information on counselling and when to refer, see the British National Formulary (BNF) and relevant product SPC and PIL, found under further information.

You may also find our pharmacy guide on counselling people on the use of medicines useful.

Additional considerations

Here are some further points to consider when supplying:

• Record-keeping – see the section on record-keeping.
• Quantity to supply and how to obtain further supplies – make sure the person is aware of how to obtain further supplies. See the section on quantity to supply and repeat requests.
• Online purchases – highlight the risks of purchasing medicines online:
  • If buying from unregulated sources, the medicines may not have been tested for safety or effectiveness.
  • Advise the person to check that the medicine is being supplied from a reputable provider before purchasing (see the guidance from the General Pharmaceutical Council (GPhC) on providing services online).
• Online pharmacies – will need to meet GPhC regulatory standards for providing services at a distance (see the GPhC guidance on providing pharmacy service at distance, including on the internet, and GPhC premises standards).
• Storage and disposal – advise the person to return any unused medicines to a pharmacy for disposal (see the section on storage).
• Delivering and posting medicines - the Medicines, Ethics and Practice (MEP) guide covers some additional points about delivering and posting medicines to patients.

Record-keeping

There is no legal requirement to make a record of the supply of a P medicine. However, professionally, you may decide to make a record of the following for audit purposes:

• Referrals.
• Discussions.
• Advice you gave about when and how to seek help if needed, (i.e.) safety netting.
• Reasons for the advice you gave.
• Repeat sales.
• If the person asked you to contact their prescriber.
• Interaction checks.

If you decide to make a record, make sure you get the person’s consent (see the GPhC guidance on confidentiality and consent).

Summary of  product information

The table below provides some product information on chloramphenicol 0.5% w/v eye drops and 1% w/w eye ointment for supply as a P medicine.

Refer to the full up-to-date product details in the relevant SPC and BNF, which can be found under further information.

Indication	Acute bacterial conjunctivitis in:  – Adults. – Children aged two years and over.
Dose	Drops:    – One drop into the affected eye(s) every two hours for the first 48 hours, then decrease the dose to every four hours. – During waking hours only. Ointment:   – If using alone – apply approximately one centimetre of ointment between the lower eyelid and the eye three to four times daily. – If using with eye drops – apply one centimetre of ointment between the lower eyelid at night. – The treatment course for both preparations is five days. – The treatment course should be completed even if you feel better and if symptoms have cleared.
Administration	– If both chloramphenicol eye drops and ointment are being used, the drops should be used during the day and the ointment should be used at night. – People should be referred to the PIL for detailed instructions on how to use the medicine.
When to refer	People should be referred to a clinician/prescriber if there is any doubt the medicine is suitable for them and there are no other alternative OTC products available, or if the person:  – Experiences any side effects. – Has a contraindication. – Is taking or using medicine(s) that has a clinically significant interaction with chloramphenicol. – Is pregnant or breastfeeding. – Is using other eye drops/ointment. – Is a contact lens wearer. Other symptoms or conditions to refer: – If the infection is not confined to conjunctivae. – Eye inflammation associated with a rash on the face or scalp. – Eye pain. – Swelling around the eye or face. – Suspected foreign body in eye(s). – Dry eyes, including dry eye disease (keratoconjunctivitis sicca) or history of this. – Glaucoma. – Recent eye infection, including conjunctivitis. – New infection during treatment (chloramphenicol can cause overgrowth of non-susceptible microorganisms). – Suspected viral infection (may be associated with an upper respiratory infection and worsening symptoms despite chloramphenicol use). Urgent referral to a hospital eye casualty or accident and emergency department if the person:    – Is experiencing severe symptoms.  – Has a cloudy looking eye. – Has an unusual looking pupil (e.g. torn, irregular, dilated, or sluggish/non-reactive to light).  – Has affected vision (e.g. vision loss, reduced vision, blurred vision, double vision and halos around lights).   – Has photophobia (abnormal sensitivity/intolerance to light).  – Has painful eye movements.  – Has significant eye pain.  – Has worsening symptoms despite chloramphenicol use.  – Wore contact lenses in the shower, or the eye with the contact lens has come into possible contact with water. – Had eye surgery or laser treatment within the past six months. After starting treatment refer people if: – Symptoms don’t improve after 48 hours of treatment with chloramphenicol. Symptoms worsen within two days, or worsen at anytime. – The person experiences any side effects.
Contraindications	Chloramphenicol OTC is not recommended in the following and the person should be referred:  – Children aged under two years. – Pregnant people and people who are breastfeeding. – Hypersensitivity or allergies to chloramphenicol or any of the other ingredients. – If the person has experienced blood disorders or bone marrow problems during or after previous chloramphenicol use. – People with a personal or family history of bone marrow problems. – Blood dyscrasias, such as aplastic anaemia.
Side/adverse effects	Advise to stop treatment and immediately refer to a prescriber if person experiences:  – Eye disorders – blurred vision, pain, swelling, irritation.  – Transient burning or stinging sensation in eye(s) after use. – Hypersensitivity reactions – rashes, fever, angioedema (a vascular reaction involving the deep dermis or subcutaneous or submucosal tissues, characterised by the development of giant wheals), urticaria and anaphylaxis.   – Rashes – vesicular and maculopapular (characterised by bumps or blisters).   – Bone marrow problems, including the idiosyncratic type of irreversible and fatal aplastic anaemia recognised to occur with systemic therapy, has been reported with the topical administration of chloramphenicol. Chloramphenicol is absorbed systemically from the eye(s) – systemic toxicity has been reported.  Some products contain preservatives which can cause allergic reactions.  Report any suspected side effects, as appropriate, via the Yellow Card scheme on the Medicines and Healthcare products Regulatory Agency website. See our Yellow Card guide for further details.
Interactions	People should be aware if taking: – Bone marrow depressant drugs.  Refer anyone with a clinically relevant interaction to their prescriber, using your professional judgement. It would be best practice to use your professional judgement to regularly check interactions with people’s concurrent medicines (including prescribed, OTC, herbal, complementary, vitamins, dietary supplements, recreational drugs, alcohol, tobacco, etc.) in case they are of clinical relevance and need referral to a prescriber. For the full list of interactions, see BNF, Stockley’s Drug Interactions and relevant product SPC and PIL, found under further information.
Pregnancy and breastfeeding	– Cannot be used while breastfeeding – Cannot be used in pregnancy
Age	For use in: – Adults – Children aged over two years
Storage	– Drops: store in a refrigerator between 2-8°C. – Ointment: store at no more than 25°C (refrigeration not required). Any remaining product should be discarded after the five-day course of treatment.

Acute bacterial conjunctivitis

Symptoms of acute bacterial conjunctivitis include:

• Yellow purulent discharge and/or eyelid(s) stuck together in the morning.
• Swelling of the eyelid(s).
• Irritated, itchy, red or watery eye(s) and/or burning or gritty sensation in eye(s).

Some causes of conjunctivitis include:

• Viruses (e.g. adenovirus, Herpes simplex, Varicella zoster, Molluscum contagiosum).
• Allergies.
• Bacterial (e.g. Streptococcus, influenzae, sexually transmitted bacteria).

For further information on chloramphenicol and acute bacterial conjunctivitis, see the National Institute for Health and Care Excellence’s (NICE) Clinical Knowledge Summaries (CKS) page and NHS.UK.

Alternative treatment options

People who present with symptoms should also be made aware of:

• All treatment options available in addition to chloramphenicol, as something else may be more suitable (e.g. prescription fusidic acid 1% eye drops). Consider referring the person to their doctor if alternate treatments are more suitable. The choice will depend on the cause, the individual and their response to treatment.
• The condition’s self-limiting nature.
• The possibility that antibacterial therapy is not necessary.
• Limiting antibiotic use, as antibiotic resistance is on the rise – see our antimicrobial stewardship (AMS) guide for further information.
• Potential for resistance from frequent, prolonged and recurrent use of chloramphenicol, which should be avoided.

Where the clinical benefits of treating with chloramphenicol are marginal, it may be useful to discuss an alternative therapeutic approach with the person.

This may involve reserving treatment with chloramphenicol where symptoms don’t improve or when the condition deteriorates over a matter of days. It may also include providing practical advice.

However, people may also be given the option of purchasing chloramphenicol to speed up recovery from acute bacterial conjunctivitis.

Other drug treatments and non-medical treatments include:

• Remove discharge by cleaning eyelid(s) from the bridge of the nose to the outer corner of the affected eye(s), with warm water and fresh cotton wool/gauze.
• A cool compress can be applied around the eye area.
• Lubricating drops can reduce discomfort.
• Infective conjunctivitis is contagious; you can avoid spreading the infection from one eye to the other, and to other people by:
  • Not rubbing your eyes.
  • Using warm soapy water to wash hands regularly, especially after touching the affected eye(s).
  • Not sharing items such as towels, facecloths or pillows.
  • Using hot water and detergent to wash pillows and facecloths.     
• You don’t need to stay at home from work or school unless you or your child are feeling very unwell.
• There’s no recommended exclusion period from school, nursery or childminders, although nurseries and primary schools may have an exclusion policy – see the Patient website for further information.

Advice for contact lens wearers

The person should seek advice from an optician, optometrist or doctor before using chloramphenicol.

If a practitioner recommends chloramphenicol, the person should be advised:

• Not to wear contact lenses until all the signs and symptoms of conjunctivitis have gone.
• Not to wear contact lenses during, or for at least 24 hours after, chloramphenicol use.
• Reusing old contact lenses can cause reinfection, so reusing lenses is not recommended even after symptoms have resolved.
• To replace contact lens containers, as continued use can lead to reinfection.

Confidence in consultation skills  

Discussing symptoms of conjunctivitis may be uncomfortable for some people, who may feel nervous approaching the pharmacy team. To ensure comfort and confidence, the pharmacy team should always be discreet, non-judgemental and put the person at ease. 

You can supply P medicines or supervise their supply. If the request needs to be referred to you by counter staff, they’ll need suitable training to handle such circumstances, since they’re usually the first point of contact. Referral should also be covered in the standard operating procedure.

To support these conversations, good communication is essential. Develop your confidence with practical tips and information in our confidence in consultation skills pharmacy guide.

Further information

• electronic medicines compendium – SPC and PIL
• BNF
• Stockely’s Drug Interactions

RCPharm

• Clinical documentation
• Confidence in consultation skills
• Counselling people on the use of medicines
• Emergency supply
• MEP
• Professional judgement
• Yellow Card scheme
• RCPharm – AMS

Clinical

• Drug and Therapeutics Bulletin: management of acute infective conjunctivitis
• NICE: CKS
• National Library of Medicine
• NHS.UK – Conjunctivitis
• Patient
• UK Health Security Agency
• UK Ophthalmic pharmacy group.

Consultation skills

• Centre for Pharmacy Postgraduate Education
• Health Education & Improvement Wales
• NHS Education for Scotland
• RCPharm counselling patients guide.