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Dosing as for patients with severe renal impairment (creatinine clearance <10 div="" min="" ml="" nbsp="">
Amoxicillin is removed from the circulation by haemodialysis. Therefore, one additional dose (500 mg for adults or 15 mg/kg for children under 40 kg) may be administered during dialysis and at the end of each dialysis.
• Prophylaxis of endocarditis: see below:
I) Dental procedures:
Prophylaxis for patients undergoing extraction, scaling or surgery involving gingival tissues and who have not received a penicillin in the previous month.
(N.B .Patients with prosthetic heart, prosthetic heart valves should be referred to hospital-see below).
a) Patient not having general anesthetic:
For adults (including elderly): the dose is 3g Amoxicillin orally 1 hour before procedure. A second dose may be given 6 hours later if considered necessary.
For children under 10 years: Half adult dose
For children under 5 years: Quarter adult dose.
b) Patient having general anesthetic :if oral antibiotics considered to be appropriate:
For adults (including elderly): Initially 3g Amoxicillin Orally 4 hours prior to anaesthesia , followed by 3g orally (or 1g IV or IM if oral dose not tolerated) as soon as possible after the operation.
For children under 10 years: Half adult dose
For children under 5 years: Quarter adult dose.
Note 1: If prophylaxis with Amoxicillin is given twice within one month emergence of resistant streptococci is unlikely to be a problem. Alternative antibiotics are recommended if more frequent prophylaxis is required, or if the patient has received a course of treatment with a penicillin during the previous month.
c) Patient having general anaesthetic. If oral antibiotics not appropriate:
For adults (including elderly): the dose is 1g Amoxicillin IV or IM immediately before induction ; with 500mg orally 6 hours later.
Note 2: To minimise pain on injection , Amoxicillin may be given as two injections of 500mg dissolved in sterile 1% lignocaine solution .
II) Dental procedures : patients for whom referral to hospital is recommended, e.g.
A) Patients to be given a general anaesthetic who have been given a penicillin in the previous month.
B) Patients to be given a general anaesthetic who have a prosthetic heart valve.
C) Patients who have had one or more attacks of endocarditis.
For adults (including elderly): Initially : 1g Amoxicillin IV or IM with 120mg gentamicin IV or IM immediately prior to anaesthesia (if given) or 15 minutes prior to dental procedure followed by
(6 hours later): 500mg Amoxicillin orally .
For children under 10 years: The doses of Amoxicillin should be half the adult dose ; the dose of gentamicin should be 2 mg/kg.
For children under 5 years: the doses of Amoxicillin should be quarter the adult dose ; the dose of gentamicin should be 2mg/kg.
See Note 2
Note3:
Amoxicillin and gentamicin should not be mixed in the same syringe.
III) Genitourinary surgery or instrumentation: Prophylaxis for patients who have no urinary tract infection and who are to have genitor-urinary surgery or instrumentation under general anaesthesia. Or Obstetric and gynecological procedures: Routine prophylaxis is recommended only for patients with prosthetic heart valves:
For adults (including elderly):
Initially 1g Amoxicillin IV or IM with 120mg gentamicin IV or IM immediately before induction followed by (6 hours later): 500mg Amoxicillin orally or IV or IM according to clinical condition.
For children under 10years :
The doses of Amoxicillin should be half the adult dose ; the dose of gentamicin should be 2 mg/kg .
For children under 5 years :
The doses of Amoxicillin should be quarter the adult dose ; the dose of gentamicin should be 2mg/kg.
See Notes 2 and 3.
IV) Surgery or instrumentations of the upper respiratory tract:
a) Patients other than those with prosthetic heart valves:
For adults (including elderly):
1g Amoxicillin IV or IM immediately before induction; 500 mg Amoxicillin IV or IM 6 hours later
For children under 10 years: Half adult dose
For children under 5 years: Quarter adult dose.
See Notes 2
Note 4:
The second dose of Amoxicillin may be administered orally as Amoxicillin suspension.
b) Patients with prosthetic heart valves:
For adults (including elderly):
Initially 1g Amoxicillin IV or IM with 120mg gentamicin IV or IM immediately before induction; followed by (6 hours later): 500mg Amoxicillin orally or IV or IM.
For children under 10years :
The doses of Amoxicillin should be half the adult dose ; the dose of gentamicin should be 2 mg/kg
For children under 5 years : the doses of Amoxicillin should be quarter the adult dose ; the dose of gentamicin should be 2mg/kg.
See Notes 2, 3 and 4
Parenteral therapy is indicated if the oral route is considered impracticable or unsuitable, and particularly for the urgent treatment of severe infection.
In renal impairment the excretion of the antibiotic will be delayed and depending on the degree of impairment, it may be necessary to reduce the total daily dosage.
Adverse Reactions
"As with other penicillins, it may be expected that untoward reactions will be essentially limited to sensitivity phenomena. They are more likely to occur in individuals who have previously demonstrated hypersensitivity to penicillins and in those with a history of allergy, asthma, hay fever, or urticaria. The following adverse reactions have been reported as associated with the use of penicillins:
• Gastrointestinal: Nausea, vomiting, diarrhea, and hemorrhagic/pseudomembranous colitis. onset of pseudomembranous colitis symptoms may occur during or after antibiotic treatment.
• Hypersensitivity Reactions: Serum sickness-like reactions, erythematous maculopapular rashes, erythema multiforme, Stevens-Johnson syndrome, exfoliative dermatitis, toxic epidermal necrolysis, acute generalized exanthematous pustulosis, hypersensitivity vasculitis and urticaria have been reported.
NOTE: These hypersensitivity reactions may be controlled with antihistamines and, if necessary, systemic corticosteroids. Whenever such reactions occur, amoxicillin should be discontinued unless, in the opinion of the physician, the condition being treated is lifethreatening and amenable only to amoxicillin therapy.
• Liver: A moderate rise in AST (SGOT) and/or ALT (SGPT) has been noted, but the significance of this finding is unknown. Hepatic dysfunction including cholestatic jaundice, hepatic cholestasis and acute cytolytic hepatitis have been reported.
• Renal: Crystalluria has also been reported .
• Hemic and Lymphatic Systems: Anemia, including hemolytic anemia, thrombocytopenia, thrombocytopenic purpura, eosinophilia, leukopenia, and agranulocytosis have been reported during therapy with penicillins. These reactions are usually reversible on discontinuation of therapy and are believed to be hypersensitivity phenomena.
• Central Nervous System: Reversible hyperactivity, agitation, anxiety, insomnia, confusion, convulsions, behavioral changes, and/or dizziness have been reported rarely.
• Miscellaneous: Tooth discoloration (brown, yellow, or gray staining) has been rarely reported. Most reports occurred in pediatric patients. Discoloration was reduced or eliminated with brushing or dental cleaning in most cases.
• Combination Therapy with Clarithromycin and Lansoprazole: In clinical trials using combination therapy with amoxicillin plus clarithromycin and lansoprazole, and amoxicillin plus lansoprazole, no adverse reactions peculiar to these drug combinations were observed. Adverse reactions that have occurred have been limited to those that had been previously reported with amoxicillin, clarithromycin, or lansoprazole
* Triple Therapy :
Amoxicillin/Clarithromycin/Lansoprazole: The most frequently reported adverse events for patients who received triple therapy were diarrhea (7%), headache (6%), and taste perversion (5%). No treatment-emergent adverse events were observed at significantly higher rates with triple therapy than with any dual therapy regimen.
*Dual Therapy
moxicillin/Lansoprazole
The most frequently reported adverse events for patients who received amoxicillin three times daily plus lansoprazole three times daily dual therapy were diarrhea (8%) and headache (7%). No treatment-emergent adverse events were observed at significantly higher rates with amoxicillin three times daily plus lansoprazole three times daily dual therapy than with lansoprazole alone
Contra Indications
Amoxicillin is a penicillin and should not be given to patients with a history of hypersensitivity to beta-lactam antibiotics (eg. penicillins, cephalosporins).
Drug Interactions
"• Probenecid decreases the renal tubular secretion of amoxicillin. Concomitant use with AMOXICILLIN may result in increased and prolonged blood levels of amoxicillin.
• In common with other antibiotics, AMOXICILLIN may affect the gut flora, leading to lower oestrogen reabsorption and reduced efficacy of combined oral contraceptives.
• Concurrent administration of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions.
• It is recommended that when testing for the presence of glucose in urine during amoxicillin treatment, enzymatic glucose oxidase methods should be used. Due to the high urinary concentrations of amoxicillin, false positive readings are common with chemical methods.
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