Persistence. Amoxicillin is potentially persistent.
Bioaccumulation. Amoxicillin has low potential for bioaccumulation.
Toxicity. Amoxicillin has a very high chronic toxicity.
Risk. Risk for selection of antibiotic resistance.
Environmental information for amoxicillin is missing on fass.se (2022-11-16). It is voluntary for manufacturers to provide information about environmental impact on fass.se. This summary information on persistence, bioaccumulation and toxicity is based on previous environmental information in Fass from 2015. For risk, see the environmental assessment from Goodpoint.
Fass environmental information
Fass environmental information for Amoxicillin Aurobindo (amoxicillin) from AstraZeneca (downloaded 2015-09-11).
Persistence: Based on the presented data, the company makes the assessment that amoxicillin is potentially persistent.
Bioaccumulation: Log P = 0.87.
Toxicity: There are data for 3 trophic levels, most sensitive Synechococcus leopoliensis (cyanobacteria) NOEC 0.78 microg/L.
PEC/PNEC is based on sales data in Sweden in year 2014. PEC/PNEC = 9.6 which gives the risk moderate.
EU water legislation
Due to the risk of ecotoxicity of amoxicillin in water, the substance has been monitored within the framework of EU water legislation to "improve knowledge of the occurrence and spread of antimicrobials in the environment". "Therefore the watch-list monitoring obligation for the three substances or groups of substances that had been on the list since 2018, namely metaflumizone, amoxicillin and ciprofloxacin, ceased in 2022. The monitoring data obtained will be considered in the context of the prioritisation exercise referred to in Article 16(2) of Directive 2000/60/EC."
Report Goodpoint 2016 and pharmaceuticals residues in the aquatic environment
Measurements in the Swedish environment/wastewater are lacking, but based on expected concentrations in wastewater treatment plants (based on high usage, high proportion of excreted substance as parent substance, and reported moderate reduction in treatment plants from other countries) there is a risk for selection of antibiotic resistance in treatment plants. That is why amoxicillin is included in Region Stockholm's table of pharmaceuticals with risk for a negative environmental impact according to the environmental programme 2017–2021.
Studies have shown that even low concentrations of antibiotics in the environment may trigger antibiotic resistance and therefore measures should be taken to ensure that as little as possible ends up in our environment.
The Wise list
Is recommended in The Wise list. Environmental classification of pharmaceuticals is taken into consideration, sometimes with other environmental aspects, when selecting pharmaceuticals for the Wise list. When comparable pharmaceuticals are equivalent to medical effects, safety and pharmaceutical efficacy, environmental impact and price are considered.
Suggestions on how to reduce emissions of amoxicillin
Concrete proposals on how to work to reduce emissions of environmentally harmful drugs on the list have been developed in close cooperation with the Stockholm Drug and Therapeutics Committee's expert groups. The action proposals were developed from an environmental perspective. The patient's best always goes first and several pharmaceuticals on the list are also included in the Wise list. However, for such pharmaceuticals, there may be measures that could reduce the environmental impact.
Concrete proposal for amoxicllin
- Eradication of Helicobacter pylori with amoxicillin only on strict indication.
- For antibiotics, the general rule is as restrictive use as possible without risking the patient's health. Relevant cultivation is important in order to choose antibiotics that have a good effect with as narrow spectrum as possible.
- Europeiska unionens officiella tidning. Kommissionens genomförandebeslut (EU) 2020/1161 av den 4 augusti 2020.
- Official Journal of the European Union. Commission implementing decision (EU) 2022/1307 of 22 July 2022.
- Goodpoint. Prioritering av läkemedel med miljörisk inom SLL. Stockholm: Goodpoint; 2016. Rapport LS 2016–0634.
- Andreozzi R, Caprio V, Ciniglia C, de Champdoré M, Lo Giudice R, Marotta R et al. Antibiotics in the environment: occurrence in Italian STPs, fate, and preliminary assessment on algal toxicity of amoxicillin. Environ Sci Technol. 2004;38:6832-8.
- Bengtsson-Palme J, Larsson DG. Concentrations of antibiotics predicted to select for resistant bacteria: Proposed limits for environmental regulation. Environ Int. 2016;86:140-9.
- Gullberg E, Cao S, Berg OG, Ilbäck C, Sandegren L, Hughes D et al. Selection of resistant bacteria at very low antibiotic concentrations. PLoS Pathog. 2011;7:e1002158.
- Region Stockholm. Förteckning över miljöbelastande läkemedel med åtgärdsförslag framtagen inom ramen för Region Stockholms miljöprogram 2017–2021.
- Fass.se för vårdpersonal
- Stockholm Drug and Therapeutics Committee. Kloka listan (Wise list).
- Stockholm Drug and Therapeutics Committee. The Wise list 2015.
Author: Health and Medical Care Administration, Region Stockholm