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Structure
Physical properties
Amoxicillin is either a white to off-white powder or crystalline solid
with the melting point of 194C and pH of 4.4-4.9 in 0.25% w/v solution. It
is stable in the presence of gastric acid (Ramos, Boison, & Friedlander,2012).
Amoxicillin has a bitter taste to it and one gram of amoxicillin dissolves
in about 370 mL of water and about 2 L of alcohol (Connors, Amidon, &
Stella, 1986). The solubility of amoxicillin is 10.7 ug/mL. Amoxicillin has
penicillin-type odor (Amoxicillin, 2017).
Chemical properties
Amoxicillin is susceptible to degradation by -lactamase-producing
bacteria (Kaur, Rao,& Nanda, 2011). The structure of amoxicillin includes
four hydrogen bond donors, seven hydrogen bond acceptors and four
rotatable bonds. The formal charge of the overall structure is zero,
meaning that the overall structure is neutral. The value of complexity is
590 (Amoxicillin, 2017).
purposes and applications
Amoxicillin could be used as a treatment for the middle ear (otitis
media), tonsils (tonsillitis & tonsillopharyngitis), throat, larynx (laryngitis),
pharynx (pharyngitis), bronchi (bronchitis), lungs (pneumonia), urinary tract
(UTI), skin, and to treat gonorrhea. Also, it is considered as a potential
treatment that could be used for chlamydia trachomatous, typhoid fever,
early Lyme disease, erythema migrans, erythema migrans borreliosis,
mucopurulent cervicitis, acute maxillary sinusitis, gastritis, peptic ulcers,
and meningitis (Kaur, Rao, & Nanda, 2011).
Amoxicillin could be found in three forms; immediate-release (IR)
tablet, chewable tablets, and extended-release (ER) tablet. Examples of
brands of Amoxicillin are Amoxil (IR tablet) and Moxatag (ER tablet). It is
a part of a class of drugs called penicillins and works by killing bacteria
and stop bacterial growth from occurring in the human body (Amoxicillin,
Oral Tablet, n.d).
References
Amoxicillin. (2017). Retrieved May 17, 2017 from
https://pubchem.ncbi.nlm.nih.gov/compound/amoxicillin#section=Top
Amoxicillin, Oral Tablet. (n.d). Retrieved May 25, 2017 from
http://www.healthline.com/health/amoxicillin-oral-tablet#highlights1
Connors, K.A., Amidon, G.L., Stella, V.J. (1986). Chemical Stability of
Pharmaceuticals: A Handbook for Pharmacists. New Jersey: Wiley-
Interscience Publications
Kaur, S.P., Rao, R., & Nanda, S. (2011). Amoxicillin: A broad spectrum
antibiotic. International
Journal of Pharmacy and Pharmaceutical Science, Vol.3, Issue 3,
pp.33-37
Ramos, F., Boison, J., Friedlander, L. G. (2012). Amoxicillin Retrieved May 17,
2017 from http://www.fao.org/fileadmin/user_upload/vetdrug/docs/
12-2012-amoxicillin.pdf
International Journal of Pharmacy and Pharmaceutical Sciences
ReviewArticle
AMOXICILLIN:ABROADSPECTRUMANTIBIOTIC
SIMARPREETKAUR1,REKHARAO*1,SANJUNANDA2
1MMCollegeofPharmacy,MMUniversity,Mullana,Ambala133001,Haryana,India,2DepartmentofPharmaceuticalSciences,MD
University,Rohtak124001,Haryana,India
Received:02April2011,RevisedandAccepted:07May2011
ABSTRACT
Amoxicillinthoughoriginallyintroducedintheearly1970sfororaluseinU.K.,hasfoundagraduallyregularplaceasbroadspectrumantibacterial
to treat the infections of various diseases. Amoxicillin has been found to be more effective against gram positive than gram negative micro
organisms and demonstrated greater efficacy to penicillin and penicillin V. Moreover, it has been found comparable to other antibiotics, e.g.
ampicillin,azithromycin, clarithromycin, cefuroximeand doxycycline in treatmentofvariousinfections/ diseases.In thepastdecade, amoxicillin
has been reported to be useful in the management of many indications and is used to treat infections of the middle ear (otitis media) , tonsils
(tonsillitis & tonsillopharyngitis), throat,larynx(laryngitis) , pharynx(pharyngitis), bronchi (bronchitis), lungs(pneumonia), urinarytract(UTI),
skinandtotreatgonorrhoea.Recentstudiessuggestedthatitcanbeusedasprophylaxisagainstbacterialendocarditis,inpatientswithprosthetic
jointreplacementsandindentistry.Therenewedinterestofthemoleculehaspromptedareviewofthesalientfacetsofthedrug.
Keywords:Amoxicillin,Antibiotic,Review
INTRODUCTION
Amoxicillin,anacidstable,semisyntheticdrugbelongstoaclassof
antibioticscalledthePenicillins( lactamantibiotics).Itisshownto
beeffectiveagainstawiderangeofinfectionscausedbywiderange
of Gram positive and Gram negative bacteria in both human and
animals14. It is a congener of ampicillin (a semisynthetic amino
penicillin) differing from the parent drug only by hydroxylation of
the phenyl side chain. It has found a niche in the treatment of
ampicillinresponsive infections after oral administration 46.
Chemically amoxicillin is (2S,5R,6R)6[[(2R)2Amino2(4
hydroxyphenyl)acetyl]amino]3,3dimethyl7oxo4thia1aza
bicyclo[3.2.0]heptane2carboxylic acid (Fig. 1). It is listed in a
number of Pharmacopoeias. Amoxicillin monograph is available in
UnitedStates,BritishandIndianpharmacopoeias79.
Fig.2:ItshowsinfectiousdiseasemortalitybyRegion,199812
TheWorldHealthOrganisation(WHO)in2005rankedinfectionsas
the leading global burden of disease and the leading cause of
mortality in children. Acute respiratory infections are the leading
infectiouscauseofdeathinallages(fig.3),worldwide13, 14.Current
key community and hospital bacterial disease burdens include
paediatric infections and multiple drug resistance in both Gram
positiveandGramnegativeorganisms1315.Anincreasingprevalence
of antibiotic resistance has led to the progressive decrease in the
effectiveness of narrowspectrum agents and to an increase in
difficulttotreat infections16. More than ever, selection of the most
appropriate antibiotic therapy has become a challenge for
clinicians17.
Fig.1:ItshowsthechemicalstructureofAmoxicillin10
HistoryandChallengesinDevelopment
Historically,infectiousdiseases(IDs)havebeenthemostimportant
contributor to human morbidity and mortality until recent times,
when noncommunicable diseases begin to rival, and sometimes
exceed,infections.Today,IDsstillaccountfora largeproportionof
death and disability worldwide and in certain regions remain the
most important cause of ill health11. IDs are major public health
issuesforbothdevelopedanddevelopingcountries.AfricaandIndia
both suffer significant population losses each year from infectious
andparasiticdiseases.Approximately5millionpeopleinAfricaand
2millionpeopleinIndiamostlychildrenandyoungadultsdieeach
yearbecauseofthesediseases.AfricaandIndias7millioninfectious
disease deaths account for 70% of infectious disease deaths
worldwideand13%ofalldeathsworldwide12. Fig.3:Itshowstheleadinginfectiouscausesofdeath
worldwide13,14
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IntJPharmPharmSci,Vol3,Issue3,2011,3037
In the 1960s, a limited range of non lactam antibacterials was added to increase their acid stability and their lactamase
available; most had certain limitations in terms of toxicity e.g. resistance11.
sulphonamides (rashes and renal toxicity); streptomycin and
kanamycin(ototoxicityandnephrotoxicity);chloramphenicol(bone Addinganelectronwithdrawinggroupontothe6position(located
marrow aplasia); erythromycin (gastrointestinal side effects); onthelactamring)amidegroupcanincreaseits acidstabilityby
tetracyclines (concentrate in developing bones and teeth) and making the amide oxygen less nucleophillic as in amoxicillin. This
colistin (neuro and nephrotoxicity). A number of betalactams, ensures that the amide oxygen will not attack the lactam ring's
penicillins: penicillin G and V (gastric acid labile), ampicillin, carbonylgrouptoopenit11.
methicillin (nephrotoxicity) and also cephalosporins: cephaloridine In the 1950s, the entire lactam family of antibiotics consisted of
andcephalothin(nephrotoxicity)werereported.Alloftheseagents twocompoundswithalimitedspectrumofactivitypenicillinGand
weregenerallygivenasafourtimesdailydoseandwereassociated penicillin V. There was considerable interest in developing new
withrashesand,rarely,anaphylaxis14. penicillinsbymodifyingthesidechainofthemolecule(Fig.4).One
At the end of the 1960s, challenging infections requiring treatment methodwastoprovidethesidechainprecursorsinthefermentation
in hospitals included meningitis, endocarditis, neonatal infections, broth.Therangeanddiversityofcompoundsthatcouldbeproduced
penicillinresistant staphylococcal infections and infections caused inthisway,however,werelimited14,19.
by Gramnegative organisms. In primary care, infections of the
urinary tract, respiratory tract and skin and soft tissues were a
common cause of morbidity and sometimes mortality. Further
problem areas emerging in the 1970s included mixed infections,
antibioticresistant bacteria, new pathogens and infections in
immunocompromised patients, those undergoing surgery, and
infections in haemodialysis patients. There was a requirement for
broadspectrumantibioticsactiveagainstresistantorganismsandin
mixedinfections14.
The 1970s saw the introduction of a number of important new
antimicrobial agents, some of which were still associated with
adverse events, such as cotrimoxazole (rashes and sulphonamide
toxicity), tobramycin and amikacin (aminoglycoside toxicity) and
metronidazole (neuropathy). Certain new betalactam antibiotics Fig.4:ItshowsthebasicstructureofPenicillin14
were also introduced including the cephalosporins cefamandole,
cefuroxime; the cephamycin, cefoxitin; and the penicillins
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Patients were included in the analysis if they completed the study. duodenalulcer(activeorwithin1year).Alldropoutswereincluded
Additionally,ifpatientsdroppedoutofthestudyduetoanadverse asfailuresoftherapy.
eventrelatedtothestudydrug,theywereincludedintheanalysisas c
failuresoftherapy. (P < 0.05) versus lansoprazole/amoxicillin and
b lansoprazole/clarithromycindualtherapy.
Patients were included in the analysis if they had documented H.
d
pylori infection at baseline as defined above and had a confirmed (P<0.05)versusclarithromycin/amoxicillindualtherapy.
Table2:ShowsHelicobacterpylorieradicationratesdualtherapy(amoxicillin/lansoprazole)54
PercentofPatientsCured[95%ConfidenceInterval] DualTherapy DualTherapy
(NumberofPatients)Study a b
EvaluableAnalysis IntenttoTreatAnalysis
Study1 c c
77 70
[62.587.2] [56.881.2]
(n=51) (n=60)
Study2 d d
66 61
[51.977.5] [48.572.9]
(n=58) (n=67)
a
Thisanalysiswasbasedonevaluablepatientswithconfirmedduodenalulcer(activeorwithin1year)andH.pyloriinfectionatbaselinedefinedas
atleast2of3positiveendoscopictestsfromCLOtest ,histology,and/orculture.Patientswereincludedintheanalysisiftheycompletedthestudy.
Additionally,ifpatientsdroppedoutofthestudyduetoanadverseeventrelatedtothestudydrug,theywereincludedintheanalysisasfailuresof
therapy.
b
PatientswereincludedintheanalysisiftheyhaddocumentedH.pyloriinfectionatbaselineasdefinedaboveandhadaconfirmedduodenalulcer
(activeorwithin1year).Alldropoutswereincludedasfailuresoftherapy.
c d
(P<0.05)versuslansoprazolealone., (P<0.05)versuslansoprazolealoneoramoxicillinalone.
Table3:ShowsadverseeventsassociatedwithAmoxicillintreatments(Reproducedfromref:2,35,56,61and62)
Organ/System Severity
Very Common Uncommon Rare VeryRare
Common (1in100to1in10) (1in1000to1in100) (1in10000to (Below1in10000)
(1in10or 1in1000)
more)
Gastrointestinal Diarrhoea Nausea,Vomiting,Lower Indigestion Antibioticassociatedcolitis
Tract(GIT) gastrointestinalirritation (pseudomembranous&
reactions(mildand haemorrhagiccolitis),Blackhairy
transitorydiarrhoea& tongue,Superficialtooth
pruritusani) discolouration
Skinand Allergicskinreactions(a TypicaltypeIallergic Erythema StevensJohnsonsyndrome,toxic
subcutaneous morbilliformexanthema) reactionslikeskinrash, multiform epidermalnecrolysis,bullous
tissues "fifthdayrash"(depends pruritis,urticariaand exfoliativedermatitis,acute
onsizeofthedose&the purpura;angiooedema generalisedexanthematous
patient'scondition) andanaphylaxis(less pustulosis
frequent).
Hepatobiliary AmoderateriseinAST Hepatitisandcholestaticjaundice
Tract and/orALTvalues &Hepaticeffects,predominantin
(significanceunknown) males&elderlypatients,
particularly,over65yrs,butvery
rareinchildren(incidence
increasesbyexceedingcoursesof
treatmentto14days)
NervousSystem Dizziness,headache Reversiblehyperactivityand
convulsionsmayoccurinpatients
withimpairedrenalfunctionorin
thosereceivinghighdoses
Bloodand Reversible Reversibleagranulocytosisand
Lymphatic Leucopenia haemolyticanaemia,prolongation
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Table4:ShowsDosageregimenofamoxicillinforvariousdiseaseconditions(Reproducedfromref36,53and56)
AdultsandPediatricPatients>3Months
Infections/Disease Severitya Usualadultdose UsualDoseforChildren>3Monthsb
Ear/Nose/Throat Mild/Moderate 500mgevery12 25mg/kg/dayindivideddosesevery12hoursor
hoursor 20mg/kg/dayindivideddosesevery8hours
250mgevery8hours
Severe 875mgevery12 45mg/kg/dayindivideddosesevery12hoursor
hoursor 40mg/kg/dayindivideddosesevery8hours
500mgevery8hours
LowerRespiratory Mild/Moderateor 875mgevery12 45mg/kg/dayindivideddosesevery12hoursor40mg/kg/dayindivided
Tract Severe hoursor500mg dosesevery8hours
every8hours
Skin/SkinStructure Mild/Moderate 500mgevery12 25mg/kg/dayindivideddosesevery12hoursor20mg/kg/dayindivided
hoursor250mg dosesevery8hours
every8hours
Severe 875mgevery12 45mg/kg/dayindivideddosesevery12hoursor40mg/kg/dayindivided
hoursor500mg dosesevery8hours
every8hours
GenitourinaryTract Mild/Moderate 500mgevery12 25mg/kg/dayindivideddosesevery12hoursor
hoursor250mg 20mg/kg/dayindivideddosesevery8hours
every8hours
Severe 875mgevery12 45mg/kg/dayindivideddosesevery12hoursor
hoursor500mg 40mg/kg/dayindivideddosesevery8hours
every8hours
Gonorrhea 3gramsassingleoral Prepubertal children:
Acute,uncomplicatedanogenital& dose 50mg/kg,combinedwith25mg/kgprobenecidasasingledose.
urethralinfectionsinmales&females Note:sinceprobenecidiscontraindicatedinchildrenunder2years,do
notusethisregimeninthesecases
Duodenalulcer, Tripleantibiotictherapy:1000mgamoxicillinwith500mgclarithromycinand30mglansoprazole
(H.pyloriassociated) twotimesadayattwelvehourintervalsfor14days
Dualantibiotictherapy:1000mgamoxicillinwith30mglansoprazolethreetimesadayat8hour
intervalsfor14days
Bacterialendocarditis 3grams1hourbeforetheprocedure,then1.5grams6hoursaftertheinitialdose
(prophylaxis)
a
Dosingforinfectionscausedbylesssusceptibleorganismsshouldfollowtherecommendationsforsevereinfections.
b
Thechildrensdosageisintendedforindividualswhoseweightislessthan40kg.Childrenweighing40kgormore
shouldbedosedaccordingtotheadultrecommendations.
Druginteractions inhibitsthedevelopmentofresistsntinlactamaseproducing
microorganisms2,14.
A. FoodDrugInteractions:
b) Clarithromycin and Lansoprazole: Clinical trials involving
B. Fatty meal significantly interfere with amoxicillin, the time the use of combination therapies (e.g. triple therapy in
above MIC (T>MIC) was prolonged by administration with combination with clarithromycin and lansoprazole, or double
food.MeanunboundT>MICof0.06g/ml(minimumrequired with lansoprazole alone against H. pylorirelated duodenal
for the inhibition of S. pyogenes) increased from 11.0 hours ulcerdisease)noadverseeffectpeculiartothesecombinations
underfastingconditionsto12.2hourswithalowfatmealand wereobserved35,56.
14.6hourswithahighfatmeal35.
c) Probenecid: Concurrent amoxicillin use with this product or
C. DrugDrugInteractions: other inhibitors of the renal acid secretory system increases
a) Clavulanic acid/ Potassium clavulanate: Clavulanic acid ( andprolongsbloodamoxicillinconcentrations34,54.
lactamase inhibitor) increases the effect of amoxicillin and d) Allopurinol:mayincreasethepossibilityofskinrash 35,56.
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