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Question: I forgot to refrigerate the antibiotic! It’s been off the fridge for two days. Is it still good?

Answer: Antibiotics are made as tablets or capsules for adults to take orally. However, this is not an option for children.

When it comes to children, medicines are better accepted in the liquid form. Also, additives such as flavourings and sweeteners can be included in the liquid form to improve the taste so that children will be more likely to take the medicine. The dilemma, however, is that a lot of antibiotics become unstable and lose their potencies if they remain in the liquid form for too long.

Thinking outside the box

Drug manufacturers have devised a way around the dilemma. They have made antibiotics into dry powders, with strict instructions on how to reconstitute them with purified water. The dry powders can be stored for a long time on the shelves of pharmacies.

Pharmacists are tasked with the responsibility of reconstituting the antibiotic powder to make it into a liquid form. They do this right before dispensing because once the water touches the powder, the process of deterioration begins.

Improper storage

Once reconstituted, a liquid antibiotic has a shelf life of five to 14 days. Improper storage causes the antibiotic to lose its potency, stability, and can impact the taste. The suspensions might start to separate, so you might see a clear liquid layer floating on top of the solids at the bottom. The colour might also change, so a white suspension might start turning brown.

The change in the physical composition of the antibiotic might be frightening to parents and they will most likely assume that the antibiotic is spoilt. That assumption would be correct. The child might also notice a difference in the taste and smell of the antibiotic once it starts to break down. From a chemical standpoint, the medicinal effect of the drug will start to decrease. In other words, it starts becoming less effective at fighting the infection. Hence, at the end of the course of treatment, unfortunately, the infection might not be cured.

‘Keep refrigerated’

When dispensing reconstituted antibiotics, the pharmacist will always remind the patient to keep the medicine refrigerated. Refrigeration slows down the deterioration process so the antibiotic remains stable and potent enough to carry out its function for the duration of the treatment.

Somehow, we take it for granted that everybody has a refrigerator, and so pharmacists normally issue the standard advice: “Keep refrigerated” without checking the patient’s socio-economic status. The fact is, some people do not have refrigerators. Also, some people do not have a consistent power supply to operate a refrigerator.

Just recently I was confronted by a similar situation after reconstituting and dispensing an antibiotic suspension for a 10-year-old boy who was very ill. When giving his father the instructions on how the medicine should be given, I was quick to point out that the antibiotic should be kept on the fridge. The father told me that the child lives with his mother and they do not have a refrigerator. They did, however, have a freezer and could keep it in the freezer, he suggested.

Of course, you don’t want to freeze the antibiotic suspension. How would you pour out the correct dose if it is frozen? Furthermore, freezing can affect the chemical composition of the antibiotic as well, rendering it less effective. However, this was the patient’s reality. So how could I address this issue to ensure that the patient got the maximum benefit from his course of antibiotics?

I proffered the advice that the antibiotic could be kept cool in an igloo with ice. Most manufacturers recommend that antibiotics should be kept between two to eight degrees Celsius. But of course, no mother is going to have a thermometer sitting around to ensure that is the temperature of her igloo. I tried to emphasise the fact that the antibiotic should be kept cool, but not frozen. Another alternative would be to store the medicine in a neighbour’s fridge.

So, to answer the question, is an antibiotic suspension still good if it is left out of the fridge? It really depends on the antibiotic. Some of the antibiotics that have a shorter shelf life of five days may really have gone bad. Some of them that have longer shelf lives of 10-14 days may not actually have gone bad. However, they might have started becoming less effective in terms of fighting infection.

Novia Jerry Stewart, MSc, RPh, is a pharmacist who specialises in ophthalmic care. She may be contacted at novia_jerry@yahoo.com.