Amoxicillin retardness

So I’ve had just about enough of the boo-hoo bantering about the USA Today article about the baby who received 5x the “normal” amount of amoxicillin and would “writhe in pain”.  Lets look at this from a purely scientific standpoint.

According to Amoxicillin on RxList.com:

A prospective study of 51 pediatric
patients at a poison-control center suggested that overdosages of less than
250 mg/kg of amoxicillin are not associated with significant clinical symptoms
and do not require gastric emptying.³

3. Swanson-Biearman B, Dean BS, Lopez G, Krenzelok EP. The effects of penicillin
   and cephalosporin ingestions in children less than six years of age. Vet
   Hum Toxicol. 1988;30:66-67.

** DISCLAIMER (I hate doing these, you all should be smarter than this) DISCLAIMER **
Before I go on, the details of what happened are sketchy at best not to mention published by a shitty sensationalist media outlet that just wants ratings and attention.  Like the 14 year old spoiled drama queen playing the rape card after her boyfriend breaks up with her, you have to treat this all with a huge grain of salt and realization that we are making assumptions here about what happened.

Now, assuming that the child is way premature, say it weighs 1 kg or 2.2 lbs.  Amoxicillin comes in your standard 125mg/5cc, 250mg/5cc, or the oddball 400mg/5cc.  Nobody writes for the 400mg/5cc so we’ll just assume that the strength doesn’t exist for our example.

For a 1 Kg infant (which im sure the child weighed a bit more than 2.2 lbs) to receive 5 times the “normal” dose (which for our assumption the upper limit will be 250mg/kg since thats the upper limit of no clinical symptoms) the parent would have to give the child 5 teaspoonfuls a day.  Thats for a 1kg infant, thats 10 teaspoonfuls a day or 50mL (1/3rd of the bottle) for a 2kg patient (which 4 lbs sounds reasonable for a premature infant).

Now what fucking parent with a fucking premature baby would think that giving 5 teaspoonfuls a day of an antibiotic (or anything) would make sense?  Now don’t get me wrong, the mistake shouldn’t of been made in the first place, but don’t you think common sense would kick in around teaspoon number 3 or 4 of “maybe something isn’t right here”.  Considering the father is a “assistant professor of biomedical engineering at the University of North Carolina” we aren’t dealing with your standard uneducated village idiot here.  How would they know the baby is “writhing in pain” due to the amoxicillin and not just pissed off because its getting over an infection that required IV antibiotics?  Do they have baby brain reading machines?  Hell, have you tasted amoxicillin suspension? It makes me writhe in pain just smelling the dust when I open the bottle.

The /only/ way that I could see this happening is if the doctor wrote 1.5mL and the pharmacist though it meant 1.5 teaspoons.  However 1.5mL’s of the 250/5 is what, 75mg of amoxicillin? For a child that was on IV antibiotics, all that’s going to do is just make the baby spit pink all over the place.  I mean thats about as retarded as when PA/NP’s write for 4.56mL’s tid of amoxicillin because their common sense is in their palm pilot and not in their brains were it belongs. 

Who knows, I may be way off base here, but from the looks of it the USA Today just added the whole Amoxicillin story as purely emotional sensationalism.  Why don’t they write shit about us catching mistakes and saving people vs publically hanging us.

Comments #

Comment by http://openid.aol.com/blastoff2them00n on 2008-02-24 04:13:42 -0800 #

Hey AP,
Not that you particularly care, but Amoxil 400/5 is pretty popular with the docs in my pharmacy (I’m from a suburb of Cleveland). It’s pretty safe to say I fill it more often than the 125/5.
Nothing beats the time Dr. Urgent Care prescribed about 4x the adult loading dose of Zithromax for an infant, and then refused to change his directions, but that’s another story.
Have an angry day!

Comment by Biggest Fan on 2008-02-24 05:46:16 -0800 #

TAP –
I wish you had a place that I could ask you questions about stuff that I think is stupid that my fellow clinic docs do. Sometimes, I have stories/comments that don’t necessarily fit into the category at hand. Anyway…
Very sorry your profession is the target of the media right now. Keep up the good work – that’s for all you pharms out there.

Comment by Shalom (R.Ph.) on 2008-02-24 07:08:24 -0800 #

I guess it depends on where you are. Here (medium size town in central NJ) the pediatricians write for the 400/5 pretty much exclusively; the only ones writing for 250/5 are dentists. I could float a boat in the amount that goes out in a week, and this is a small independent that’s only been open a year.
I once asked the highest-volume pediatrician here why he always writes for half a teaspoon on the 400/5 rather than 1 teaspoon on the 200/5, and he said it’s because he’s trying to minimize the volume administered: 2.5ml is more likely to be swallowed, where a whole teaspoon would be either spat out or thrown up. (I would think this is more of a problem on the augmentin rather than the amoxicillin, but they do it for both.)
As far as smelling the dust. Amoxicillin is not anywhere near the top of the list. Cephalexin smells a whole lot worse (although it doesn’t taste all that bad). Rocephin injection smells like cat’s urine, especially if it’s been sitting around for a while, but the absolute king of stink is the Cleocin 75/5. That one smells like a garbage dump on a hot day. I have no idea how anyone of any age can take that without vomiting. Just mixing the stuff makes me nauseous.
Regarding the 1.5 tsp vs 1.5ml, I did have an argument once with a pediatrician who thought that Zantac syrup was 15mg/tsp rather than 15mg/ml, and wound up writing for 5x the dose he wanted. He did thank me for the correction once he found out I was right.
Completely off topic, has anyone else been having trouble getting hydroxyzine oral solution?

Comment by Debbie on 2008-02-24 10:30:57 -0800 #

As an RN, I’ve seen over and over how pharmacists truly are the last line of defense in med errors. When I worked in a clinic, Pharmacists would often call when a patient would come in with a nex RX to say there was an interaction. Often it was something we know…ie: coumadin and an antibiotic, in which case patient will return every few days for INR.
The biggest clusterfuck I saw was with a mentally ill neighbor, who was put on Zyvox for a huge ankle ulcer that her infectious disease doctor had been ignorring for a least a year, despite several visits. He did NOT tell her it was an MAOI,and of course she was on 2 antidepressants. It was the pharmacist who explained it all to her, that she would have to go off her Psych meds for 2 weeks, then take the antibiotic and then wait another 2 weeks before tapering back on the antidepressants.Pharmacist also told her about the low tyramine diet she would have to be on. I checked in with her often and it was a very hard time for her.Of course the zyvox made her deathly ill,vomiting/diarrhea etc so she couldnt even finish the Zyvox course.
Long story short, it was osteomylitis, blown off by MD and she ended up losing her leg at 37yrs old. It could have only been worse if she’s ended up in hypertensive crisis or seratonin syndrome, but did’nt, because of the pharmacist.
So I agree completely TAP.The media has NO idea of the extent to which pharmacists save lives everyday.

Comment by Phathead on 2008-02-24 10:47:35 -0800 #

I always love how we’re held accountable for the fact that other people are a few fries short of a happy meal.
And Shalom we use Amerisource and Dakota Drug for our wholesalers and I have DC’d by Manuf on one brand and Unavailable from Manuf on the other. I’m in northern Minnesota if that helps any.

Comment by WedgeTalon on 2008-02-24 11:19:26 -0800 #

We primarily do 400/5 here in East TN too.
And Shalom – We don’t really sell much hydroxyzine oral… at all. But the 25 mg tab is back-ordered for us until, like, mid to late April.

Comment by PharmDude on 2008-02-24 17:30:32 -0800 #

“Completely off topic, has anyone else been having trouble getting hydroxyzine oral solution?”
I was told it will no longer be made by my wholesaler. But, who knows…. they have told me things in the past that wasn’t true.

Comment by drh on 2008-02-24 18:13:08 -0800 #

OK, even if you didn’t realize that maybe 5 tsp. of amoxicillin is a bit too much for a preemie baby, how the hell do you get that much amoxicillin into a tiny baby?
Does amoxicillin really taste that bad? All the kids want “the pink stuff”.
BTW, I use 400mg/tsp. all the time, too, because with the 80-90 mg/kg/day dosing for ear infections, it gets to be a boatload of volume to get kids to take otherwise, especially the huge ones who really should be old enough to swallow pills but can’t. I’m in the “the more you give, the more get spat out” camp.

Comment by madge on 2008-02-24 20:20:39 -0800 #

amen! fabulous post!
send that back to the sensationalist media….for whatver reason, when people are dealing with kids, all common sense seems to fly out the window!
thank you for trying to bring logic back the profession!

Comment by Molly on 2008-02-24 20:20:58 -0800 #

Hydroxyzine oral sol’n is currently on ‘back order’ by the manuf. No ETA on when it will be avail. Have tried with no luck to get other manuf. that might have some.

Comment by rph3664 on 2008-02-24 20:54:53 -0800 #

I seriously doubt that a 1 kilogram baby would be in the care of its parents, and if it was, it wouldn’t be on amoxicillin.
The doctors around here (upper Midwest) write for a lot of 400/5 too. It’s that way both here and in the other city where I used to live, 150 miles away.
Biaxin liquid smells really good, but I once licked a drop off my finger and could taste those sour granules all day. BLECCCHHHHHH!
I had to take Gantrisin suspension several times as a child. My parents had to keep a chart so I wouldn’t go ask the other one for a dose – it tasted that good. I had no idea what I had taken until I was doing my retail rotation and when I opened that bottle, I knew instantly what it was just by the smell. It’s also the only bottled white suspension I’ve ever seen.
One woman I know had a child on Cleocin solution, and she mixed each dose with an entire packet of sugar-free Kool-Aid and he took it without any problems.
Ever gotten a whiff of Zarontin? That’s some nasty stuff, and both of the children for whom I have seen it dispensed were disabled. Good luck getting it down them. The capsules didn’t smell very good either.

Comment by Hogarth on 2008-02-25 06:46:35 -0800 #

“Why don’t they write shit about us catching mistakes and saving people vs publically hanging us.”
Probably the same reason that they don’t report on airline Captains successfully landing airplanes. It’s kind of, well, expected.
Not saying the media is right, of course, just pointing out the nature of the beast.

Comment by Steve on 2009-03-08 06:56:22 -0700 #

Does amoxicillin really taste that bad? All the kids
want “the pink stuff”.
No it is nearly tasteless. Very very slightly bitter.
It just so happens I found this thread while doing some google searching because my fiancee is on amoxicillin. She said she wanted to “See what it looks like”. So I twisted the top off one of the capsules to show her, a tiny bit spilled out, and she she went to lick it off my hand.
My first reaction was to, just a bit too late, say “you probably don’t want to do that” (I will never forget the taste of caffeine, or any of several other chemicals I have had the displeasure of tasting). She claimed it had “no taste”.
Shocked, I put some on my own tounge. Indeed… almost no flavor. Just very slightly bitter…. and thats not the “pink stuff”, thats the “white stuff” 🙂

Comment by Megan on 2010-04-07 10:27:25 -0700 #

Steve- The “pink stuff” is the liquid version of Amoxicillin. I think it tastes great- I had it after I had my tonsils taken out and thought it had a great taste. All the kids love the Amoxil, Augmentin on the other hand is discusting! We ALWAYS have to flavor that! Surprisingly, the other day we filled five bottles of Cleocin for one patient and told them that it was discusting and that it should be flavored and the mother refused. I felt so bad for that kid.