- 1. Name of the medicinal product
- 2. Qualitative and quantitative composition
- 3. Pharmaceutical form
- 4. Clinical particulars
- 4.1 Therapeutic indications
- 4.2 Posology and method of administration
- 4.3 Contraindications
- 4.4 Special warnings and precautions for use
- 4.5 Interaction with other medicinal products and other forms of interaction
- 4.6 Fertility, pregnancy and lactation
- 4.7 Effects on ability to drive and use machines
- 4.8 Undesirable effects
- 4.9 Overdose
- 5. Pharmacological properties
- 5.1 Pharmacodynamic properties
- 5.2 Pharmacokinetic properties
- 5.3 Preclinical safety data
- 6. Pharmaceutical particulars
- 6.1 List of excipients
- 6.2 Incompatibilities
- 6.3 Shelf life
- 6.4 Special precautions for storage
- 6.5 Nature and contents of container
- 6.6 Special precautions for disposal and other handling
- 7. Marketing authorisation holder
- 8. Marketing authorisation number(s)
- 9. Date of first authorisation/renewal of the authorisation
- 10. Date of revision of the text
PosologyThe dose of Amoxil that is selected to treat an individual infection should take into account:• The expected pathogens and their likely susceptibility to antibacterial agents (see section 4.4) • The severity and the site of the infection • The age, weight and renal function of the patient; as shown below The duration of therapy should be determined by the type of infection and the response of the patient, and should generally be as short as possible. Some infections require longer periods of treatment (see section 4.4 regarding prolonged therapy).
Adults and children ≥40 kg
|Acute bacterial sinusitis||250 mg to 500 mg every 8 hours or 750 mg to 1 g every 12 hours For severe infections 750 mg to 1 g every 8 hours Acute cystitis may be treated with 3 g twice daily for one day|
|Asymptomatic bacteriuria in pregnancy|
|Dental abscess with spreading cellulitis|
|Acute otitis media||500 mg every 8 hours, 750 mg to 1 g every 12 hours For severe infections 750 mg to 1 g every 8 hours for 10 days|
|Acute streptococcal tonsillitis and pharyngitis|
|Acute exacerbations of chronic bronchitis|
|Community acquired pneumonia||500 mg to 1 g every 8 hours|
|Typhoid and paratyphoid fever||500 mg to 2 g every 8 hours|
|Prosthetic joint infections||500 mg to 1 g every 8 hours|
|Prophylaxis of endocarditis||2 g orally, single dose 30 to 60 minutes before procedure|
|Helicobacter pylori eradication||750 mg to 1 g twice daily in combination with a proton pump inhibitor (e.g. omeprazole, lansoprazole) and another antibiotic (e.g. clarithromycin, metronidazole) for 7 days|
|Lyme disease (see section 4.4)||Early stage: 500 mg to 1 g every 8 hours up to a maximum of 4 g/day in divided doses for 14 days (10 to 21 days) Late stage (systemic involvement): 500 mg to 2 g every 8 hours up to a maximum of 6 g/day in divided doses for 10 to 30 days|
|*Consideration should be given to the official treatment guidelines for each indication|
Children <40 kgChildren may be treated with Amoxil capsules, dispersible tablets suspensions or sachets.Amoxil Paediatric Suspension is recommended for children under six months of age.Children weighing 40 kg or more should be prescribed the adult dosage.
|Acute bacterial sinusitis||20 to 90 mg/kg/day in divided doses*|
|Acute otitis media|
|Community acquired pneumonia|
|Dental abscess with spreading cellulitis|
|Acute streptococcal tonsillitis and pharyngitis||40 to 90 mg/kg/day in divided doses*|
|Typhoid and paratyphoid fever||100 mg/kg/day in three divided doses|
|Prophylaxis of endocarditis||50 mg/kg orally, single dose 30 to 60 minutes before procedure|
|Lyme disease (see section 4.4)||Early stage: 25 to 50 mg/kg/day in three divided doses for 10 to 21 days Late stage (systemic involvement): 100 mg/kg/day in three divided doses for 10 to 30 days|
|+ Consideration should be given to the official treatment guidelines for each indication. *Twice daily dosing regimens should only be considered when the dose is in the upper range.|
ElderlyNo dose adjustment is considered necessary.
|GFR (ml/min)||Adults and children ≥ 40 kg||Children < 40 kg#|
|greater than 30||no adjustment necessary||no adjustment necessary|
|10 to 30||maximum 500 mg twice daily||15 mg/kg given twice daily (maximum 500 mg twice daily)|
|less than 10||maximum 500 mg/day.||15 mg/kg given as a single daily dose (maximum 500 mg)|
|# In the majority of cases, parenteral therapy is preferred.|
In patients receiving haemodialysisAmoxicillin may be removed from the circulation by haemodialysis.
|Adults and children ≥ 40 kg||15 mg/kg/day given as a single daily dose. Prior to haemodialysis one additional dose of 15 mg/kg should be administered. In order to restore circulating drug levels, another dose of 15 mg/kg should be administered after haemodialysis.|
In patients receiving peritoneal dialysisAmoxicillin maximum 500 mg/day.
Hepatic impairmentDose with caution and monitor hepatic function at regular intervals (see sections 4.4 and 4.8).
Method of administrationAmoxil is for oral use.Absorption of Amoxil is unimpaired by food.Therapy can be started parenterally according to the dosing recommendations of the intravenous formulation and continued with an oral preparation.Put the content of the sachet in 10 to 20 ml of water. Shake until a suspension is formed. Take immediately.
Hypersensitivity reactionsBefore initiating therapy with amoxicillin, careful enquiry should be made concerning previous hypersensitivity reactions to penicillins, cephalosporins or other beta-lactam agents (see sections 4.3 and 4.8).Serious and occasionally fatal hypersensitivity (anaphylactoid) reactions have been reported in patients on penicillin therapy. These reactions are more likely to occur in individuals with a history of penicillin hypersensitivity and in atopic individuals. If an allergic reaction occurs, amoxicillin therapy must be discontinued and appropriate alternative therapy instituted.
Non-susceptible microorganismsAmoxicillin is not suitable for the treatment of some types of infection unless the pathogen is already documented and known to be susceptible or there is a very high likelihood that the pathogen would be suitable for treatment with amoxicillin (see section 5.1). This particularly applies when considering the treatment of patients with urinary tract infections and severe infections of the ear, nose and throat.
ConvulsionsConvulsions may occur in patients with impaired renal function or in those receiving high doses or in patients with predisposing factors (e.g. history of seizures, treated epilepsy or meningeal disorders (see section 4.8).
Renal impairmentIn patients with renal impairment, the dose should be adjusted according to the degree of impairment (see section 4.2).
Skin reactionsThe occurrence at the treatment initiation of a feverish generalised erythema associated with pustula may be a symptom of acute generalised exanthemous pustulosis (AEGP, see section 4.8). This reaction requires amoxicillin discontinuation and contra-indicates any subsequent administration.Amoxicillin should be avoided if infectious mononucleosis is suspected since the occurrence of a morbilliform rash has been associated with this condition following the use of amoxicillin.
Jarisch-Herxheimer reactionThe Jarisch-Herxheimer reaction has been seen following amoxicillin treatment of Lyme disease (see section 4.8). It results directly from the bactericidal activity of amoxicillin on the causative bacteria of Lyme disease, the spirochaete Borrelia burgdorferi. Patients should be reassured that this is a common and usually self-limiting consequence of antibiotic treatment of Lyme disease.
Overgrowth of non-susceptible microorganismsProlonged use may occasionally result in overgrowth of non-susceptible organisms.Antibiotic-associated colitis has been reported with nearly all antibacterial agents and may range in severity from mild to life threatening (see section 4.8). Therefore, it is important to consider this diagnosis in patients who present with diarrhoea during, or subsequent to, the administration of any antibiotics. Should antibiotic-associated colitis occur, amoxicillin should immediately be discontinued, a physician consulted and an appropriate therapy initiated. Anti-peristaltic medicinal products are contra-indicated in this situation.
Prolonged therapyPeriodic assessment of organ system functions; including renal, hepatic and haematopoietic function is advisable during prolonged therapy. Elevated liver enzymes and changes in blood counts have been reported (see section 4.8).
AnticoagulantsProlongation of prothrombin time has been reported rarely in patients receiving amoxicillin. Appropriate monitoring should be undertaken when anticoagulants are prescribed concomitantly. Adjustments in the dose of oral anticoagulants may be necessary to maintain the desired level of anticoagulation (see section 4.5 and 4.8).
CrystalluriaIn patients with reduced urine output, crystalluria has been observed very rarely, predominantly with parenteral therapy. During the administration of high doses of amoxicillin, it is advisable to maintain adequate fluid intake and urinary output in order to reduce the possibility of amoxicillin crystalluria. In patients with bladder catheters, a regular check of patency should be maintained (see section 4.8 and 4.9).
Interference with diagnostic testsElevated serum and urinary levels of amoxicillin are likely to affect certain laboratory tests. Due to the high urinary concentrations of amoxicillin, false positive readings are common with chemical methods.It is recommended that when testing for the presence of glucose in urine during amoxicillin treatment, enzymatic glucose oxidase methods should be used. The presence of amoxicillin may distort assay results for oestriol in pregnant women.
ProbenecidConcomitant use of probenecid is not recommended. Probenecid decreases the renal tubular secretion of amoxicillin. Concomitant use of probenecid may result in increased and prolonged blood levels of amoxicillin.
AllopurinolConcurrent administration of allopurinol during treatment with amoxicillin can increase the likelihood of allergic skin reactions.
TetracyclinesTetracyclines and other bacteriostatic drugs may interfere with the bactericidal effects of amoxicillin.
Oral anticoagulantsOral anticoagulants and penicillin antibiotics have been widely used in practice without reports of interaction. However, in the literature there are cases of increased international normalised ratio in patients maintained on acenocoumarol or warfarin and prescribed a course of amoxicillin. If co-administration is necessary, the prothrombin time or international normalised ratio should be carefully monitored with the addition or withdrawal of amoxicillin. Moreover, adjustments in the dose of oral anticoagulants may be necessary (see sections 4.4 and 4.8).
MethotrexatePenicillins may reduce the excretion of methotrexate causing a potential increase in toxicity.
PregnancyAnimal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity. Limited data on the use of amoxicillin during pregnancy in humans do not indicate an increased risk of congenital malformations. Amoxicillin may be used in pregnancy when the potential benefits outweigh the potential risks associated with treatment.
BreastfeedingAmoxicillin is excreted into breast milk in small quantities with the possible risk of sensitisation. Consequently, diarrhoea and fungus infection of the mucous membranes are possible in the breast-fed infant, so that breast-feeding might have to be discontinued. Amoxicillin should only be used during breast-feeding after benefit/risk assessment by the physician in charge.
FertilityThere are no data on the effects of amoxicillin on fertility in humans. Reproductive studies in animals have shown no effects on fertility.
|Infections and infestations|
|Very rare||Mucocutaneous candidiasis|
|Blood and lymphatic system disorders|
|Very rare||Reversible leucopenia (including severe neutropenia or agranulocytosis), reversible thrombocytopenia and haemolytic anaemia. Prolongation of bleeding time and prothrombin time (see section 4.4).|
|Immune system disorders|
|Very rare||Severe allergic reactions, including angioneurotic oedema, anaphylaxis, serum sickness and hypersensitivity vasculitis (see section 4.4).|
|Not known||Jarisch-Herxheimer reaction (see section 4.4).|
|Nervous system disorders|
|Very rare||Hyperkinesia, dizziness and convulsions (see section 4.4).|
|Clinical Trial Data|
|*Common||Diarrhoea and nausea|
|Very rare||Antibiotic associated colitis (including pseudomembraneous colitis and haemorrhagic colitis see section 4.4). Black hairy tongue Superficial tooth discolouration#|
|Very rare||Hepatitis and cholestatic jaundice. A moderate rise in AST and/or ALT.|
|Skin and subcutaneous tissue disorders|
|Clinical Trial Data|
|*Uncommon||Urticaria and pruritus|
|Very rare||Skin reactions such as erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis, bullous and exfoliative dermatitis and acute generalised exanthematous pustulosis (AGEP) (see section 4.4).|
|Renal and urinary tract disorders|
|Very rare:||Interstitial nephritis Crystalluria (see sections 4.4 and 4.9 Overdose)|
|* The incidence of these AEs was derived from clinical studies involving a total of approximately 6,000 adult and paediatric patients taking amoxicillin. # Superficial tooth discolouration has been reported in children. Good oral hygiene may help to prevent tooth discolouration as it can usually be removed by brushing.|
Reporting of suspected adverse reactionsReporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at: www.mhra.gov.uk/yellowcard
Symptoms and signs of overdoseGastrointestinal symptoms (such as nausea, vomiting and diarrhoea) and disturbance of the fluid and electrolyte balances may be evident. Amoxicillin crystalluria, in some cases leading to renal failure, has been observed. Convulsions may occur in patients with impaired renal function or in those receiving high doses (see sections 4.4 and 4.8).
Treatment of intoxicationGastrointestinal symptoms may be treated symptomatically, with attention to the water/electrolyte balance.Amoxicillin can be removed from the circulation by haemodialysis.
Mechanism of actionAmoxicillin is a semisynthetic penicillin (beta-lactam antibiotic) that inhibits one or more enzymes (often referred to as penicillin-binding proteins, PBPs) in the biosynthetic pathway of bacterial peptidoglycan, which is an integral structural component of the bacterial cell wall. Inhibition of peptidoglycan synthesis leads to weakening of the cell wall, which is usually followed by cell lysis and death. Amoxicillin is susceptible to degradation by beta-lactamases produced by resistant bacteria and therefore the spectrum of activity of amoxicillin alone does not include organisms which produce these enzymes.
Pharmacokinetic/pharmacodynamic relationshipThe time above the minimum inhibitory concentration (T>MIC) is considered to be the major determinant of efficacy for amoxicillin.
Mechanisms of resistanceThe main mechanisms of resistance to amoxicillin are: • Inactivation by bacterial beta-lactamases.• Alteration of PBPs, which reduce the affinity of the antibacterial agent for the target.Impermeability of bacteria or efflux pump mechanisms may cause or contribute to bacterial resistance, particularly in Gram-negative bacteria.
BreakpointsMIC breakpoints for amoxicillin are those of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) version 5.0.
|Organism||MIC breakpoint (mg/L)|
|Susceptible ≤||Resistant >|
|Staphylococcus spp.||Note2||Note 2|
|Streptococcus groups A, B, C and G||Note 4||Note 4|
|Streptococcus pneumoniae||Note 5||Note 5|
|Viridans group steprococci||0.5||2|
|Moraxella catarrhalis||Note 7||Note 7|
|Gram positive anaerobes except Clostridium difficile8||4||8|
|Gram negative anaerobes8||0.5||2|
|Non- species related breakpoints10||2||8|
|1Wild type Enterobacteriaceae are categorised as susceptible to aminopenicillins. Some countries prefer to categorise wild type isolates of E. coli and P. mirabilis as intermediate. When this is the case, use the MIC breakpoint S ≤ 0.5 mg/L 2Most staphylococci are penicillinase producers, which are resistant to amoxicillin. Methicillin resistant isolates are, with few exceptions, resistant to all beta-lactam agents. 3Susceptibility to amoxicillin can be inferred from ampicillin 4The susceptibility of streptococcus groups A, B, C and G to penicillins is inferred from the benzylpenicillin susceptibility. 5Breakpoints relate only to non-meningitis isolates. For isolates categorised as intermediate to ampicillin avoid oral treatment with amoxicillin. Susceptibility inferred from the MIC of ampicillin. 6Breakpoints are based on intravenous administration. Beta-lactamase positive isolates should be reported resistant. 7Beta lactamase producers should be reported resistant 8Susceptibility to amoxicillin can be inferred from benzylpenicillin. 9The breakpoints are based on epidemiological cut-off values (ECOFFs), which distinguish wild-type isolates from those with reduced susceptibility. 10The non-species related breakpoints are based on doses of at least 0.5 g x 3or 4 doses daily (1.5 to 2 g/day).|
|In vitro susceptibility of micro-organisms to Amoxicillin|
|Commonly Susceptible Species|
|Gram-positive aerobes: Enterococcus faecalis Beta-hemolytic streptococci (Groups A, B, C and G) Listeria monocytogenes|
|Species for which acquired resistance may be a problem|
|Gram-negative aerobes: Escherichia coli Haemophilus influenzae Helicobacter pylori Proteus mirabilis Salmonella typhi Salmonella paratyphi Pasteurella multocida|
|Gram-positive aerobes: Coagulase negative staphylococcus Staphylococcus aureus£ Streptococcus pneumoniae Viridans group streptococcus|
|Gram-positive anaerobes: Clostridium spp.|
|Gram-negative anaerobes: Fusobacterium spp.|
|Other: Borrelia burgdorferi|
|Inherently resistant organisms|
|Gram-positive aerobes: Enterococcus faecium|
|Gram-negative aerobes: Acinetobacter spp. Enterobacter spp. Klebsiella spp. Pseudomonas spp.|
|Gram-negative anaerobes: Bacteroides spp. (many strains of Bacteroides fragilis are resistant).|
|Others: Chlamydia spp. Mycoplasma spp. Legionella spp.|
| Natural intermediate susceptibility in the absence of acquired mechanism of resistance. £ Almost all S.aureus are resistant to amoxilcillin due to production of penicillinase. In addition, all methicillin-resistant strains are resistant to amoxicillin.|
AbsorptionAmoxicillin fully dissociates in aqueous solution at physiological pH. It is rapidly and well absorbed by the oral route of administration. Following oral administration, amoxicillin is approximately 70% bioavailable. The time to peak plasma concentration (Tmax) is approximately one hour. The pharmacokinetic results for a study, in which an amoxicillin dose of 250 mg three times daily was administered in the fasting state to groups of healthy volunteers are presented below.
|Cmax||Tmax *||AUC (0-24h)||T ½|
|3.3 ± 1.12||1.5 (1.0-2.0)||26.7 ± 4.56||1.36 ± 0.56|
DistributionAbout 18% of total plasma amoxicillin is bound to protein and the apparent volume of distribution is around 0.3 to 0.4 l/kg. Following intravenous administration, amoxicillin has been found in gall bladder, abdominal tissue, skin, fat, muscle tissues, synovial and peritoneal fluids, bile and pus. Amoxicillin does not adequately distribute into the cerebrospinal fluid.From animal studies there is no evidence for significant tissue retention of drug-derived material. Amoxicillin, like most penicillins, can be detected in breast milk (see section 4.6). Amoxicillin has been shown to cross the placental barrier (see section 4.6).
BiotransformationAmoxicillin is partly excreted in the urine as the inactive penicilloic acid in quantities equivalent to up to 10 to 25% of the initial dose.
EliminationThe major route of elimination for amoxicillin is via the kidney.Amoxicillin has a mean elimination half-life of approximately one hour and a mean total clearance of approximately 25 l/hour in healthy subjects. Approximately 60 to 70% of the amoxicillin is excreted unchanged in urine during the first 6 hours after administration of a single 250 mg or 500 mg dose of amoxicillin. Various studies have found the urinary excretion to be 50-85% for amoxicillin over a 24 hour period. Concomitant use of probenecid delays amoxicillin excretion (see section 4.5).
AgeThe elimination half-life of amoxicillin is similar for children aged around 3 months to 2 years and older children and adults. For very young children (including preterm newborns) in the first week of life the interval of administration should not exceed twice daily administration due to immaturity of the renal pathway of elimination. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function.
GenderFollowing oral administration of amoxicillin/ to healthy males and female subjects, gender has no significant impact on the pharmacokinetics of amoxicillin.
Renal impairmentThe total serum clearance of amoxicillin decreases proportionately with decreasing renal function (see sections 4.2 and 4.4).
Hepatic impairmentHepatically impaired patients should be dosed with caution and hepatic function monitored at regular intervals.
The preparations being discontinued are:
- Amoxil 3g oral powder sachets sucrose free (GlaxoSmithKline UK Ltd)
The pharmaceutical company has decided to discontinue the product and so it may not be available in the future. This document has been left on the eMC for information purposes.
Stockley Park West, Uxbridge, Middlesex, UB11 1BT
+44 (0)208 990 4328
0800 221 441
0800 221 441