To question pharmacist RE: antibiotic

[WineDup]

My son (11m) was prescribed amoxicillin on the 16th. We struggled to get the exact prescription but a pharmacist agreed to prescribe double strength, and just give half a dose from 5ml to 2.5ml. Makes sense.

However, I think they have given him an abnormally long course, he’s still not finished! This is day 10. There isn’t much left and we may have missed a dose here and there but we have been pretty consistent.

His illness was a relatively minor upper respiratory issue, the only reason we were seen as he was hospitalised last year (only for one night) with croup and bronchiolitis and I was concerned it was the same thing again.

My suspicion is that he was supposed to get 100ml of the weaker antibiotic, but take 5ml 3x/day, and I feel like they have given 100ml of the stronger antibiotic to be taken at 2.5ml/day, thus doubling the amount of antibiotic. A 10+ day course of antibiotics just doesn’t make sense to me.

Am I correct to think that the pharmacist (and in turn myself) have made a mistake?

Ten days is usual for antibiotics. 5
, 7, 10 and while not as common 14 days are all normal lengths for a course. However it's not possible to part make up a bottle of antibiotics. So if the bottle is 100mls then regardless of the length of the course and quantity needed it can only be made in 100mls so a 7 day course of 2.5mls four times a day would mean there is leftover suspension. There should be some indication on how long to take the course. Often when giving it out the pharmacy team will explain there should be leftovers. And to dispose of it once the course is completed.

To be fair we had alot of prescription request changes when Strep A was in the news and antibiotics were running low but seems stocks are better now in our area at least. Guess our pharmacies wanted to check with the Dr and have a new script put through to cover everyone's backs!

Why are you doubling down? Just accept and admit you were wrong. Of course they do all that like any non medical prescriber they are actually trained to prescribe safely. It's not the doctors arse. The pharmacist is a trained independent practitioner. Do you not have pharmacy minor surgery schemes? I'm doubting whether you actually do work in a GP or have done in the last 10 years.

They can make mistakes, especially when substituting. We recently had a sub of amoxicillin for penicillin oral solution; however, they forgot to alter the dosage and amount as the two drugs have a different dosage, meaning we were initially under dosing and only had 4 days worth of medicine. Once I realised, I went back to the pharmacy and they apologised and issued an additional 100ml bottle and advised to give a different dose.

Hopefully yours is a ten day dose, but just check if unsure. Although I should think a couple of extra days of meds is going to make a huge difference.

Why would you doubt I work at a gp surgery??? Why would I lie about my blumming job??? I wasn't aware of the new legislation so shoot me. Honestly guess I'm in the wrong for caring.

They were being proactive as he was in nicu as a newborn for breathing issues (treated with antibiotics) and in paeds again earlier this winter as he ended up with multiple infections after the bronchiolitis and croup.

They couldn’t rule anything out but they know I have only been at the doctors a handful of times between two kids so I guess they were maybe over cautious?

He got steroids too.

Sorry, haven’t read all of thread. When they make antibiotics the dry suspension is filled and shipped in bottles form he manufacturers. the pharmacist makes it up the the registered volume as they dispense to the patient.
They can’t vary the amount of water - the formulation includes a lot of other ingredients that have to be right dilution, such as flavourings. This is registered protocol with the regulatory authorities in the country it’s sold in. Pharmacists can’t change those instructions on whims.

so, I am either being dumb here, or you should have half a bottle left at end of 10 days course, because you’re using a 2.5ml does, half the volume of normal 5ml dose prescribed for that strength of formulation.
am I misunderstanding the issue?

don’t use it after 10 days unless you are specifically instructed to by pharmacist or gp- do check if you weren’t told a 10 day course - just go back and speak directly to pharmacist. I know GP would have said to finish the course, but you’ll have twice the volume of course you needed if you’re using a half dose.

antibiotics in suspension ( they’re not solutions as sugar was removed in mid 1980s) and they degrade rapidly on contact with water. They’re not formulated to last more than 10 days. Hence why waters not added until it’s handed over to patient. The reason we’d ( I was formulation scientist in antibiotics) put colouring in the suspension is because after 5 days they start going yellow then brown and any parent seeing it would be alarmed🤣. It’s harmless at that stage, but past 10/ days the amount of actual active drug is below a therapeutic dose, and impurities build. Antibiotics have a bitter flavour (hence why they’re flavoured ), and will taste increasing worse after 10 days. There are some formulations that are developed to be shorter or longer shelf life , but 10 days is typical. Once they go past about 15 days you could make your child ill if you continue to dose - stomach upset and the likes.

@LittleDonkeyKong

It will be on the pharmacist not the GP if they alter the script and it will be at their discretion, and only in certain circumstances. What are pharmacist's supposed to do when GP surgeries are closed and presented with prescriptions that have stock unavailable? Tell the paitent to wait until the surgery opens? They won't change the drug prescribed but will certainly be very competent to give alternative strengths.

It’s not anything particularly new it’s very standard procedure for long lasting medication supply issues to allow pharmacists to substitute. After 4 years of a masters degree and a further year and exams to register its well within their competency. There’s no need to take up precious GP time with that. Other changes may require a phone call.

It didn’t tell me how long the course was. The label says:

”100ml amoxicillin 250mg/5ml oral susp
2.5mls three times a day
space the doses evenly. Keep taking until the course is finished, unless you are told to stop. Shake the bottle well before using. Store in a fridge. Warning contains penicillin”

No mention of how long to keep taking for.

Id also add if the pharmacist did not alter the printed dispensing label to limit it to 10 days or tell you, definitely, check by speaking to hem, and if they confirm you stop after 10 days , ask them to investigate why that wasn’t on your dispensing label. Check your label has also been signed ( 2nd person verified) by the pharmacist at time they issued it.

I would say, if they did not instruct you properly they need to raise it with appropriate authorities . Don’t make a song and dance about it, but dispensing is strictly regulated and any errors have to be recorded by law by the pharmacist .

Guess that had past me by as I aren't clinical just the woman who answers the phone.

By my calculations, we should have had:

20x5ml doses at 3 doses a day, so just shy of a week

And we got:

40x2.5ml doses at 3 doses per day, so just shy of two weeks.

Its obviously a relatively minor incident but I feel like if more and more expectations are being put on pharmacists, they would probably want to know themselves if this is a potential issue going forward. It was a small, independent pharmacy.

The label is signed off as okay and everything else was correct, the only difference was that the “finish the course” guidance wasn’t changed.

When we hand out antibiotics at my pharmacy we always tell patients how long they should take them for as a standard practice even if it’s already on the label.

I would say your DC should have taken their antibiotics for 7 days. 100ml at 5ml 3 times a day is 7 days, so the double strength at half dose should also be 7 days, I would stop giving them now and I would speak to the pharmacy to flag it with them, they should have clarified the length of treatment with you when making the change.

I can phone the pharmacy/GP tomorrow morning - he has had all todays doses anyway.

I actually think both the doctor and the dispensing assistant told me specifically to “finish the course” but obviously the quantity of antibiotic doubled with the change in concentration.

I honestly wouldn’t have thought to even question it, my partner had just been giving our son the medicine (he normally takes charge of things like medicine, but was not at the doctors or the pharmacy to question it) and it wasn’t until I went into the fridge to get something that I realised we still had some. I thought maybe he had missed doses so I questioned him and he confirmed he’d been giving it 3x/day.

I kinda feel like a lot of people might not even pick up on this - I have a science degree and did a bit chemistry/biochemistry and a tiiiiny bit of pharmacology so although I didn’t have a good understanding of it, I had enough of a hunch that it wasn’t quite right. But then I was also doubting myself because I’m a known idiot and I’ve got dyscalculia so I thought there was every chance I was going to sound like a twat if I phoned them.

They’re highly qualified professionals not Dave down the corner shop.

The pharmacist can only give the dose according to the prescription from the Dr . Definitely speak to GP in the morning.

The label is signed off as okay and everything else was correct, the only difference was that the “finish the course” guidance wasn’t changed.

The finish the course warning is the standard BNF warning wording. That shouldn’t need to be removed. It’s the patient directions that are an issue. They should have stated how many days the course was for. It’s usually something like take ……mls ……times a day for …… days.

This is SO wrong. It is VERY important to finish all that you have been prescribed, even if you start to feel better.

We are also always told to finish the bottle. However, recently it has always been (roughly) ten day courses. Absolutely check with the pharmacist again though. It's not a silly question at all.

You finish the prescribed course - not necessarily the bottle. A typical course for kids (pre scarlet fever outbreak) would be 5ml 3 x a day which is 75ml. As the bottles contain 100ml you would expect there to be a bit left. Sometimes it’s a 3 day course so more would be leftover. For a 7 or 10 day course you get 2 bottles. So it’s fine for some to be left in the bottle once you have taken the prescribed doses. Finish the course doesn’t mean finish the bottle.

The OP didn’t seem to know how long to give the medicine or how often which is the real issue here.

Antibiotics are usually 5, 7 or 10 days. I don't know why you just assume it's a mistake.

Nah, I’m not sure a pharmacist would bother to check any medication allergies and/or sensitivities. It’s not like that’s part of the clinical screening process or anything…

There’s always so much misinformation and confusion on threads about medicines, I wish they’d get pulled. If I was the OP I’d be even more confused now!
If you have any queries about what you’ve been prescribed/what’s been dispensed to you, clarify with the pharmacist OR the prescriber as soon as you can.

The "course" is the advised duration, not the quantity you've been given. Taking antibiotics for a couple of days extra though isn't medically significant for the individual

It’s really up to your prescriber to tell you how long the course is, did they not do this? It’s also meant to be on the prescription. Giving 100ml without a course length isn’t good practice because how are you meant to finish the course if you don’t know how long it is?? Antibiotics are reconstituted for you so you’d usually be given the entire bottle. So yes pharmacist should have asked you whether you knew what the course length was but it’s the prescribers responsibility to clarify the course length with you initially. So not best practice from
either but not really an error either. clarify with either prescriber or pharmacist.