Discussion

Community pharmacists in this survey observed prescribing conventions, manufacturing, regulatory, and electronic medical record constraints that lead to liquid amoxicillin waste or confusing amounts for families to use. Antibiotic contamination of the soil or water may increase antibiotic-resistant bacteria and represents potential sources of human and animal exposure. Antibiotics in surface water and soil have been detected across the U.S. and directly impact groundwater and drinking/recreational water sources in urban areas. ^{Reference Segura, François, Gagnon and Sauvé5} Antibiotics placed down drains can further propagate antibiotic resistance among persistent bacterial communities associated with biofilms and water stagnation in plumbing systems. ^{Reference Lapworth, Baran, Stuart and Ward6,Reference Voigt, Faerber and Wilbring7}

Considerations to minimize liquid amoxicillin waste include chewable amoxicillin tablets, which are available in a generic format, considered safe down to two years of age, ^{Reference Michele, Knorr, Vadas and Reiss8} and would result in decreased antibiotic waste and plastic waste and avoids the need for refrigeration. Chewable tablets can be provided precisely without concern of spillage. Avoiding extra amounts of liquid can both avoid confusion for families and decreases the likelihood that families will use the antibiotic later inappropriately. ^{Reference Bharath, Sathian and Zmitrovich9} Finally, regulators and manufacturers could consider providing bulk powder to pharmacies for reconstitution so that the patient-specific amount can be dispensed each time. Another opportunity for modification of regulations would be to allow the pharmacist to round for bounded, short-duration antibiotic courses to preserve antibiotic stockpiles and minimize waste. Infectious diseases societies could consider advocacy to change these types of regulation.

Another area that community pharmacists noted was that many prescriptions are very specific, such as, for example, 7.2 mL of amoxicillin to be given per dose. Errors in dispensing liquid medication by parents are not uncommon, noted as up to 40% in one study of 287 family units. ¹⁰ Avoiding this type of hyper precise dosing could be undertaken by electronic medical record informaticists with the help of clinical pharmacists to use standard doses for weight ranges. Dosing for common upper respiratory tract infections for amoxicillin ranges from 70 to 90 mg/kg/day for acute otitis media, pneumonia, and sinusitis, so provides some flexibility in the amount to be dispensed.

Limitations of this study include that it mostly represented pharmacists practicing in Georgia and independent pharmacy personnel, introducing potential for bias. There was an assumed low response rate (exact rate was unable to be calculated), which limits the generalizability of this study. These can be considered preliminary data that could be confirmed by a larger survey.