February 1, 2013 | 6
Busy primary care doctors, especially those who see children, prescribe it ten times a day, sometimes more. For over thirty years it’s been our old steady friend, our go-to medication for bacterial ear infections, pneumonia, strep throat, and sinusitis. Evidence-based literature has its back. It’s the “pink medicine,” the yummy “bubble gum medicine,” to which even obstinate toddlers will grudgingly capitulate.
Doctors use it so often (when medically indicated, of course) that we barely even think about it. The anesthetic of the routine has been induced. But if we allow that anesthetic to be lifted, for a bit, the lifted curtain reveals a medication with a momentous history, mind-numbing amount of human good, and probably doomed future.
Prior to the germ theory of disease, our concept of infection was as primitive as our “cures.” The advent of modern science and enlightenment thought then changed medicine forever. “When I woke up just after dawn on September 28, 1928, I certainly didn’t plan to revolutionize all medicine by discovering the world’s first antibiotic, or bacteria killer,” Alexander Fleming would later say, “But I suppose that was exactly what I did.”
Fleming returned to his laboratory after vacationing with his family. He noticed that a bacterial culture he had been growing was contaminated with a fungus, and that the bacteria immediately surrounding the fungus had been destroyed. Fleming grew the mould and found that it produced a substance, which he named penicillin, that killed a number of disease-causing bacteria.
Decades later, with the assistance of other medical researchers and funds from the U.S. and British governments, penicillin was mass produced after the bombing of Pearl Harbor. When D-Day arrived, enough penicillin had been produced to treat all the wounded Allied forces.
Since then penicillin and its derivatives have been called the most efficacious life-saving medications in the world, conquering some of humankind’s most ancient scourges. Antibiotics as a whole have been estimated to have saved over 80 million lives.
Amoxicillin, a penicillin derivative, was synthesized by Beecham Research Laboratories in 1972. During cell wall synthesis, amoxicillin inhibits linear peptidoglycan polymer chains from being cross-linked, resulting in a defective bacterial cell wall and cell death. Compared to penicillin, amoxicillin offers a broader spectrum of bacteriocidal activity, greater duration, and, of course, better taste.
According to a report from the IMS Institute for Healthcare Informatics, in 2010 52.3 million prescriptions were written for amoxicillin in the U.S., more than any other antibiotic except azithromycin at 52.6 million. (The most prescribed drug in any category? Hydrocodone/acetaminophen, 131.2 million).
Doctors can feel a deeper sense of meaning for what we do every day the more we appreciate the wider significance of our actions. At the turn of the century in 1900, rheumatic fever complications from strep throat infections were the number one cause of death in school-age children. Now we hardly see rheumatic fever in this country anymore. If you are a health care provider, the next time you prescribe amoxicillin pause for brief moment and think that you may have just saved a life.
Now, as is well known, the tide is turning in the evolutionary arms race, with bacterial resistance on the rise. This is in part due to antibiotic overuse, in humans and in livestock. Because of bacterial résistance, recommendations for treating appropriate bacterial infections are now trending towards higher routine amoxicillin doses or adding B-lactamase inhibitors. It is doubtful that “the pink medicine” will be the first choice for the next generation of pediatricians.
So, amoxicillin … humdrum or miraculous? Humdrum only in the sense that it is commonplace. Miraculous? Well, no. Antibiotics are the result of human genius, ingenuity, serendipity, industry, and good will. Like so many scientific advances, its blessings are many, and its risks, if we drive more recklessly than road conditions allow, are frightening.