♪ Bob and Brad the two most famous ♪
♪ Physical therapists on the internet ♪
- Welcome my friends to the Bob and Brad podcast
produced by Bob and Brad,
the two most famous physical therapists
on the internet in our opinion of course.
I'm Brad Heineck and we're just absolutely
delighted to have Chris, the Pharmacist with us.
- Hey guys.
- We've got a wonderful podcast today.
You can see it on YouTube as well.
But it's amoxicillin,
how and when we use it
plus dangers of overuse
which is definitely out there
and it's something that it's good to know.
- Oh yeah.
I mean amoxicillin, it is one of the most widely
prevalent drugs used in the world.
In the United States 2017,
it was pretty much number 18 on the list
of 27 million prescriptions filled.
So it's a big number.
- In the United States?
- In USA. You know it.
- 27 million?
- 27 million scripts.
- Okay.
- So that's a lot.
- Yeah.
- It's a lot.
- So being used out there?
- It is being used. It's an essential drug.
I mean the WHO, I mean it's an essential medication.
They have it on hand.
I mean it, it treats a variety of different infections.
- And so how long has it been around?
- Well its, Amoxicillin isolated 1958 but first used, 1972.
But I mean penicillin itself,
we go back a little bit further-
- What's penicillin got to do with amoxicillin?
- Well, amoxicillin is a penicillin, so.
- Its just a,
- Yeah. It's just a version of it.
So it's a more readily available version.
But I mean, I think it's kind of crazy.
There's a Dr. Alexander Fleming in 1928,
just came back from vacation in England
and he went back to his lab and it was a mess.
So he started to clean things up
and he noticed that his aggro dishes,
that is all his staff infections
had this mold on there and it was penicillium,
noc no Tatum and so basically around that area,
there was no bacteria growth.
And he thought, well, that's kind of odd.
So he looked at it under microscope to make sure it
was a little bit more clear.
He was like, wow, it is not there.
And at that point he had realized he'd probably come up
with probably the single most greatest medical revolution
in the history of mankind, which was the discovery of
penicillin.
- 28 and that's some mold, it killed some bacteria.
You know.
- Exactly.
- Went on from there.
- Well, and then it kinda just sort of died.
He was, he was a research physician and he was brilliant.
He actually came up with a couple
of the things along the way, but 10 years later
another doctor at Oxford read his paper.
And so, and just, so his name was Howard Florey.
And so he was at the William
and Dunn college pathology and medicine
and he just thought this and he was, he was a Rainmaker.
So this guy would go out and just make money.
So he found this and he goes
I think we can probably make some money with this.
So he got in contact with the doctor and he
they basically started to work on it.
So he had a big lab group
in the Oxford department that he worked in.
And so there was Dr. Ernst chain
and then another player was a Dr. Norm Healey
who is a biochemist.
- So they came up together to make penicillin
- Well that was kind of a process.
So they started working on it and it was really
really hard to isolate.
And so it, as a matter of fact, when they got down to it
it took 2000 liters of extract to treat one human being.
So can you imagine 2000 one liter bottles
I mean it would fill up this room?
- Yeah.
- I mean, it's, it's huge to treat one person.
- So through we could get onto the amoxicillin.
so this all developed in the 50's
and then we got penicillin.
- What yeah actually, what happened is
world war II actually is when
this has happened in world war II.
So they're getting bombed out by the Germans all the time.
And so they had a guy that fed a gardening
accident was pretty wicked
and he was dying because of this horrible staph infection.
And so they were like, well, we just did a trial
a trial on 50 mice a little while ago.
- Yeah.
- 25 that were treated with penicillin lived.
They're like, let's try it on this dude.
And so basically they gave this guy penicillin
and they had enough to give him for five days.
And so basically they gave it to him.
He was recovering and then they couldn't get any more
because they couldn't make it.
And this is so they're actually taking his urine
because it was very strongly metabolized
by the kidney and re isolating it out of his urine
but they couldn't make enough.
And that's where this Dr. Healy comes into play.
He's actually probably, he's the one that in this hospital
he took every bottle bedpan, anything he could put
in it to try and grow this penicillin isolate
but unfortunately ran out of time
and sadly the poor individual passed away.
But so they were like, what did we do next?
And so it's 1941 middle world war II.
They can't do anything in Europe
because they're getting bombed to Jesus.
And so they came to the United States, ended up in Peoria.
They talked to several different manufacturers
and there was this Dr. Aj Moyer
that this Healey guy came in contact with.
He made a couple of quick suggestions.
They changed the type
of mold substance that you use for penicillin.
And they got the extract.
And by 42, it was being made
by billions upon billions of units.
And so they had it in 1942
the first American person used it
a young lady that had a very sepsis due
to a miscarriage, sepsis infection, and that pulled through.
And then it was widely proven on the battlefields in Europe
basic enormity specifically.
And, and so what happened then as the biggest world war two
to world war one, the thing that was killing people
in battles was infection.
It wasn't necessarily the war wounds.
So they went from about 18% death rate to 1% death
rate simply because of penicillin.
- Oh.
- So fast forward to amoxicillin, which was isolated
in 1958, actually I should say real quickly,
Dr. Fleming and his group got the Nobel prize in 1945.
And so the interesting and Fleming speech though, is that
with penicillin, we have to be careful with our use
because resistance could develop.
So we've come up with.
- So he warned.
- He wanted back in 1945 he was astute
enough to recognize that it could be a very
real problem in the future.
And as we look at this, and as we look at how
we treat people with antibiotics today, one of the very real
with anti-microbial stewardship, that's what in my world
as a pharmacist, we see lots of doctors really trying,
you know, where people are.
- Starting to, I don't, the big words Chris.
- Okay. All right,
- Keep it down for me.
- All right. So we're trying to cut
down the use of any antibiotic really
because resistances are developing
- Wait, wait, wait.
We're, we're getting to we're jumping here.
We went from penicillin, got invented.
And then all of a sudden Amoxicillin in 1958.
So Amoxicillin was a part
of penicillin and they use it for infections.
- Correct.
Very commonly and grew and grew and grew.
And we're still using amoxicillin today
- We use it today. But it's, it's funny.
I mean, I've been doing this for 25 years as a pharmacist.
And actually the doses of amoxicillin have gone up
for my first day in 1995 to where I am right now
in 2021 vastly different dosing.
So you see higher doses to make it useful.
- For the same.
- Because
- Same individual or same problem.
- Because of the resistance of, of the amoxicillin,
which is a penicillinic
- Let's back up even one more step.
So we've got amoxicillin now it's working well
we're changing the doses, but what is it primarily used
for an infection from a nail and infection from a cut
- It's a very versatile well drugs.
So it's going to treat things like pneumonia, UTI
a staph infection, strep infection
ear infections for parents, for children.
So it's safe in pregnancy.
- Sure. And it works well ?
- Yeah. It works very well when used appropriately
and dose properly.
I mean, the biggest thing for people is to make sure
that when your doctor gives you a prescription
you take it exactly as directed until they tell you to stop.
So basically a lot
of people are inclined to want to stop taking the medication
after three days and then they'll say.
- They feel better.
- Yeah they feel better.
I don't need the rest of it.
So they'll save it
for later where once something invariably comes back
and then they could be mistreating the infection
because it might be not the appropriate bacteria.
And then they can that bacteria
all your bacteria absorbs the antibiotic.
And so, and that's why
and we can talk about that resistance
in the food supply and things like that if we want.
- So the big thing about dosage is now your doctor gives it
to you, take it all the way as prescribed until it
the bottle is gone.
And they'll tell you that, or the Pharmacist.
- Pharmacist will reinforce that.
- Right.
- So to make sure.
- So adults, infants.
- Yeah, Everybody.
- Children everyone, can use this.
- You name it.
- And the I'm assuming the dosage is going to be different
from an infant to an adult.
- Yes it's definitely going to be different.
So as, as you know, so for ear infections in particular
they do a much higher dose of amoxicillin than what they
would do for say a skin infection or a sore throat, so
or strep throat.
So it just kind of depends.
And they always dose that by a milligram per kilogram.
So they base it on your body weight, particularly with kids
adults, it's a little bit more standard.
So it's a little bit easier to dose as an adult.
- So that's all, it seems pretty straightforward.
So far the diet, you get an infection, very treatable
with amoxicillin, followed directions from the doctor.
Typically it's successful as, and I've had this myself
has been a long time, but like the doctor mentioned 1945.
There could be some problems with over usage
- Over usage and resistance.
And that's one of the biggest problems that we face now
as a society.
I mean, you were looking at, what's predicted right now
by 2050, they think that actually resistant
to antibiotics may actually over that death rate
may take overtake the cancer death rate.
- So you're saying someone has an infection
they take amoxicillin, it's not going to
- Work. It doesn't work.
And then the infection is going to take over their body.
- Why doesn't it, why isn't it working?
- Well, the bacteria want to live.
And so basically what they do is they, they assimilate ways
they've developed enzymatic systems to help
to fight against it.
So it's, it's kind of
- So it kind of mutates
that the amoxicillin is no longer effective
because of the previous history.
- Correct.
From person to person, generation to generation.
So if I had amoxicillin used on me and so the,
or the bacteria all starts to mutate, I'm going to pass that
onto my child and they're going to be
- It doesn't work that way.
It's the bacteria, it's it goes from bacteria to bacteria.
So you have your own normal flora.
I've got my own normal flora.
And so, and, and cattle
and livestock have their own normal flora.
And so oftentimes, you know
there's antibiotics in the food chain
because they want to keep the herd healthy.
- So they're using amoxicillin
- They're using types of penicillin.
It's not amoxicillin in, but it's
penicillin specific for cattle,
- But it's it's still will affect us
because they inject it into the herd.
- Yeah the heard so the bacteria within those cows, you know
it goes all the way down.
It gets into the water system
you name it, we're adjusting tons and tons of
- You mean because it's injected at the cow
goes into their meat, we eat the meat.
So it gets into us.
And it's kind of the same thing as an injection.
- And they excrete things, it goes into the water
and it's in our water supplies and you name it.
- So.
- It's a very widespread problem.
- So dairy, not just meat.
- No, I, I'm just picking on cows, but it can be anything.
it could be chickens.
- Pigs, chickens
Everyone that, so this is where people are concerned.
Well, I better get organic, correct.
To avoid, to try and avoid some
of that avoid taking in the antibiotics that animals are in.
- Yeah and even than even organic farmers
have to treat their animals
with antibiotics, but it's much less.
So, I mean, that's something to be understood.
I mean, big commercial farmers tend to use antibiotics
just prophylactically to make sure
that that herd remains healthy
- Before there's an infection they'll use it
just to make sure.
- It is preventative.
- Because they got a thousand cows in there.
If one gets an infection in it
- It can spread, it can be a big deal.
So it's very expensive.
I mean, it's a double-edged sword.
I mean, it is not an easy business.
I mean, it's, it's not that farmers, you know
they're just trying to indiscriminately do that.
I mean their livelihoods.
- Sure.
- So you can't blame them.
It's just a situation that's arised over the years.
I mean, for a while there
it seemed like it was an ingenious idea.
And now we're just learning
because these bacteria basically have learned how
to develop enzymatic systems to help break
down these antibiotics.
So they're resistant to it, so it doesn't affect them.
So all of a sudden you give them a shot of
penicillin its like why am I not getting better.
And that's the fear that we have.
so using antibiotics, indiscriminately, you know
when you don't need it, and that's hard
because most times you go in and visit a doctor
and a doctor, unless they actually take a culture
they aren't going to definitively know they're
going to have a pretty darn good idea
because they are very smart, you know, people that deal
with cultures and sensitivities, the, the talk
about what's the infecting organisms are in the area
and they have a, these, these infectious disease people
- They just don't say, oh, it's an infection.
No, I mean, it's, it's thought it's a very, it's
it's an even more so today doctors being much more selective
about their use of, of infection.
So let's say you went in and, and you had an ear infection
and then your doctor they'd probably actually
give you augmented, but we'll, we'll not going to talk
about that, but we'll pretend that they're going to
give you amoxicillin.
And so we're going to give you an 875 milligram
dose twice a day.
So then you've got this ear, that's killing him.
So it's a it's.
So if you come into the pharmacy and you go, Hey
I need this.
Okay, Brad, we've giving you amoxicillin
so what's going on?
And you say, I've got a horrible ear.
- Terrible earache
worked really good for my mom.
She says, I should get
this amoxicillin and it's going to be fine.
- So your doctor agreed with your mother, huh?
- Well, yeah, she was, she's adamant
that I get this amoxicillin and I,
it's, it's going to take care of the problem.
And she argued with them a little bit.
And he gave it to me.
- Well I got to say, you've got a smart mom,
but I think your, your doctor probably assessed
the situation and probably looked
at that era was probably pretty red and goopy
and you had a fever.
So, and he made the selective decision to go, all right.
I think Brad would be a good candidate for this dose
of amoxicillin.
So we'd look at it.
You're going to take it twice a day.
We're going to have you on this for 10 days.
And the reason that we would, yeah, sometimes
it can be a five day course, a seven-day course
or 10 day course.
It sort of depends on the nature of the infection.
- Sure.
- So, and, and a lot of times, actually, even for otitis
they'd probably only do seven days for you,
but sometimes ear infections could be worse
because your ears and your sinuses are
all kind of interwoven together.
- Right.
- So you may see a prescription for seven to ten days
depending upon what your clinician believes is most
appropriate for you.
And so they will prescribe it the biggest thing
with the amoxicillin it's tough on the tummy.So.
- Oh.
- I want to make sure you eat before you get a dose.
- Oh.
- yeah.
Because you can get really irritated gut so.
- So you take it after you eat.
- Yup so food first and because
it's a twice a day dose, it's pretty convenient.
We're going to tell you to take it
after breakfast, after supper.
And you might say, well, Chris, it's three in the afternoon.
What do I do?
Do I get both doses in today?
And on day one, a lot
of times we're going to tell you to get both doses.
So let's say you're up around 10 o'clock.
I'd tell you to get that second dose in because
as we kind of put a more aggressive loading dose in
there to try and get a head
start on getting those nasty bacteria kind of calmed down.
But then the next day we want you to
resume a uniform dosing pattern so
that we keep a good concentration level
of drug in your system to aggressively manage
and fight that infection.
- You know, I was making that point with a mother.
I was pretending, and I was just trying to get
to the point where sometimes the doctors kind
of may get a pressure from the patient
or the family member that it had worked in the past.
And the doctor's going to might say
because a history of a user before
that you don't want to use it all the time.
- Correct.
Because the doctor may say, no, we're not going to
- And then you got a frustrated patient, but yes.
And that's, that's one of the things that doctors
find this dilemma, I think on a day-to-day basis really, as
to what's the most effective choice, but now we've got
you know, most hospitals and clinics have what
they call anti-microbial stewardship programs
in place where they, they go through lots of education
and doctors already have tons and tons of hours
of education.
So they know when it's appropriate and when it's not.
And, and even they, they generally are not going to
succumb to patient calling their shots, so to speak.
- Sure.
- I mean, I'm going to go in and I'm going to, I'm going to
take some amoxicillin because it worked great for my kid.
I mean, it might be because there's maybe
a genetic component there, but if there's an allergy
in place or if they're, you know, maybe it's not appropriate
or there's certain drugs that could interfere with that
you know, there's a lot of reasons why a clinician
is going to maybe choose something differently.
But for the purposes of our discussion, we're going to say
you're not on any drugs that are gonna interfere
like a blood thinner.
We're going to pretend that you're healthy otherwise
and you have no allergies.
- But let's say you have a history of using
amoxicillin like me or maybe I
used it quite a few times in my past.
Would that be a reason not to continue to use it ?
- Yes, absolutely, exactly.
That's one of the biggest things that we watch for
in the pharmacy is usually the guideline
that, that we've seen put
in place is you don't want to repeat the same drug
within at least 30 days.
And I think they're getting even more stringent about that.
So it kind of depends because, you know, with sinusitis
that's a really tough infection to treat to begin with.
And sometimes it takes a much longer course of antibody
even two weeks and three weeks.
So those are long courses of antibiotics.
And, you know, an antibiotic goes in there, indiscriminately
it kills your good bacteria, and your bad bacteria
which is, so it makes it tough.
That's why people have digestive woes when
they're taking antibiotics
because their good bacteria got killed off.
That's what helps digest our food.
- And that's real.
They were really talking about that.
I'm reading a book
they're talking about the gut, the microbiome
- The biome of the gut.
- Yeah which is good bacteria.
- Correct.
- Which, you know, 20 years ago
I just figured every, all bacteria is good
until I start, you know, got in the health field.
- Yeah. Well and I mean, all bacteria, I mean
that's what happens with an infection is, you know
it's all about, it's like checks and balances.
It's like with our government.
I mean, and all sudden we have billions
and billions of bacteria, all of our bodies
at any given point at a different point in our body.
And when it gets your immune system has an insult
something gets overgrown.
That's when the bacteria takes advantage, like, Hey
I got a weakness here.
This is my chance to really proliferate
and get big and get nasty.
And that's why, you know
in the case of like your ear infection, you know
it found a spot behind that eardrum
your station tube, wasn't draining properly
it clogged it up and it's nice warm breeding
environment and boom, it grew bad.
And then you had the infection assessed it
and the antibiotic.
So yeah, repeating it over
and over is not a successful plan just
because it worked for the last time.
It doesn't mean it's the most appropriate choice.
A lot of times physicians will recognize that
and they will go in a different direction
and select a different, although effective antibiotic.
- Right.
- And then, but sometimes they'll have to go
let's say the second antibiotic didn't work as effectively
for whatever reason, they might have to go back to
we'll say amoxicillin in this particular case.
So it depends.
So there's a lot of work that goes on.
I mean, if it was easy, everybody would be doing it.
- Right.
- So it's, it's definitely a challenge for sure.
- Well, I think that we covered a lot
of ground there from the, the history.
It's amazing how things in life
and in history accidents happen and something incredible.
- Oh yeah.
I mean, it does.
I mean, it's changed us.
- You know, develops from itself.
- Yeah.
- Yeah. Amoxicillin sounds like a good drug.
It sounds like you gotta be careful with it and, you know
understand how to take it and when to
and when not to take it and you know
what the doctors have to take in consideration.
- Yup. And so, I mean, a lot of, you know, going forward
I mean, we're going to have to have these drug
companies start doing more research on new antimicrobials.
Otherwise I think we're going to end really in a very
short period of time could history wise, we could have
some very big issues
- Well, you said 2050, so that's 30 years.
- That's not that far away.
- I suppose.
- 29 years is pretty quick.
- Things happened fast. So very good.
I appreciate everyone listening.
I hope you learned a lot and you feel comfortable
with your amoxicillin and enjoy the week.
- Thanks guys.
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