Would you dispense it?

Well, I'd definately call the physician. Then if he said go ahead, I'd probably refuse. What is that, like 250% of the maximum recommended dose?

"For the treatment of adults with gonorrhea the dose is 3 g given as one dose."

Not sure if that's relevant.

I think Scarlet is a Streptococci, which Gonorrhea isn't. Usually whenever you see people getting treated for Strp throat, it's something like 2 500mg caps BID/TID x 7days. But nothing near 4000mg/day. I think it's high and I 'd really love to hear the physicians reasoning. There might be something I've overlooked. You can only give so much Amoxil before an additional quantity doesn't give any added benefits; I would assume, anyway. I wonder why they just didn't try Augmentin if Amoxil was perceived to not be strong enough?

i searched a little last night and didn't come up with anything other than 250mg... there were some articles on pubmed but it was just the title and i didn't feel like going to find them.

i would call to verify the dose

oh and btw its strep pyogenes

and clinical pcol stated a similar dose to strep throat

Here were the max doses:

Maximum Dosage Limits:
•Adults: 1750 mg/day PO.
•Elderly: 1750 mg/day PO.
•Adolescents: 1750 mg/day PO.
•Children (weight >= 40 kg): 1750 mg/day PO.
•Children (weight < 40 kg): 40 mg/kg/day PO for most indications. To increase the efficacy of amoxicillin against penicillin-resistant S. pneumoniae, up to 90 mg/kg/day PO has been used.
•Infants > 3 months: 40 mg/kg/day PO for most indications. To increase the efficacy of amoxicillin against penicillin-resistant S. pneumoniae, up to 90 mg/kg/day PO has been used.
•Infants <= 3 months: 30 mg/kg/day PO.
•Neonates: 30 mg/kg/day PO.


Salmonella gets a hefty 1g TID

When i clicked for the dose of strep pyogenes it gives the susceptible organisms and says this:
For the treatment of mild to severe infections caused by susceptible organisms including upper respiratory tract infections (e.g. sinusitis, pharyngitis), and skin and skin structure infections (e.g. cellulitis):
Oral dosage:
Adults, adolescents, and children (weight >= 40 kg): For mild to moderate infections due to highly susceptible organisms, the recommended dosage is 500 mg PO every 12 hours or 250 mg PO every 8 hours. For severe infections or infections caused by less susceptible organisms, the recommended dosage is 875 mg PO every 12 hours or 500 mg PO every 8 hours.
Children and infants > 3 months (weight < 40 kg): For mild to moderate infections due to highly susceptible organisms, the recommended dosage is 20 mg/kg/day PO given in equally divided doses every 8 hours or 25 mg/kg/day PO in equally divided doses given every 12 hours. For severe infections or infections caused by less susceptible organisms, the recommended dosage is 40 mg/kg/day PO in equally divided doses every 8 hours or 45 mg/kg/day PO in equally divided doses every 12 hours.
Neonates and infants <= 3 months: The recommended maximum dosage is 30 mg/kg/day PO given in divided doses every 12 hours.


When i searched scarlet fever penn V came up as the only drug listed for treatment and it said this:

For the treatment of Streptococcus pyogenes (group A beta-hemolytic streptococci) infections such as mild to moderately severe skin and skin structure infections (e.g. erysipelas), upper respiratory tract infections (e.g. pharyngitis, otitis media, tonsillitis), scarlet fever:
Oral dosage:
Adults and children >= 12 years: The recommended dose is 125—250 mg PO every 6—8 hours for 10 days or 500 mg PO every 12 hours for 10 days.
Children < 12 years: The recommended dose is 25—50 mg/kg/day PO divided into doses given every 6—8 hours. Maximum dose is 3 g/24 hours.



I would definitely look all of this stuff up prior to calling and have it in front of me and then i would say "do you mind me asking why? i have never seen that dose given" if they are mean about it i would be highly suspect and continue to make phone calls and search.... if i really couldn't find anything and the dr was a jerk and wouldn't tell me his reasoning then i don't think i would fill it... i would offer to transfer it anywhere the patient wanted.

baggywrinkle said:

Amoxicillin 2000mg twice daily for 7 days.

Young woman with Scarlet Fever. 105 pounds

Click to expand...

Call and verify....ask what the physician's source is....and keep in mind that the only probable side effect from a toxic dose of PCN or an aminoPCN is seizure, in the face of renal failure.

i would say.....that we don't carry that medications....but maybe another pharmacy might

rofl....j/k... I would definetly verify that with the doctor and find some way to have in writing that whatever happens to her is HIS responsibility....not mine.

But i'm only a first year....don't have that much knowledge in stuff like that

baggywrinkle said:

The doc cited expanded dosing guidlines but was unwilling to give me a source to read. She put it in writing and I stapled it to the script. Then I extensively counseled the patient telling her what I knew based on the information I had at hand then had the patient sign a statement of informed consent on the back of the script itself regarding the risks of high dose amoxicillin. The doc was pissed I had mentioned seizures to the patient stating I had undermined the trust between patient and physician. So be it, her attitude was shut up and fill it with the conversation ending with promises to document on both sides.

The patient purchased the prescription and then went and got a second opinion ultimately declining to take the amoxicillin yet retaining the option to take it later. She and her mother came in and thanked me for being a pain e the doc's behind.

Bottom line. It is difficult to do this job without stepping on someone's toes. The pharmacist, by definition, is charged with removing the punch bowl just when the party is getting good.

If anyone out there is aware of dosing guidelines up to 4000mg per day I would like to hear from you. The best I have been able to find so far is 3000mg/day in Lexi-Drugs. Indeed, Amoxil is not even the drug of choice or second choice for Scarlet Fever, but I didn't even venture down THAT
road....

Click to expand...

OK, from uptodate.com, in an article titled "Spontaneous gangrenous myositis caused by Streptococcus pyogenes." This is the most closely related GAS thing I could find:




Antibiotics — Penicillin has been commonly used in the treatment of spontaneous gangrenous myositis caused by S. pyogenes, since penicillin resistance among S. pyogenes strains has not been documented. Nevertheless, clinical experience and animal models indicate that penicillin monotherapy of severe infections due to S. pyogenes is associated with high rates of morbidity and mortality [2,3,13]. The lack of response to penicillin may be due to an inoculum effect in which penicillin becomes less effective at higher concentrations of the organism [13]. (See "Streptococcal toxic shock syndrome", section on Mechanism of penicillin failure).

Clinical trials of antibiotic efficacy in humans with spontaneous gangrenous myositis or necrotizing fasciitis have not been performed. However, clindamycin is more effective in animal models and has several unique properties which could theoretically improve outcome [11,14] (See "Streptococcal toxic shock syndrome", section on Clindamycin). A retrospective study confirmed that clindamycin use was associated with improved efficacy [15].
Clindamycin is not affected by the bacterial inoculum size or stage of growth (in contrast to penicillin).

The drug suppresses toxin synthesis and facilitates phagocytosis of S. pyogenes by inhibiting synthesis of the antiphagocytic M-protein.

We recommend therapy with penicillin G (4 million units intravenously every four hours in patients with normal renal function) in combination with clindamycin (900 mg intravenously every eight hours). If penicillin is not available because of supply shortages, then ampicillin (2 grams intravenously every four hours in patients with normal renal function) can be used.




I'm not sure if 2g Amp IV q4 is equivalent to 2g amoxicillin BID....anyway, hope that helps!

The only thing remotely related:

Acute otitis media due to highly-resistant strains of S. pneumoniae: Doses as high as 80-90 mg/kg/day divided every 12 hours have been used