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Medication Safety Issues
Sound-alike/look-alike issues:
Amoxicillin may be confused with amoxapine, Amoxil®, Atarax®
Amoxil® may be confused with amoxapine, amoxicillin
International issues:
Fisamox® [Australia] may be confused with Fosamax® which is a brand name for alendronate in the U.S.
Fisamox® [Australia] may be confused with Vigamox™ which is a brand name for moxifloxacin in the U.S.
Pronunciation
(a moks i SIL in)
U.S. Brand Names
Index Terms
Generic Available
Yes: Excludes drops
Canadian Brand Names
Pharmacologic Category
Pharmacologic Category Synonyms
Use: Labeled Indications
Treatment of otitis media, sinusitis, and infections caused by susceptible organisms involving the respiratory tract, skin, and urinary tract; prophylaxis of infective endocarditis in patients undergoing surgical or dental procedures; as part of a multidrug regimen for H. pylori eradication
Use: Dental
Antibiotic for standard prophylactic regimen for dental patients who are at risk for infective endocarditis; prophylaxis in total joint replacement patients undergoing dental procedures which produce bacteremia; antibiotic used to treat orofacial infections
Use: Unlabeled/Investigational
Postexposure prophylaxis for anthrax exposure with documented susceptible organisms
Pregnancy Risk Factor
B
Pregnancy Considerations
Adverse events have not been observed in animal studies; therefore, amoxicillin is classified as pregnancy category B. There is no documented increased risk of adverse pregnancy outcome or teratogenic affects caused by amoxicillin. It is the drug of choice for the treatment of chlamydial infections in pregnancy and for anthrax prophylaxis when penicillin susceptibility is documented.Due to pregnancy-induced physiologic changes, amoxicillin clearance is increased during pregnancy resulting in lower concentrations and smaller AUCs. Oral ampicillin-class antibiotics are poorly-absorbed during labor.
Lactation
Enters breast milk/compatible
Breast-Feeding Considerations
Very small amounts of amoxicillin are excreted in breast milk. The manufacturer recommends that caution be exercised when administering amoxicillin to nursing women. The AAP considers amoxicillin to be “usually compatible with breastfeeding." Nondose-related effects could include modification of bowel flora and allergic sensitization of the infant.
Contraindications
Hypersensitivity to amoxicillin, penicillin, or any component of the formulation
Warnings/Precautions
Concerns related to adverse effects:
• Anaphylactoid/hypersensitivity reactions: Serious and occasionally severe or fatal hypersensitivity (anaphylactoid) reactions have been reported in patients on penicillin therapy, especially with a history of beta-lactam hypersensitivity, history of sensitivity to multiple allergens, or previous IgE-mediated reactions (eg, anaphylaxis, angioedema, urticaria). Use with caution in asthmatic patients.
• Superinfection: Prolonged use may result in fungal or bacterial superinfection, including C. difficile-associated diarrhea (CDAD) and pseudomembranous colitis; CDAD has been observed >2 months postantibiotic treatment.
Disease-related concerns:
• Infectious mononucleosis: A high percentage of patients with infectious mononucleosis have developed rash during therapy.
• Renal impairment: Use with caution in patients with renal impairment; dosage adjustment recommended.
Dosage form specific issues:
• Phenylalanine: Chewable tablets contain phenylalanine.
Adverse Reactions
Frequency not defined.
Central nervous system: Hyperactivity, agitation, anxiety, insomnia, confusion, convulsions, behavioral changes, dizziness
Dermatologic: Acute exanthematous pustulosis, erythematous maculopapular rash, erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis, hypersensitivity vasculitis, urticaria
Gastrointestinal: Nausea, vomiting, diarrhea, hemorrhagic colitis, pseudomembranous colitis, tooth discoloration (brown, yellow, or gray; rare)
Hematologic: Anemia, hemolytic anemia, thrombocytopenia, thrombocytopenia purpura, eosinophilia, leukopenia, agranulocytosis
Hepatic: AST and ALT increased, cholestatic jaundice, hepatic cholestasis, acute cytolytic hepatitis
Renal: Crystalluria
Drug Interactions
Allopurinol: May enhance the potential for allergic or hypersensitivity reactions to Amoxicillin. Risk C: Monitor therapy
Fusidic Acid: May diminish the therapeutic effect of Penicillins. Risk D: Consider therapy modification
Methotrexate: Penicillins may decrease the excretion of Methotrexate. Risk C: Monitor therapy
Tetracycline Derivatives: May diminish the therapeutic effect of Penicillins. Risk D: Consider therapy modification
Typhoid Vaccine: Antibiotics may diminish the therapeutic effect of Typhoid Vaccine. Only the live attenuated Ty21a strain is affected. Risk D: Consider therapy modification
Uricosuric Agents: May decrease the excretion of Penicillins. Risk C: Monitor therapy
Storage
Amoxil®: Oral suspension remains stable for 14 days at room temperature or if refrigerated (refrigeration preferred). Unit-dose antibiotic oral syringes are stable for 48 hours.
Mechanism of Action
Inhibits bacterial cell wall synthesis by binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.
Pharmacodynamics/Kinetics
Absorption: Oral: Rapid and nearly complete; food does not interfere
Distribution: Widely to most body fluids and bone; poor penetration into cells, eyes, and across normal meninges
Pleural fluids, lungs, and peritoneal fluid; high urine concentrations are attained; also into synovial fluid, liver, prostate, muscle, and gallbladder; penetrates into middle ear effusions, maxillary sinus secretions, tonsils, sputum, and bronchial secretions
CSF:blood level ratio: Normal meninges: <1%; Inflamed meninges: 8% to 90%
Protein binding: 17% to 20%
Metabolism: Partially hepatic
Half-life elimination:
Neonates, full-term: 3.7 hours
Infants and Children: 1-2 hours
Adults: Normal renal function: 0.7-1.4 hours
Clcr <10 mL/minute: 7-21 hours
Time to peak: Capsule: 2 hours; Suspension: 1 hour
Excretion: Urine (80% as unchanged drug); lower in neonates
Dosage
Usual dosage range:
Children ?3 months: Oral: 20-30 mg/kg/day divided every 12 hours
Children >3 months and <40 kg: Oral: 20-50 mg/kg/day in divided doses every 8-12 hours
Adults: Oral: 250-500 mg every 8 hours or 500-875 mg twice daily
Indication-specific dosing:
Children >3 months and <40 kg: Oral:
Acute otitis media: 80-90 mg/kg/day divided every 12 hours
Anthrax exposure (CDC guidelines): Note: Postexposure prophylaxis only with documented susceptible organisms: 80 mg/kg/day in divided doses every 8 hours (maximum: 500 mg/dose)
Community-acquired pneumonia:
4 months to <5 years: 80-100 mg/kg/day divided every 8 hours
5-15 years: 100 mg/kg/day divided every 8 hours; Note: Treatment with a macrolide or doxycycline (if age >8 years) is preferred due to higher prevalence of atypical pathogens in this age group
Ear, nose, throat, genitourinary tract, or skin/skin structure infections:
Mild to moderate: 25 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours
Severe: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours
Lower respiratory tract infections: 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours
Lyme disease: 25-50 mg/kg/day divided every 8 hours (maximum: 500 mg)
Prophylaxis against infective endocarditis: 50 mg/kg 1 hour before procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Adults: Oral:
Anthrax exposure (CDC guidelines): Note: Postexposure prophylaxis in pregnant or nursing women only with documented susceptible organisms: 500 mg every 8 hours
Ear, nose, throat, genitourinary tract, or skin/skin structure infections:
Mild to moderate: 500 mg every 12 hours or 250 mg every 8 hours
Severe: 875 mg every 12 hours or 500 mg every 8 hours
Helicobacter pylori
eradication: 1000 mg twice daily; requires combination therapy with at least one other antibiotic and an acid-suppressing agent (proton pump inhibitor or H2 blocker)
Lower respiratory tract infections: 875 mg every 12 hours or 500 mg every 8 hours
Lyme disease: 500 mg every 6-8 hours (depending on size of patient) for 21-30 days
Prophylaxis against infective endocarditis: 2 g 30-60 minutes before procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Prophylaxis in total joint replacement patients undergoing dental procedures which produce bacteremia: 2 g 1 hour prior to procedure
Dosing interval in renal impairment: The 875 mg tablet should not be used in patients with Clcr <30 mL/minute.
Clcr 10-30 mL/minute: 250-500 mg every 12 hours
Clcr <10 mL/minute: 250-500 mg every 24 hours
Dialysis: Moderately dialyzable (20% to 50%) by hemo- or peritoneal dialysis; approximately 50 mg of amoxicillin per liter of filtrate is removed by continuous arteriovenous or venovenous hemofiltration; dose as per Clcr <10 mL/minute guidelines
Dental Usual Dosing
Oral:
Children >3 months and <40 kg: Prophylaxis against infective endocarditis: 50 mg/kg 30-60 minutes before procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Adults:
Prophylaxis against infective endocarditis: 2 g 30-60 minutes before procedure. Note: American Heart Association (AHA) guidelines now recommend prophylaxis only in patients undergoing invasive procedures and in whom underlying cardiac conditions may predispose to a higher risk of adverse outcomes should infection occur. As of April 2007, routine prophylaxis for GI/GU procedures is no longer recommended by the AHA.
Orofacial infection: 250-500 mg every 8 hours or 500-875 mg twice daily
Prophylaxis in total joint replacement patients undergoing dental procedures which produce bacteremia: 2 g 1 hour prior to procedure
Administration: Oral
Administer around-the-clock to promote less variation in peak and trough serum levels. The appropriate amount of suspension may be mixed with formula, milk, fruit juice, water, ginger ale, or cold drinks; administer dose immediately after mixing.
Some penicillins (eg, carbenicillin, ticarcillin, and piperacillin) have been shown to inactivate aminoglycosides in vitro. This has been observed to a greater extent with tobramycin and gentamicin, while amikacin has shown greater stability against inactivation. Concurrent use of these agents may pose a risk of reduced antibacterial efficacy in vivo, particularly in the setting of profound renal impairment. However, definitive clinical evidence is lacking. If combination penicillin/aminoglycoside therapy is desired in a patient with renal dysfunction, separation of doses (if feasible), and routine monitoring of aminoglycoside levels, CBC, and clinical response should be considered.
Monitoring Parameters
With prolonged therapy, monitor renal, hepatic, and hematologic function periodically; assess patient at beginning and throughout therapy for infection; monitor for signs of anaphylaxis during first dose
Test Interactions
May interfere with urinary glucose tests using cupric sulfate (Benedict's solution, Clinitest®)
Some penicillin derivatives may accelerate the degradation of aminoglycosides in vitro, leading to a potential underestimation of aminoglycoside serum concentration.
Dietary Considerations
May be taken with food. Amoxil® chewable contains phenylalanine 1.82 mg per 200 mg tablet, phenylalanine 3.64 mg per 400 mg tablet.
Patient Education
Do not take any new medication during therapy unless approved by prescriber. Take entire prescription, even if you are feeling better. Take at equal intervals around-the-clock. May be taken with milk, juice, or food. If you have diabetes, drug may cause false test results with Clinitest® urine glucose monitoring; use of another type of glucose monitoring is preferable. May cause nausea or vomiting (small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help). Report rash; unusual or persistent diarrhea; vaginal itching, burning, or pain; unresolved vomiting or constipation; fever or chills; abdominal pain; jaundice; unusual bruising or bleeding; opportunistic infection [fever, chills, unhealed sores, white plaques in mouth or vagina, purulent vaginal discharge, fatigue]; or if condition being treated worsens or does not improve by the time prescription is completed.
Geriatric Considerations
Resistance to amoxicillin has been a problem in patients on frequent antibiotics or in nursing homes. Alternative antibiotics may be necessary in these populations. Consider renal function.
Cardiovascular Considerations
For the prevention of bacterial endocarditis, amoxicillin 2 g orally can be given 1 hour before, in the absence of a contraindication, for a dental, oral, respiratory tract, or esophageal procedure.
Dental Health: Effects on Dental Treatment
Prolonged use of penicillins may lead to development of oral candidiasis
Dental Health: Vasoconstrictor/Local Anesthetic Precautions
No information available to require special precautions
Infectious Diseases Comment
A well-documented reaction can occur between beta-lactam and aminoglycoside antibiotics in vitro, leading to complexation, opening of the beta-lactam ring and presumably, loss of antibacterial activity for one or both agents. However, the conditions under which this reaction occurs are variable and influenced by (but not limited to) assay methodology, sampling time and storage, and drug selection and concentration. In general, many of the in vitro studies employed artificial conditions that tested high concentrations of the penicillin derivative (equating to serum levels most likely observed only in severe renal impairment) in combination with gentamicin or tobramycin. Incubation of the agents at conditions of 37°C for up to 48 hours has definitely demonstrated inactivation and loss of bactericidal activity. However, some of these studies permitted a considerable time lapse prior to assaying the medium, or stored the samples at higher temperatures (-20°C or greater), which may have allowed continued chemical degradation prior to assay. In general, amikacin was the most resistant to penicillin-mediated chemical degradation, and cephalosporins were much less likely than penicillins to inactivate the aminoglycosides.
The more robust studies have been those which evaluated in vivo effects via rapid and frequent blood sampling during concomitant dosing. In vivo, there are a number of studies documenting significant changes in the half-life of gentamicin in combination with primarily ticarcillin and carbenicillin, but usually only in the setting of end-stage renal disease. A number of literature reports suggest that despite documented changes in gentamicin kinetics, this is not likely to lead to clinically-significant differences in outcomes in patients with normal renal function. Furthermore, there are no published, prospective, outcomes-based studies that provide compelling evidence of changes in rates of clinical or microbiological response as a function of dosing separation.
Based on the weight of evidence to date, coadministration of (but not coadmixture of) a penicillin or cephalosporin antibiotic with an aminoglycoside should not pose a significant concern in patients with even mild renal impairment. However, specific circumstances exist in which this approach should be undertaken with caution. Concurrent administration of either gentamicin or tobramycin with piperacillin, carbenicillin, or ticarcillin (including combinations with beta-lactamase inhibitors), particularly in the face of moderate-to-severe renal failure, would warrant careful monitoring of aminoglycoside serum levels, CBCs and clinical response to avoid potentially reduced efficacy due to chemical inactivation.
Mental Health: Effects on Mental Status
Rarely large doses may produce confusion, hallucinations, and depression; penicillins have been reported to cause apprehension, illusions, agitation, insomnia, depersonalization, and encephalopathy
Mental Health: Effects on Psychiatric Treatment
Disulfiram may increase amoxicillin levels
Nursing: Physical Assessment/Monitoring
Assess culture and sensitivity report and patient allergy history prior to starting therapy. Assess potential for interactions with other medications patient may be taking. Caution patients with diabetes about altered response to Clinitest®. Assess for therapeutic effectiveness and adverse reactions (eg, opportunistic infection [fever, chills, unhealed sores, white plaques in mouth or vagina, purulent vaginal discharge, fatigue] - see Adverse Reactions and Overdose/Toxicology). Teach patient proper use, possible side effects/appropriate interventions, and adverse symptoms to report.
Dosage Forms
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Capsule: 250 mg, 500 mg
Amoxil®: 500 mg
Powder for oral suspension: 125 mg/5 mL (80 mL, 100 mL, 150 mL); 200 mg/5 mL (50 mL, 75 mL, 100 mL); 250 mg/5 mL (80 mL, 100 mL, 150 mL); 400 mg/5 mL (50 mL, 75 mL, 100 mL)
Amoxil®: 200 mg/5 mL (50 mL, 75 mL, 100 mL) [contains sodium benzoate; bubble gum flavor] [DSC]; 250 mg/5 mL (100 mL, 150 mL) [contains sodium benzoate; bubble gum flavor]; 400 mg/5 mL (5 mL [DSC], 50 mL [DSC], 75 mL [DSC], 100 mL) [contains sodium benzoate; bubble gum flavor]
Powder for oral suspension [drops]:
Amoxil®: 50 mg/mL (30 mL) [contains sodium benzoate; bubble gum flavor]
Tablet: 500 mg, 875 mg
Amoxil®: 500 mg, 875 mg [DSC]
Tablet, chewable: 125 mg, 200 mg, 250 mg, 400 mg
Amoxil®: 200 mg [contains phenylalanine 1.82 mg/tablet; cherry banana peppermint flavor] [DSC]; 400 mg [contains phenylalanine 3.64 mg/tablet; cherry banana peppermint flavor] [DSC]
Pricing: U.S. (www.drugstore.com)
Capsules (Amoxicillin)
250 mg (90): $15.00
500 mg (30): $12.99
Capsules (Amoxil)
500 mg (30): $15.99
Chewable (Amoxicillin)
125 mg (21): $11.99
250 mg (30): $13.99
400 mg (20): $10.91
Chewable (Amoxil)
400 mg (20): $13.99
Suspension (reconstituted) (Amoxicillin)
250 mg/5 mL (150): $12.99
Suspension (reconstituted) (Amoxil)
50 mg/mL (30): $8.99
200 mg/5 mL (100): $11.99
250 mg/5 mL (100): $8.99
250 mg/5 mL (150): $8.99
400 mg/5 mL (50): $8.99
400 mg/5 mL (75): $9.99
400 mg/5 mL (100): $11.99
Suspension (reconstituted) (Trimox)
125 mg/5 mL (100): $11.99
250 mg/5 mL (80): $11.99
Tablets (Amoxicillin)
500 mg (100): $49.99
875 mg (30): $24.99
Tablets (Amoxil)
500 mg (21): $12.99
875 mg (21): $21.99
References
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International Brand Names
Lexi-Comp.com
Last full review/revision August 2008
Content last modified August 2008
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