This article is a transcribed edited summary of a video Bob and Brad recorded in May of 2021. For the original video go to https://www.youtube.com/watch?v=N4Iia-XIsV8
Brad: We have Chris the Pharmacist with us, and we have a wonderful topic to talk about today. It’s amoxicillin, how and when we use it, plus dangers of overuse, which is out there and it’s something that it’s good to know.
Chris: Oh yeah. Amoxicillin is one of the most widely prevalent drugs used in the world. In the United States in 2017, it was number 18 on the list of 27 million prescriptions filled. It’s a big number.
Brad: 27 million?
Chris: 27 million scripts.
Brad: It’s being used out there.
Chris: It’s being used. It’s an essential drug. It treats a variety of different infections.
Brad: How long has it been around?
Chris: Amoxicillin was isolated in 1958 but first used, in 1972. Penicillin itself we go back further.
Brad: What’s penicillin have to do with amoxicillin?
Chris: Amoxicillin is a penicillin. It’s a version of it. It’s a more readily available version. I think it’s crazy. There’s a Dr. Alexander Fleming in 1928, who just came back from vacation in England and he went back to his lab, and it was a mess. He started to clean things up and he noticed that on his Petri dishes all his staph infections had this mold on there, and it was penicillium notatum and around that area, there was no bacteria growth. He thought that was odd. So, he looked at it under the microscope to make sure it was clear and said wow, it was not there. At that point, he realized he probably came up with probably the single greatest medical revolution in the history of mankind, which was the discovery of penicillin.
Brad: So, in 1928, there’s mold, killed bacteria and he invented penicillin.
Chris: Exactly. Then it sort of died. He was a research physician, and he was brilliant. He came up with a couple of other things along the way, but 10 years later another doctor at Oxford read his paper. His name was Howard Florey. He was at the William and Dunn college of pathology and medicine, and he was a Rainmaker. This guy would go out and just make money. He found this and goes, I think we can make some money with this. He got in contact with the doctor, and they basically started to work on it. He had a big lab group in the Oxford department where he worked. There was Dr. Ernst Chain and then Dr. Norm Healey who is a biochemist.
Brad: So, they came up together to make penicillin?
Chris: It was a process. They started working on it and it was hard to isolate. As a matter of fact, when they got down to it, it took 2000 liters of extract to treat one human being. Can you imagine 2000 one-liter bottles? It would fill up this room. It’s huge to treat one person.
Brad: So, we could get onto Amoxicillin, this all developed in the 50s and then we got penicillin?
Chris: What happened is, during World War II is when this happened. They’re getting bombed out by the Germans all the time. They had a guy that had a gardening accident, and he was dying because of this horrible staph infection. They did a trial on 50 mice a little while ago. 25 that were treated with penicillin lived so let’s try it on this guy. They gave this guy penicillin and they had enough to give him for five days. They gave it to him, he was recovering and then they couldn’t get anymore because they couldn’t make it so they’re taking his urine because it was strongly metabolized by the kidney and reisolating it out of his urine, but they couldn’t make enough. That’s where Dr. Healey comes in. He’s the one in this hospital, he took every bottle, bedpan, and anything he could put in it to try and grow this penicillin isolate, but unfortunately ran out of time and sadly the poor individual passed away. So, they were like, what do we do next? So, in 1941, middle of World War II, they can’t do anything in Europe because they were getting bombed, they came to the United States and ended up in Peoria. They talked to several different manufacturers and there was this Dr. Aj Moyer that Healey met. He made suggestions. They changed the type of mold substance that you use for penicillin, and they got the extract. By 1942, it was being made by billion upon billions of units. They had it in 1942, the first American person used it and that pulled through. Then it was widely proven on the battlefields in Europe. What happened then, from World War II to World War I, the thing that was killing people in battles was an infection. It wasn’t the war wounds. They went from an 18% death rate to a 1% death rate simply because of penicillin. Dr. Fleming and his group got the Nobel prize in 1945. The interesting thing in Fleming's speech was with penicillin, we must be careful with our use because resistance could develop.
Brad: So, he warned it back then.
Chris: Yes. As we look at this and how we treat people with antibiotics today, we’re trying to cut down the use of any antibiotic really, because resistances are developing.
Brad: Wait. We’re jumping here. We went from penicillin got invented and suddenly Amoxicillin in 1958. So, Amoxicillin is a part of penicillin, and they use it for infections very commonly, and it grew and grew and we’re still using Amoxicillin today.
Chris: Correct. We use it today but it’s funny. I’ve been doing this for 25 years as a pharmacist and the doses of the amoxicillin have gone up from my first day in 1995 to where I am right now, vastly different dosing. You see higher doses to make it useful.
Brad: For the same individual or same problem.
Chris: Because of the resistance of amoxicillin.
Brad: Let’s back up one more step. So, we have amoxicillin now, it’s working well, and we’re changing the doses, but what is it primarily used for? Infection from a nail? Infection from a cut?
Chris: It’s a versatile drug. It’s going to treat things like pneumonia, UTI, staph infection, strep, and ear infections for parents or children. It’s safe during pregnancy. It works very well when used appropriately. The biggest thing for people is to make sure when your doctor gives you your prescription, you take it exactly as directed until they tell you to stop. Basically, people are inclined to want to stop taking the medication after three days and they’ll say they feel better. They’ll save it for later when something comes back and then they could be mistreating the infection because it might not be the appropriate bacteria. All your bacteria absorb the antibiotic. That’s why and we can talk about that resistance in the food supply and things like that if we want.
Brad: The big thing about dosages now, your doctor gives it to you, take it all the way as prescribed until the bottle is gone and they’ll tell you that or the pharmacists will. Adults, infants, and everybody can use this.
Chris: You name it.
Brad: I’m assuming the dosage is going to be different from an infant to an adult.
Chris: Yeah. For ear infections, they do a much higher dose of amoxicillin than what they would do for say a skin infection or a sore throat. It just depends. They always dose that by a milligram per kilogram. They base it on your body weight, particularly with kids. With adults, it is more standard and easier to dose as an adult.
Brad: It seems straightforward. If you get an infection, treatable with amoxicillin, follow the directions from the doctor. Typically, it’s successful and I’ve had this myself, like the doctor mentioned in 1945, there could be some problems with over-usage.
Chris: That’s one of the biggest problems that we face now as a society. You’re looking at what’s predicted right now by 2050, they think that resistance to antibiotics may overtake the cancer death rate.
Brad: So, you’re saying someone has an infection, they take amoxicillin, but it’s not going to work.
Chris: Then the infection is going to take over their body.
Brad: Why isn’t it working?
Chris: The bacteria want to live. Basically, what they do is they assimilate ways they’ve developed enzymatic systems to help to fight against it.
Brad: So, it mutates, and the amoxicillin is no longer effective because of the previous history. It’s used from person to person, generation to generation. If I had amoxicillin used on me and the bacteria start to mutate, I’m going to pass that on to my child.
Chris: It doesn’t work that way. It goes from bacteria to bacteria. You have your own normal flora, I have my own normal flora. Cattle and livestock have their own normal flora. Oftentimes, there are antibiotics in the food chain because they want to keep the herd healthy.
Brad: So, they’re using amoxicillin in cattle?
Chris: It’s not amoxicillin, but it’s penicillin specific for cattle.
Brad: But it still will affect us because they inject it into the herd.
Chris: Yeah, so the bacteria within those cows, it goes all the way down. It gets into the water system, you name it.
Brad: You mean because it’s injected in the cow, it goes into them, we eat the meat, so it gets into us and it’s kind of the same thing as an injection into us.
Chris: And they excrete things, it goes into the water and it’s in our water supplies. It’s a very widespread problem.
Brad: So, dairy, not just meat.
Chris: No, I’m just picking on cows, but it can be anything. It could be chickens.
Brad: Pigs, chickens. So, this is where people are concerned. I better get organic to avoid taking in the antibiotics that animals are taking.
Chris: Even then, organic farmers must treat their animals with antibiotics, but it’s much less. That’s something to be understood. Big commercial farmers tend to use antibiotics just prophylactically to make sure that the herd remains healthy.
Brad: Before there’s an infection, they’ll use it just to make sure because they have a thousand cows and if one gets an infection, it can spread.
Chris: Right, it’s a double-edged sword. It’s not an easy business. Farmers aren't just trying to indiscriminately do that. They’re livelihoods. You can’t blame them. It’s just a situation that’s arisen over the years. For a while, it seemed like an ingenious idea and now we’re just learning because these bacteria have learned how to develop enzymatic systems to help break down these antibiotics so they’re resistant to it, so it doesn’t affect them. Suddenly you give a shot of penicillin and it’s like, why am I not getting better? That’s the fear we have. Using antibiotics indiscriminately, when you don’t need it, and that’s hard because most times you go in and visit a doctor and unless they take a culture, they aren’t going to definitively know. They’ll have a good idea because they have smart people that deal with cultures and sensitivities. They talk about what the infecting organisms are in the area, and they have these infectious disease people.
Brad: They just don’t say it’s an infection.
Chris: No, even more so today, doctors are being much more selective about their use of infection. Let’s say you went in, and you had an ear infection, and your doctor, they’d probably give you Augmentin, but we’re not going to talk about that. But we’ll pretend they give you amoxicillin and we’re going to give you an 875-milligram dose twice a day. You have this ear that’s killing you, so you come into the pharmacy and you go, hey, I need this. Okay, Brad, we’re giving you amoxicillin, so what’s going on? And you say you have a horrible ear infection. Your doctor made the selective decision, I think Brad will be a good candidate for amoxicillin. We look at it, you’re going to take it twice a day for ten days. Sometimes it can be a five-day, seven days, or ten-day course. It depends on the nature of the infection. Sometimes ear infections can be worse because your ears and sinuses are interwoven together. You may see a prescription for seven-10 days depending on what your clinician believes what’s most appropriate for you. The biggest thing with amoxicillin, it’s tough on the stomach. I want to make sure you eat before you take a dose.
Brad: So, take it after you eat.
Chris: Right. Food first. Because it’s a twice-a-day dose, it’s convenient. We’re going to tell you to take it after breakfast and after supper. You might say, it’s three in the afternoon, what do I do? On day one, we’re going to tell you to get both doses in. Let’s say you’re up at 10, I’d tell you to get that second dose in. As we put more of an aggressive loading dose in there to try and get a head start on getting that nasty bacteria kind of calmed down. Then the next day, we want you to resume a uniform dosing pattern, so we keep a good concentration level of the drug in your system to aggressively manage and fight that infection.
Brad: Sometimes the doctors may get pressure from the patient or the family member that it had worked in the past and the doctor might say because of the history of using it before that you don’t want to use it all the time. The doctor might say, no we’re not going to use that.
Chris: Then you have a frustrated patient. That’s one of the things that doctors find this dilemma, I think on a day-to-day basis, is to what’s the most effective choice. Now we have most hospitals and clinics have what they call anti-microbial stewardship programs in place where they go through a lot of education and doctors already have a ton of hours of education, so they know when it’s appropriate and when it’s not. They generally are not going to succumb to patients calling their shots, so to speak. I’m going to go in and take some amoxicillin because it worked for my kid. It might be because there’s maybe a genetic component there but if there’s an allergy in place, maybe it’s not appropriate, or there are certain drugs that could interfere with that. There are a lot of reasons why clinicians may choose something different but for the purpose of our discussion, we’re going to say you’re not on any drugs that could interfere like a blood thinner. We’re going to pretend that you’re healthy otherwise and you have no allergies.
Brad: Let’s say you have a history of using amoxicillin like me or maybe I used it a few times in my past. Would that be a reason not to continue to use it?
Chris: Yes, absolutely. That’s one of the biggest things that we watch for in the pharmacy is usually the guideline that we’ve seen put in place is you don’t want to repeat the same drug within at least 30 days. I think they’re getting even more stringent about that. It kind of depends because with sinusitis that’s a tough infection to treat, to begin with. Sometimes it takes a much longer course of antibiotics even two weeks, or three weeks. Those are long courses of antibiotics. An antibiotic goes in there, indiscriminately. It kills your good bacteria and your bad bacteria, so it makes it tough. That’s why people have digestive woes when they’re taking antibiotics because their good bacteria got killed off. That’s what helps us digest our food.
Brad: I’m reading a book and they’re talking about the gut, the microbiome.
Chris: The biome of the gut.
Brad: Yeah, which is good bacteria.
Brad: Which, 20 years ago I just figured all bacteria are good until I got in the health field.
Chris: That’s what happens with an infection, it’s like checks and balances like our government. Suddenly, we have billions of bacteria, all over our bodies at any given point in our body. When your immune system has an insult, something gets overgrown, and that’s when the bacteria take advantage and say "hey, I have a weakness here. This is my chance to proliferate and get big and nasty." That’s why, in the case of like an ear infection, it found a spot behind that eardrum, your eustachian tube wasn’t drained properly, it clogged up and it’s a nice warm breeding environment, and boom, it grew bad, and you had the infection necessitating the use of the antibiotic. Repeating it over and over is not a successful plan. Just because it worked last time doesn’t mean it’s the most appropriate plan. A lot of times physicians will recognize that, and they will go in a different direction and select a different, although effective antibiotic. Let’s say the second antibiotic didn’t work as effectively for whatever reason, they might have to go back to we’ll say amoxicillin in this case. So, it depends. There’s a lot of work that goes on. If it was easy, everyone would do it. It’s a challenge for sure.
Brad: Well, I think we covered a lot of ground there from the history. It’s amazing how things in life and in history, accidents happen and something incredible comes of it. Amoxicillin sounds like a good drug. It sounds like you have to be careful with it and understand how to take it and when to and when not to take it, and you know what the doctors have to take into consideration.
Chris: Yup. And going forward we're going to have to have these drug companies start doing more research on new antimicrobials. Otherwise, I think in a very short period of time could history wise, we could have some very big issues.
Brad: Well, you said 2050, so that's 30 years.
Chris: That's not that far away.
Brad: I suppose. Things happened fast. So very good. I hope you learned a lot and you feel comfortable with your amoxicillin and enjoy the week.
Chris: Thanks, guys.
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