Drug

Tackling Antimicrobial Resistance: Optimizing Use

of an Older Antibiotic-Amoxicillin
Rajiv Garg

Abstract
Antimicrobial resistance has become a major clinical and public health problem today. It not only poses a serious threat to
human health and welfare but also undermines national economies worldwide. There are major international efforts to tackle
the challenge of antimicrobial resistance. Similarly, being seriously concerned about the high resistance rate in our country,
‘Chennai Declaration’ was an initiative to formulate a national policy to control the rising trend of antimicrobial resistance.
In such a scenario, it is prudent to focus on first-generation antibiotics such as amoxicillin. In this review, we have highlighted
the efficacy and usefulness of amoxicillin in clinical practice. 
Keywords: Antimicrobial resistance, older antibiotics, antibiotic smart use, amoxicillin, respiratory tract infections

A
fter saving countless lives, antibiotics are in
danger of losing their effectiveness.1 The reason
is an alarming increase in bacterial resistance
that has become a major clinical and public health
problem within the lifetime of most people living
today. Confronted by increasing amounts of antibiotics
over the past 60 years, bacteria have responded to the
deluge with the propagation of progeny no longer
susceptible to them.2 Antimicrobial resistance not only
poses a serious threat to human health and welfare but
also undermines national economies worldwide. Every
continent and country is facing the menace of antibiotic-
resistant ‘super bugs,’ although the extent and the
severity of the problem varies.3 According to a recent
study in Thailand, in 2010, antimicrobial resistance was
responsible for at least 3.2 million extra hospitalization
days and 38,481 deaths, and for losses amounting to US$
84.6-202.8 million in direct medical costs and more
than US$ 1,333 million in indirect costs. Annual losses
stemming from antimicrobial resistance are estimated
to range from US$ 21,000 to 34,000 million in the United
States and about € 1,500 million in Europe.4 In Indian
hospitals also, very high gram-negative resistance
rates have been reported, with very high prevalence of
extended-spectrum beta-lactamases (ESBLs) producers
and also high carbapenem resistance rates. Increasing
carbapenem resistance invariably results in increased
usage of colistin, currently the last-line of defense, with
Senior Medical Specialist and Head
Dept. of Medicine, ESI Hospital, Noida, Uttar Pradesh
a potential for colistin-resistant and pandrug-resistant
bacterial infections.3
Global Efforts for Tackling AntiMicrobial
Resistance
There are major international efforts to tackle the
challenge of antimicrobial resistance. Antibiotics Smart
Use (ASU) was introduced in 2007 as an innovative
model to promote the rational use of medicines and
counteract antimicrobial resistance.4 The World Alliance
against Resistance to antibiotics (WAAR) is an action
plan designed by a small group of professionals and by
the patient support group LIEN to deal with the current
emergency. The scientific committee is composed of
80 international physicians of considerable renown.
The Alliance receives support from 50 learned societies
or professional groups in France and throughout
the world.1 To cope with this growing problem and
the consequent treatment failures, the European
Commission has also come up with a comprehensive
Action Plan on Antimicrobial Resistance that unveiled
12 concrete actions to be implemented in close
cooperation with the Member States.5 Similarly, being
seriously concerned about the high resistance rate in
our country, a joint meeting of ‘Medical Societies in
India’ was organized as a preconference symposium of
the 2nd Annual Conference of the Clinical Infectious
Disease Society (CIDSCON 2012) at Chennai with
a plan to formulate a roadmap to tackle the global
challenge of antimicrobial resistance from the Indian
perspective. ‘Chennai Declaration’ was an initiative to
formulate a national policy to control the rising trend

Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014 843
Drug
of antimicrobial resistance after consultation with all
relevant stakeholders and to take all possible measures
to implement the strategy.3
The European Society of Clinical Microbiology and
Infectious Diseases (ESCMID) Study Group for
Antibiotic Policies (ESGAP) performed a review in
2006, which showed that shortages of narrow-spectrum
antibacterial drugs forced clinicians to use broad-
spectrum drugs, adversely influencing the policies of
prudent use.6 The reasons for shortages and market
withdrawals of older antibiotics are incompletely
understood. However, the lack of profit for drugs in
limited market areas (small countries) and increasing
regulatory requirements and bureaucracy appear to
play a role. Several older, potentially useful, sometimes
‘forgotten,’ antibiotics were not available in many
countries, either never having been introduced or
having but now been withdrawn.6
Appropriate Use of Antibiotics
The majority of antibiotics are prescribed in general
practice and most prescriptions are attributable to
treatment of respiratory tract infections. In many cases
of infections, microorganisms are now fully-resistant to
commonly used newer generation antibiotics such as
ESBL producers, and cephalosporins and carbapenems.
Today, the world is facing a crisis due to antimicrobial
resistance emerging as a major concern. In such a
scenario, it is prudent to focus on first-generation
antibiotics such as amoxicillin. Promoting the rational
use of antibiotics among prescribers and the general
public are key to combating the unnecessary use of
these drugs. We need to take the following steps:
ÂÂ We should try to isolate the causative pathogen
whenever a patient comes for treatment, so that we
start a specific first-generation antibiotic.
ÂÂ Sensitivity test should be undertaken to choose the
antibiotic that will be most effective against the
pathogen isolated.
ÂÂ Treatment should be started with older first-
generation antibiotics such as amoxicillin,
ampicillin, cloxacillin and cephalexin.
ÂÂ Antibiotics should be given in proper doses and
treatment durations should be kept as short as
possible, and when appropriate, antibiotics should
be stopped after a careful reappraisal (based
on the clinical course and new results from the
microbiology laboratory).
ÂÂ Preference should be given to antibiotics that have
limited ecological effects.
844 Indian Journal of Clinical Practice, Vol. 24, No. 9, February 2014
ÂÂ The second- and third-generation antibiotics such
as ceftriaxone and oral azithromycin should be used
only when treatment with older antibiotics fail.
Older Antibiotics: Amoxicillin in Clinical
Practice
In an era, where there is a gap between the current
worldwide spread of multi-resistant bacteria and the
development of new antimicrobial drugs, there is a
growing need to optimize the use of older antibiotics
to treat infections.6 Amoxicillin is a gold standard
antibiotic and a drug of choice in various infections.
In this review, we would highlight the efficacy and
usefulness of amoxicillin in clinical practice. It is an
humble effort to ignite the reuse of such a wonderful
molecule. Moreover, amoxicillin, which was earlier
manufactured by chemical processes and was not
eco-friendly, is now being produced by unique
enzymatic technology and is available as an
environmentally friendly antibiotic.
Group A Streptococcal Pharyngitis
Group A streptococcal (GAS) pharyngitis is a
significant cause of community-associated infections.
Inappropriate antimicrobial use for upper respiratory
tract infections, including acute pharyngitis, has been a
major contributor to the development of antimicrobial
resistance among common pathogens. Based on their
narrow-spectrum of activity, infrequency of adverse
reactions and modest cost, penicillin or amoxicillin
is the recommended drug of choice for those
nonallergic to these agents. A 10-day course of an oral
cephalosporin is recommended for most penicillin-
allergic individuals. Narrow-spectrum cephalosporins,
such as cefadroxil or cephalexin, are much preferred to
broad-spectrum cephalosporins, such as cefuroxime,
cefixime, cefdinir and cefpodoxime.7
Although acute rheumatic fever is now uncommon
in most developed countries, it continues to be the
leading cause of acquired heart disease in children
in areas such as India, sub-Saharan Africa and parts
of Australia and New Zealand. Even after decades
of use, phenoxymethylpenicillin (penicillin V) is
first choice because it remains effective against
Group A beta-hemolytic streptococci (GABHS). It is
the only antibiotic that has been shown to effectively
prevent primary and secondary attacks of rheumatic
fever. Two or three daily doses are as effective as four
daily doses but, when the indication for treatment is
to eradicate GABHS for rheumatic fever prevention, a
10-day course is required. It must be taken on an empty

stomach. Amoxicillin at higher doses 500 mg to 1.0 g
three times daily is a useful alternative.
Acute Otitis Media
Streptococcus pneumoniae and Haemophilus influenzae
are usually implicated in bacterial acute otitis
media (AOM). Antibiotic use is indicated in the
following clinical situations:
ÂÂ Children with systemic symptoms
ÂÂ Children under 3 years with severe or bilateral
AOM
ÂÂ Children under 6 months.
Amoxicillin is the drug of choice if an antibiotic is to
be used. High doses are used to combat nonsusceptible
S. pneumoniae. The recommended dose is 15 mg/kg
(up to 500 mg) three times a day or 30 mg/kg (up to
1,000 mg) twice-daily for 5 days. Cotrimoxazole and
cefaclor are effective alternatives.
Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) can be
diagnosed clinically when a patient acquires a lower
respiratory tract infection in the community and has
the following:
ÂÂ New focal chest signs
ÂÂ Systemic illness such as sweating, aches and pains,
or temperature >38°C
ÂÂ No other explanation for the illness.
People with nonsevere CAP can be given empirical
antibiotic treatment at home without the need for
microbiological and radiological investigations. It is
seen that only a small range of pathogen cause CAP,
the commonest being S. pneumoniae. Amoxicillin at
higher doses 500 mg to 1.0 g three times daily remains
the preferred agent for community-managed CAP.
Chronic Obstructive Pulmonary Disease
Chronic obstructive pulmonary disease (COPD) is
the name for a collection of lung diseases including
chronic bronchitis, emphysema and chronic obstructive
airways disease. Patient with exacerbations of
COPD with clinical signs of infection (increased
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Drug
volume and change in color of sputum and/or
fever, leukocytosis) benefit from antibiotic therapy.
The patients should have a home supply of antibiotics
so that they can initiate treatment themselves because
earlier the antibiotics are started, early the better it is.
Amoxicillin 500 mg to 1.0 g three times daily for
7-10 days is appropriate as first-line therapy.
Conclusion
In conclusion, we would like to emphasize that it
is high time that we start reusing the gold standard
amoxicillin as the first-line of treatment before it is too
late and there is no pool of antibiotics left for the use of
our future generations.
References
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