How have antibiotic prescription patterns changed since 2015. What are the most commonly prescribed antibiotic classes and agents. Which healthcare providers prescribe the most antibiotics. How do antibiotic prescription rates vary across different regions and states in the US.

Antibiotic Prescription Trends: A Comprehensive Overview

In 2015, healthcare providers in the United States prescribed a staggering 269.4 million antibiotic prescriptions, equivalent to 838 prescriptions per 1,000 persons. This data, extracted from the QuintilesIMS Xponent database, captures an estimated 88% of outpatient prescriptions nationwide. While this information provides a snapshot of antibiotic use from several years ago, it serves as a crucial baseline for understanding current trends and patterns in antibiotic prescribing.

Prescription Patterns by Demographics

Analyzing the data reveals interesting patterns across different age groups and genders:

• Adults (20 years and older) received more prescriptions (203.3 million) compared to those under 20 years (64.7 million).
• Females were prescribed significantly more antibiotics (164.0 million) than males (104.9 million).
• The prescription rate for females was 1,005 per 1,000 persons, while for males it was 663 per 1,000 persons.

These disparities raise important questions about the factors influencing antibiotic prescribing practices. Are women more prone to infections requiring antibiotics, or are there other underlying factors at play?

Regional Variations in Antibiotic Prescribing

The study highlights significant regional differences in antibiotic prescribing rates across the United States:

1. South: 920 prescriptions per 1,000 persons
2. Midwest: 898 prescriptions per 1,000 persons
3. Northeast: 867 prescriptions per 1,000 persons
4. West: 632 prescriptions per 1,000 persons

The stark contrast between the South and the West is particularly noteworthy. What factors contribute to this regional disparity? Could differences in healthcare access, population demographics, or prescribing practices be responsible?

Top Antibiotic Classes and Agents: Breaking Down the Numbers

Understanding which antibiotics are most frequently prescribed provides valuable insights into treatment patterns and potential areas for intervention. The top five antibiotic classes prescribed in 2015 were:

• Penicillins: 61.6 million prescriptions (192 per 1,000 persons)
• Macrolides: 49.4 million prescriptions (154 per 1,000 persons)
• Cephalosporins: 36.3 million prescriptions (113 per 1,000 persons)
• Fluoroquinolones: 32.5 million prescriptions (101 per 1,000 persons)
• Beta-lactams with increased activity: 25.3 million prescriptions (79 per 1,000 persons)

When examining specific antibiotic agents, the following were the most commonly prescribed:

1. Amoxicillin: 54.8 million prescriptions (171 per 1,000 persons)
2. Azithromycin: 46.2 million prescriptions (144 per 1,000 persons)
3. Amoxicillin/clavulanic acid: 25.3 million prescriptions (79 per 1,000 persons)
4. Cephalexin: 21.4 million prescriptions (67 per 1,000 persons)
5. Ciprofloxacin: 20.3 million prescriptions (63 per 1,000 persons)

The prevalence of broad-spectrum antibiotics like azithromycin and ciprofloxacin raises concerns about potential overuse and the development of antibiotic resistance. How can healthcare providers balance effective treatment with responsible antibiotic stewardship?

Antibiotic Prescribing by Provider Specialty: Who’s Writing the Scripts?

The study provides a breakdown of antibiotic prescribing patterns across different healthcare provider specialties:

• Primary Care Physicians: 110.8 million prescriptions (466 per provider)
• Physician Assistants and Nurse Practitioners: 62.9 million prescriptions (363 per provider)
• Dentistry: 25.1 million prescriptions (205 per provider)
• Surgical Specialties: 19.5 million prescriptions (219 per provider)
• Emergency Medicine: 14.8 million prescriptions (457 per provider)
• Dermatology: 7.1 million prescriptions (628 per provider)
• Obstetrics/Gynecology: 6.3 million prescriptions (167 per provider)

Interestingly, while primary care physicians prescribe the highest number of antibiotics overall, dermatologists have the highest rate of prescriptions per provider. This data prompts us to consider the unique challenges and prescribing patterns within each specialty.

State-by-State Analysis: Mapping Antibiotic Use Across America

The study provides a detailed breakdown of antibiotic prescription rates for each state, revealing significant variations across the country. Some notable findings include:

• Highest prescription rates: Kentucky (1,256 per 1,000 persons), Mississippi (1,254 per 1,000 persons), and Louisiana (1,174 per 1,000 persons)
• Lowest prescription rates: Alaska (511 per 1,000 persons), Hawaii (640 per 1,000 persons), and Oregon (582 per 1,000 persons)

These stark contrasts between states raise important questions about the factors influencing antibiotic prescribing practices. Are these differences due to variations in population health, healthcare access, or local prescribing guidelines?

Implications for Antibiotic Stewardship and Future Research

The comprehensive data presented in this study provides a solid foundation for understanding antibiotic prescribing patterns in the United States. However, it also highlights the need for continued research and monitoring of antibiotic use. Some key areas for future investigation include:

• Tracking changes in prescribing patterns since 2015
• Investigating the reasons behind regional and state-level variations
• Assessing the impact of antibiotic stewardship programs on prescribing rates
• Exploring the relationship between antibiotic use and rates of antibiotic resistance
• Evaluating the appropriateness of antibiotic prescriptions across different specialties

By addressing these questions, healthcare professionals and policymakers can work towards more targeted and effective strategies for promoting responsible antibiotic use.

The Role of Education and Guidelines in Shaping Antibiotic Use

The significant variations in antibiotic prescribing rates across regions, states, and specialties underscore the importance of standardized guidelines and ongoing education for healthcare providers. Several initiatives could help promote more uniform and appropriate antibiotic use:

• Developing and disseminating evidence-based prescribing guidelines tailored to specific specialties and common conditions
• Implementing mandatory continuing education programs on antibiotic stewardship for all healthcare providers
• Integrating antibiotic prescribing decision support tools into electronic health record systems
• Conducting regular audits and providing feedback to healthcare providers on their prescribing patterns
• Launching public awareness campaigns to educate patients about appropriate antibiotic use and the risks of antibiotic resistance

By focusing on these areas, the medical community can work towards reducing unnecessary antibiotic prescriptions and preserving the efficacy of these vital medications for future generations.

Emerging Trends and Future Projections in Antibiotic Use

While the data from 2015 provides valuable insights, it’s essential to consider how antibiotic prescribing patterns may have evolved since then. Several factors could influence current and future trends:

1. Increased awareness of antibiotic resistance: Growing concern about the threat of antibiotic-resistant bacteria may have led to more cautious prescribing practices.
2. Advancements in diagnostic technologies: Rapid diagnostic tests for bacterial infections could help reduce unnecessary antibiotic prescriptions.
3. Shift towards telemedicine: The COVID-19 pandemic has accelerated the adoption of telehealth services, which may impact how antibiotics are prescribed.
4. Development of new antibiotics: The introduction of novel antibiotic classes could change prescribing patterns, particularly for resistant infections.
5. Changes in healthcare policies: Implementation of new guidelines or reimbursement policies may influence antibiotic prescribing behavior.

Monitoring these trends and their impact on antibiotic use will be crucial for developing effective strategies to combat antibiotic resistance and ensure optimal patient care.

The Global Context: Comparing U.S. Antibiotic Use to International Patterns

While this study focuses on antibiotic prescribing patterns in the United States, it’s important to consider how these trends compare to other countries. Global variations in antibiotic use can provide valuable insights and context:

• European Union: Many EU countries have implemented strict antibiotic stewardship programs, resulting in lower overall prescribing rates compared to the U.S.
• Low- and middle-income countries: Some regions face challenges with both over-prescribing and lack of access to essential antibiotics.
• Scandinavian countries: Nations like Sweden and Denmark are often cited as models for responsible antibiotic use, with significantly lower prescribing rates than the U.S.
• Asian countries: Some nations, such as Japan and South Korea, have historically had high rates of antibiotic use, prompting recent efforts to reduce unnecessary prescriptions.

Examining these international differences can help identify best practices and inform global strategies for promoting responsible antibiotic use. What lessons can the United States learn from countries with successful antibiotic stewardship programs? How can these insights be adapted to fit the unique healthcare landscape of the U.S.?

The Economic Impact of Antibiotic Prescribing Patterns

The high volume of antibiotic prescriptions in the United States has significant economic implications, both for individual patients and the healthcare system as a whole. Consider the following aspects:

1. Direct costs: The financial burden of purchasing antibiotics, particularly for uninsured or underinsured patients.
2. Healthcare utilization: Costs associated with office visits, diagnostic tests, and potential hospitalizations for antibiotic-related adverse events.
3. Productivity loss: Time off work due to illness or medical appointments related to antibiotic prescriptions.
4. Long-term consequences: The economic impact of antibiotic resistance, including the need for more expensive second-line treatments and prolonged hospital stays.
5. Research and development: Investments required to develop new antibiotics to combat resistant bacteria.

Quantifying these economic factors can help policymakers and healthcare administrators make informed decisions about resource allocation and interventions to promote judicious antibiotic use. How can we balance the short-term costs of implementing antibiotic stewardship programs with the long-term economic benefits of reduced antibiotic resistance?

As we continue to analyze and address the complex issue of antibiotic prescribing, it’s clear that a multifaceted approach involving healthcare providers, policymakers, researchers, and the public will be necessary to ensure the responsible use of these vital medications. By leveraging data, implementing evidence-based practices, and fostering a culture of antibiotic stewardship, we can work towards preserving the efficacy of antibiotics for future generations while providing optimal care for patients today.

Outpatient Antibiotic Prescriptions — United States, 2015 | Antibiotic Use

Healthcare providers prescribed 269.4 million antibiotic prescriptions—equivalent to 838 antibiotic prescriptions per 1000 persons.

Print only version: Outpatient Antibiotic Prescriptions — United States, 2015  pdf icon[PDF – 366 KB]

Citation: Centers for Disease Control and Prevention. Outpatient antibiotic prescriptions — United States, 2015.

Systemic oral antibiotics were extracted from the QuintilesIMS Xponent database. QuintilesIMS captured an estimated 88% of outpatient prescriptions for any medication nationally, reconciled them to wholesale deliveries, and projected to 100% coverage. These data represent all outpatient antibiotic prescriptions from community pharmacies from all payers, but exclude federal facilities. Provider specialties are taken from the American Medical Association (AMA) self-designated practice specialties and categorized into one of 17 groups.  Population data were obtained from the U.S. Census bridging files.

References

Hicks, L.A., et al., US Outpatient Antibiotic Prescribing Variation According to Geography, Patient Population, and Provider Specialty in 2011. Clin Infect Dis, 2015. 60(9): p. 1308-16.

Table 1b. Oral antibiotic prescriptions by age, sex and region—United States, 2015

Sex	NUMBER OF ANTIBIOTIC PRESCRIPTIONS (MILLIONS)	ANTIBIOTIC PRESCRIPTIONS PER 1,000 PERSONS, RATE
Femalea	164. 0	1,005
Malea	104.9	663

^aTotals may not add to all oral prescriptions (269.4 million) due to missing data
^bTotals may not add to all oral prescriptions (269.4 million) due to rounding.

Table 2. Top oral antibiotic classes and agents prescribed—United States, 2015

Table 2a. Top oral antibiotic classes and agents prescribed—United States, 2015

ANTIBIOTIC CLASS	NUMBER OF ANTIBIOTIC PRESCRIPTIONS (MILLIONS)	ANTIBIOTIC PRESCRIPTIONS PER 1,000 PERSONS, RATE
Penicillins	61.6	192
Macrolides	49.4	154
Cephalosporins	36.3	113
Fluoroquinolones	32.5	101
Beta-lactams, increased activity	25.3	79

Table 2b. Top oral antibiotic classes and agents prescribed—United States, 2015

ANTIBIOTIC AGENT	NUMBER OF ANTIBIOTIC PRESCRIPTIONS (MILLIONS)	ANTIBIOTIC PRESCRIPTIONS PER 1,000 PERSONS, RATE
Amoxicillin	54.8	171
Azithromycin	46.2	144
Amoxicillin/clavulanic acid	25. 3	79
Cephalexin	21.4	67
Ciprofloxacin	20.3	63

Table 3. Oral antibiotic prescribing by provider specialty — United States, 2015

Table 3. Oral antibiotic prescribing by provider specialty — United States, 2015

PROVIDER SPECIALTY	NUMBER OF ANTIBIOTIC PRESCRIPTIONS (MILLIONS)	ANTIBIOTIC PRESCRIPTIONS PER PROVIDER, RATE
Primary Care Physicians	110.8	466
Physician Assistants and Nurse Practitioners	62.9	363
Surgical Specialties	19.5	219
Dentistry	25.1	205
Emergency Medicine	14.8	457
Dermatology	7. 1	628
Obstetrics/Gynecology	6.3	167
Other	22.9	110
All Providers	269.4	295

Figure 1. Antibiotic prescriptions per 1000 persons by state (sextiles) for all ages — United States, 2015.

This project was made possible through a partnership with the CDC Foundation. Support for this project was provided by The Pew Charitable Trusts.

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Amoxicillin – StatPearls – NCBI Bookshelf

Continuing Education Activity

Amoxicillin is one of the most commonly used antibiotics in the primary care setting. It is an amino-penicillin, created by adding an extra amino group to penicillin to battle antibiotic resistance. Amoxicillin covers a wide variety of gram-positive bacteria, with some added gram-negative coverage compared to penicillin. Like penicillin, it covers most Streptococcus species and has improved coverage of Listeria monocytogenes and Enterococcus spp. It also has coverage over Haemophilus influenzae, some Escherichia coli, Actinomyces spp., Clostridium species, Salmonella spp., Shigella spp., and Corynebacteria species. This activity covers amoxicillin, a beta-lactam antimicrobial that interprofessional team members need to review its indications, coverage, contraindications, and adverse event profile to manage patients with infectious disease optimally.

Objectives:

• Outline the indications for initiating amoxicillin as an anti-infective strategy for patient care.

• Identify the mechanism of action of amoxicillin and its target coverage.

• Summarize the adverse effects of amoxicillin.

• Explain the importance of antimicrobial stewardship and how it affects antimicrobial selection to improve care coordination among the interprofessional team when initiating amoxicillin antimicrobial therapy.

Access free multiple choice questions on this topic.

Indications

Amoxicillin is one of the most commonly used antibiotics in the primary care setting. It is an amino-penicillin, created by adding an extra amino group to penicillin to battle antimicrobial resistance. Amoxicillin covers a wide variety of gram-positive bacteria, with some added gram-negative coverage compared to penicillin. Like penicillin, it covers most Streptococcus species and is also effective against Listeria monocytogenes and Enterococcus species. It also covers Haemophilus influenza, some Escherichia coli, Actinomyces species, Clostridium species, Salmonella species, Shigella species, and Corynebacteria species.

FDA-approved Indications

• Amoxicillin is indicated in treating infections due to susceptible (only beta-lactamase–negative) isolates of the selected bacteria in the conditions listed below.

• Ear, nose, and throat infections: Treatment of tonsillitis, pharyngitis, and otitis media in adults and pediatric patients ≥12 years of age. The microbiological spectrum is infections due to beta-lactamase-negative Streptococcus species (alpha- and beta-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcus species, or Haemophilus influenza.[1]

• Helicobacter pylori eradication: Triple therapy for Helicobacter pylori with clarithromycin, amoxicillin, and lansoprazole to eradicate Helicobacter pylori reduces the risk of duodenal ulcer recurrence. Dual treatment with amoxicillin and lansoprazole is also FDA approved to eradicate Helicobacter pylori infection.[2]

• Lower respiratory tract infections: Treatment of lower respiratory tract infection due to beta-lactamase-negative Streptococcus species (alpha- and beta-hemolytic strains only), pneumococcus, Staphylococcus species, or Haemophilus influenzae. For community-acquired pneumonia, IDSA recommends a combination of amoxicillin and macrolide.[3]

• Acute Bacterial Sinusitis: Treating infections due to beta-lactamase-negative Streptococcus species (alpha- and beta-hemolytic isolates only), Streptococcus pneumoniae, Staphylococcus species, or Haemophilus influenzae.[4]

• Skin and skin structure infections: Immediate release: Treatment of skin and skin structure infections due to beta-lactamase-negative Streptococcus species (alpha and beta-hemolytic strains only), Staphylococcus species, or Escherichia coli.[5]

• Urinary tract infection: Treatment of the genitourinary tract infections. Organisms include beta-lactamase-negative Escherichia coli, Proteus mirabilis, or Enterococcus faecalis.[6]

• The Centers for Disease Control and Prevention (CDC) recommends using amoxicillin for post-exposure prophylaxis for anthrax(second-line agent). [7]      

Off-label Clinical Uses

• Infectious endocarditis prophylaxis(cardiac conditions associated with the high risk such as the presence of prosthetic cardiac valve or congenital heart disease)[9]

• Actinomycosis[11]

Mechanism of Action

Amoxicillin is in the class of beta-lactam antimicrobials. Beta-lactams act by binding to penicillin-binding proteins that inhibit a process called transpeptidation (the cross-linking process in cell wall synthesis), leading to activation of autolytic enzymes in the bacterial cell wall. This process leads to lysis of the cell wall, thus destroying the bacterial cell. This type of activity is referred to as bactericidal killing.[12]

Amoxicillin administration can also be in combination with a beta-lactamase inhibitor. Some examples of these are clavulanic acid and sulbactam. These beta-lactamase inhibitors work by binding irreversibly to the catalytic site of an organism’s beta-lactamase enzyme, which causes resistance to the original beta-lactam ring of amoxicillin. These drugs do not have inherent bactericidal activity; however, they may broaden amoxicillin’s spectrum to organisms that produce the beta-lactamase enzyme when combined with amoxicillin.[13]

Administration

Bactericidal antimicrobials, such as amoxicillin, often are most effective in a “time-dependent” manner rather than a “concentration-dependent” manner. Time-dependent refers to the time that serum concentrations exceed the minimum-inhibitor-concentration (MIC) for the microorganism. Therefore, they are often dosed more frequently, rather than the concentration-dependent drugs, which can be dosed, for example, daily. The more “around-the-clock” dosing provides minor variation in peak and trough serum concentrations.[14]

Amoxicillin is an oral antimicrobial; whereas, ampicillin (which is structurally similar) can be given orally, intravenously, or intramuscularly. Amoxicillin comes in immediate-release or extended-release tablets. It also comes in a chewable tablet or a suspension. It may be mixed (after thoroughly shaking) and administered with formula, milk, water, fruit juice, ginger ale, or other cold drinks if given in suspension. The administration should take place immediately after mixing. Patients should not crush Extended-release tablets, and the administration should be within 1 hour after finishing a meal. Amoxicillin is sometimes preferred over penicillin in children because of its taste.

Dosing

• In adults, 750-1750 mg/day in divided doses every 8-12 hours.

• In Pediatric Patients > 3 Months of Age, 20-45 mg/kg/day in divided doses every 8-12 hours.

• Dosing for H. pylori Infection: Triple therapy: 1 gram amoxicillin, 500 mg clarithromycin, and 30 mg lansoprazole, all given twice daily (every 12 hours) for 14 days.

• Dual therapy: 1 gram amoxicillin and 30 mg lansoprazole, each given three times daily.

Dosing in Renal Impairment

• Patients with impaired renal function do not generally require a reduction in dose unless the impairment is severe.

• Severely impaired patients with a glomerular filtration rate of < 30 mL/min should not receive an 875-mg dose.

• Patients with a glomerular filtration rate of 10 to 30 mL/min should receive 500 mg or 250 mg every 12 hours, depending on the severity of the infection.

• Patients with a glomerular filtration rate less than 10 mL/min should receive 500 mg or 250 mg every 24 hours, depending on the severity of the infection.

• Hemodialysis patients should receive 500 mg or 250 mg every 24 hours, depending on the severity of the infection. They should receive an additional dose both during and at the end of dialysis.

Geriatric Consideration

• It is important to note that it is excreted in most people by the kidney, and some renal adjustment and extra caution may be necessary for renal insufficiency. Because elderly patients are more likely to have decreased renal function, the clinician should adjust the dose. It is reported to be partially dialyzable, and therefore, immediate-release tablets can be an option for dosing after hemodialysis.[15]

Pregnancy

• Amoxicillin is a pregnancy category B drug under the old FDA classification system, which means there have been no studies demonstrating clear risk. Amoxicillin is widely used in pregnant women. Based on available data, amoxicillin is usually considered compatible for use during pregnancy. The dose and duration of amoxicillin therapy in pregnant and postpartum women are the same as in nonpregnant adults.[16]

Breastfeeding

• An exclusively breastfed infant would be expected to receive a maximum daily dosage of about 0.1 mg/kg of amoxicillin with a maternal dose of 500 mg three times daily. This amounts to 0.25 to 0.5% of a typical infant amoxicillin dosage. As discussed above, amoxicillin produces low levels in milk that are not expected to cause adverse effects in breastfed infants. Occasionally, rash and disruption of the infant’s gastrointestinal flora, resulting in diarrhea or thrush, have been reported. Consequently, amoxicillin is acceptable in nursing mothers.[17]

Adverse Effects

Common Adverse Drug Reactions: Amoxicillin is well-tolerated, but some common complaints can be gastrointestinal (GI) symptoms, such as nausea, vomiting, and diarrhea.

Superinfections: Mucocutaneous candidiasis, clostridium difficile associated diarrhea. Of note, patients who take amoxicillin may have less diarrhea than those who take ampicillin because of better absorption in the gut.[18]

Nephrotoxicity: Crystalluria, interstitial nephritis[19][20]

Hypersensitivity
Reactions: Amoxicillin can lead to type-I, II, III, or IV reactions. It is essential to differentiate between a type-I and type-IV hypersensitivity reaction because one may be more dangerous than the other. A type-I hypersensitivity reaction is an IgE-mediated response to a sensitized patient that triggers widespread histamine release leading to an urticarial-like pruritic rash or severe anaphylaxis. A type-IV hypersensitivity reaction is not mediated by histamine release and is more papular or morbilliform and often not itchy. Professionals suggest that almost all patients that receive amoxicillin inadvertently for infectious mononucleosis develop a maculopapular rash caused by a type IV-mediated hypersensitivity reaction. These types of reactions are not known to cause anaphylaxis.[21]

Hepatotoxicity: instances of idiosyncratic liver injury have been reported in persons receiving amoxicillin.  The serum enzyme pattern associated with the liver injury is the hepatocellular pattern with marked elevations in AST and ALT. There are minimal elevations in alkaline phosphatase. Most patients recover rapidly after withdrawal of amoxicillin and rapid recovery after withdrawal. The cause of the liver injury associated with amoxicillin use is hypersensitivity. Rare cases of acute liver failure and vanishing bile duct syndrome have been reported. Corticosteroids have often been used to treat the allergic manifestations of penicillin-related immunoallergic hepatitis. Likelihood score: B (highly likely but rare cause of clinically apparent liver injury).[22]

Postmarketing Adverse Drug Reactions

Gastrointestinal: black hairy tongue, pseudomembranous colitis, hemorrhagic colitis[23]

Neurological: reversible hyperactivity, agitation, anxiety, insomnia, confusion, convulsions, aseptic meningitis[24]

Hematological: hemolytic anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, and neutropenia[25]

Dermatological: serum sickness-like reactions, erythematous maculopapular rashes, exfoliative dermatitis, toxic epidermal necrolysis, hypersensitivity vasculitis[26]

Contraindications

• Any previous anaphylactic or serious skin reaction (for example, Stevens-Johnson syndrome) to amoxicillin or any other beta-lactam is a contraindication to amoxicillin. These reactions may have crossover sensitivity with cephalosporins or carbapenems. However, it is important to note that newer data has suggested a much lower cross-reactivity with cephalosporins and carbapenems than once suspected.

• An important consideration is determining if the patient’s allergic rash is a type-I or a type-IV hypersensitivity reaction. Occasionally patients will report a childhood allergy to amoxicillin, which is, in fact, a type-IV-mediated hypersensitivity reaction, often in the setting of infectious mononucleosis; this is not a contraindication to giving repeat amoxicillin. However, a type-1 mediated hypersensitivity reaction is a contraindication given that a repeat exposure puts the patient at risk for anaphylaxis.

• Skin testing has been approved to help assist in hypersensitivity to penicillins. Reports are that the risk of an allergic reaction in a patient with a positive skin test is roughly four percent. In contrast, a negative skin test has a relatively high sensitivity in ruling out a type-I hypersensitivity reaction.[27]

Monitoring

• It is essential to be aware of hypersensitivity reactions, and the patient should understand to notify their physician of any rashes. [27]

• In a patient on a short-term course of amoxicillin, no specific laboratory monitoring parameters are suggested. However, during prolonged administration, such as for osteomyelitis, it is essential to monitor renal and hepatic function and hematologic function periodically throughout treatment.[22]

• Mild diarrhea is often tolerable. However, prolonged diarrhea with fever and abdominal pain should prompt evaluation by a clinician for CDAD.[28]

• Penicillins in high doses can cause seizures which is a concern, especially in patients with renal failure.[29]

Toxicity

A prospective study of 51 pediatric patients at a poison-control center proposed that less than 250 mg/kg of amoxicillin overdosages are not associated with significant clinical symptoms(Product labeling FDA).

Clinical Features

• Interstitial nephritis resulting in oliguric renal failure has been reported in a small number of patients after overdosage with amoxicillin. [19][20]

• Crystalluria leading to renal failure has been reported after amoxicillin overdosage in adult and pediatric patients.[30]

Management

• In case of overdose, discontinue medication, treat symptomatically.

• Maintain airway, breathing, and circulation.

• For updated information about the overdose of amoxicillin, call a poison control center (1-800-222-1222)

Enhancing Healthcare Team Outcomes

Amoxicillin is a common antimicrobial often prescribed by nurse practitioners, primary care providers, and internists. The drug is safe, but it is essential always to get a good history of allergy before prescribing the medication. Due to the widespread use of amoxicillin, all healthcare providers should understand the mechanism, resistance patterns, adverse drug reactions, and toxicity management.[27][32]

The clinician usually initiates amoxicillin therapy for appropriate indication. However, a pharmacist should verify the dosing and duration are correct for the infection being treated and confirm that no drug interactions could impede treatment. Nursing staff can counsel on administration, verify adherence. Additionally, nurses should educate the patient not to discontinue amoxicillin when they start to feel better. If the nurse or pharmacist encounters any issues, they should address them with the prescriber immediately.

In case of significant overdose, triage nurses should admit the patient. Emergency physicians need to evaluate and manage nephrotoxicity. Nephrologist consultation is necessary for hemodialysis. Consult a medical toxicologist or poison control center for the latest information.[33] Infectious disease specialists should ensure proper management of pseudomembranous colitis resulting from irrational amoxicillin use. Additionally, infectious disease specialists should emphasize the importance of antimicrobial stewardship. Antimicrobial stewardship is a coordinated program that encourages the proper use of antimicrobials, enhances patient outcomes, decreases microbial resistance, and reduces the spread of infections caused by multidrug-resistant organisms. [34]

As depicted above, clinicians(MDs, DOs, NPs, PAs), specialists, pharmacists, nurses, and other healthcare providers should collaborate to maximize efficacy and minimize adverse drug reactions related to amoxicillin therapy. This type of interprofessional team approach and antimicrobial stewardship will improve the likelihood of more favorable patient outcomes.[35] [Level 2]

Review Questions

• Access free multiple choice questions on this topic.

• Comment on this article.

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Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM., Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 Apr;54(8):e72-e112. [PubMed: 22438350]

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Disclosure: Bobak Akhavan declares no relevant financial relationships with ineligible companies.

Disclosure: Niloufar Khanna declares no relevant financial relationships with ineligible companies.

Disclosure: Praveen Vijhani declares no relevant financial relationships with ineligible companies.

What are antibiotics? – article on the website Aptechestvo, Nizhny Novgorod

Antibiotics are a group of drugs that are used in the treatment of bacterial infections. Bacteria are living microorganisms that, having penetrated into the human body, begin active life and reproduction. The effect of antibiotic therapy is the direct destruction of the pathogen, as well as slowing down the reproduction of pathogens. In connection with these antibacterial drugs are divided into 2 large groups: bactericidal – destroying the bacterium itself, as well as bacteriostatic, inhibiting their growth. In addition, antibiotics have a narrow and broad spectrum of action. Narrow-spectrum drugs destroy the infection selectively, while broad-spectrum drugs destroy most of the microorganisms, including those that benefit humans. What antibiotics to take for the treatment of various diseases should be decided by the doctor after the diagnosis. Taking such drugs at your own discretion is fraught with complications.

Fluoroquinolones

They suppress the activity of enzymes involved in the formation of bacterial DNA, as a result of which the infection dies. The drugs are available in the form of tablets, injections, ophthalmic drops. Indications for appointment:

This group of drugs:

• Ciprofloxacin;

• Ofloxacin;

• Pefloxacin;

• Norfloxacin.

Aminoglycosides

Broad-spectrum agents that kill most types of Gram-negative aerobic and facultative bacteria. The active substance disrupts the process of protein synthesis, as a result of which the pathogen is destroyed and dies.

Aminoglycosides are poorly absorbed when taken orally, so, as a rule, they are prescribed as intravenous or intramuscular injections. Members of this group:

• Amikacin;

• Gentamicin;

• Kanamycin;

• Neomycin;

• Plazomycin;

• Streptomycin.

As a rule, these drugs are used in combination with other antibiotics to treat such infectious diseases:

Tetracyclines

Bacteriostatic antibiotics that retard the growth of pathogenic microorganisms, but do not completely destroy them. As a result, the reproduction of the infection stops, and it gradually dies.

Tetracyclines have a wide spectrum of activity, with pronounced activity against aerobic gram-positive and gram-negative bacteria. Tetracyclines are not prescribed for children under 8 years of age, since long-term use causes a number of serious complications.

The drugs of this group can be prescribed in tablet forms and in the form of injections. For the treatment of ophthalmic infections, ointments are produced, the active substance of which is tetracycline.

Medicines:

• doxycycline;

• minocycline;

• Tetracycline;

• Oxytetracycline.

Diseases for which tetracyclines are prescribed:

Macrolides

They suppress vital activity and prevent the reproduction of anaerobic and aerobic gram-positive bacteria. Preparations of this group are used in the treatment of bronchopulmonary infections, tonsillitis, otitis, scarlet fever, intestinal infections. Medicines that are included in this group:

• Erythromycin;

• Azithromycin;

• Clarithromycin;

• Spiramycin.

Penicilli

A group of antibiotics produced by the fungus Penicillium. Penicilli are active against most Gram-positive and some Gram-negative bacteria. This group of drugs:

• Amoxicillin;

• Augumetin;

• Amoxiclav;

• Flemoxin Slutab.

Cephalosporins

These are bactericidal beta-beta-lactam antibiotics that interfere with cell protein synthesis. There are 5 generations of cephalosporins. The active substance penetrates well into most body fluids, having a pronounced bactericidal effect. Cephalosporins are used for uncomplicated skin and soft tissue infections caused by staphylococcal and streptococcal bacteria. This group of drugs:

• Ceftriaxone;

• Cefodox;

• Cefix;

• Tsepefim.

Bacteria are organisms that do not live long, but in order to restore their population, they multiply rapidly, and, accordingly, quickly mutate, adapting to new living conditions. Microorganisms that survive after taking antibiotics become resistant to them. Their offspring also become immune to a particular drug.

Antibiotic resistance is a common problem of modern man, which causes serious complications. A person who has tried many antibiotics, that is, self-medicated, is at risk for patients with antibiotic resistance. Very often they die before a specialist can pick up a drug that works against a specific pathogen. Therefore, it is important to follow the recommendations of the doctor and take antibacterial agents strictly according to an individual scheme.

Adverse events in people taking macrolide antibiotics

Survey question

We wanted to find out if people taking macrolide antibiotics experience more adverse events than those taking placebo.

Relevance

Macrolide antibiotics are a group of antibiotics commonly used to treat acute and chronic infections. The four most commonly used macrolides are: azithromycin, clarithromycin, erythromycin, and roxithromycin. People taking macrolide antibiotics are at risk for adverse events such as nausea, diarrhea, and rash.

Search Date

We searched the literature up to May 2018.

Study profile

We included 183 studies with 252,886 participants. Most of the studies were conducted in a hospital setting. Azithromycin and erythromycin have been studied to a greater extent than clarithromycin and roxithromycin. Most of the studies (89%) reported some adverse events, or at least stated that no adverse events were observed.

Research funding sources

Pharmaceutical companies supplied the study drugs or funded the study, or both, in 91 studies. Funding sources were unclear in 59 studies.

Main results

People treated with macrolide antibiotics experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhea more frequently than those treated with placebo.

Taste disturbance was reported more often by people treated with macrolides than by placebo. However, since only a few studies reported these adverse events, these results should be interpreted with caution.

Hearing loss was reported more frequently in people taking macrolide antibiotics, but only four studies reported this outcome.

Macrolides caused less cough and fewer respiratory tract infections than placebo.

We found no evidence that macrolides cause more heart problems, liver problems, blood infections, skin and soft tissue infections, liver enzyme changes, loss of appetite, dizziness, headache, respiratory symptoms, itching, or rash than placebo.

We did not find more deaths in people treated with macrolides than those treated with placebo.

There was very limited information on whether people treated with macrolides were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria resistant to macrolide antibiotics were found more frequently immediately after treatment in people taking macrolides than in those taking placebo, but the difference in resistance after treatment was inconsistent.

Quality of evidence

The quality of the evidence ranged from very low (cardiac disorders, altered liver enzymes, liver problems) to low (abdominal pain, death, diarrhea, dizziness, hearing loss, skin and soft tissue infections, taste disorders, wheezing), to moderate (loss of appetite, blood infections, cough, fever, headache, itching, nausea, rash, respiratory symptoms, respiratory infections, vomiting).