What is the recommended dose of amoxicillin (amoxicillin) for pediatric otitis media?

Recommended Amoxicillin Dosing for Pediatric Otitis Media

The recommended dose of amoxicillin for pediatric acute otitis media is 80-90 mg/kg/day divided into 2 doses. 1

First-line Treatment Algorithm

1. Standard first-line therapy:

   • Amoxicillin 80-90 mg/kg/day divided into 2 doses for 10 days 1

2. Special situations requiring amoxicillin-clavulanate instead:

   • Child has taken amoxicillin in the previous 30 days
   • Child has concurrent conjunctivitis (otitis-conjunctivitis syndrome)
   • Coverage for beta-lactamase producing organisms is desired
   • In these cases: Amoxicillin-clavulanate 90/6.4 mg/kg/day (amoxicillin component) divided into 2 doses 1

Rationale for High-Dose Amoxicillin

High-dose amoxicillin (80-90 mg/kg/day) is preferred over standard-dose (40-45 mg/kg/day) because:

• It achieves middle ear fluid levels that exceed the minimum inhibitory concentration (MIC) of intermediately resistant Streptococcus pneumoniae (penicillin MICs 0.12-1.0 μg/mL) 1
• It can overcome many highly resistant pneumococcal strains (penicillin MICs ≥2 μg/mL) 1
• Current US data indicate approximately 87% of S. pneumoniae isolates are susceptible to high-dose amoxicillin 1

Alternative Options for Penicillin-Allergic Patients

For patients with non-type I penicillin allergy:

• Cefdinir (14 mg/kg/day in 1-2 doses)
• Cefuroxime (30 mg/kg/day in 2 divided doses)
• Cefpodoxime (10 mg/kg/day in 2 divided doses) 1

These second and third-generation cephalosporins have minimal cross-reactivity with penicillin allergies due to their distinct chemical structures 1.

Treatment Failure Management

If no improvement after 48-72 hours of initial therapy:

1. Reassess to confirm AOM diagnosis
2. Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) if initially treated with amoxicillin alone 1

Age-Specific Considerations

• Neonates and infants <12 weeks: 30 mg/kg/day divided every 12 hours 2
• Children 12 weeks and older: 80-90 mg/kg/day in 2 divided doses 1, 2
• Children weighing ≥40 kg: Use adult dosing 2

Important Clinical Pearls

• The twice-daily regimen (every 12 hours) is associated with significantly less diarrhea than three-times daily dosing (14% vs 34%) 2
• Duration of therapy studied and recommended for acute otitis media is 10 days 2
• High-dose amoxicillin has been shown to improve both bacteriologic and clinical efficacy compared to standard dosing 1
• The World Health Organization's Essential Medicines list also recommends amoxicillin as first-choice antibiotic for otitis media 1

Common Pitfalls to Avoid

1. Underdosing: Using standard-dose amoxicillin (40-45 mg/kg/day) may be inadequate against resistant pneumococcal strains
2. Inappropriate first-line use of broad-spectrum antibiotics: Reserve amoxicillin-clavulanate for specific situations
3. Failure to reassess: Always re-evaluate patients who don't improve within 48-72 hours
4. Overtreatment: Remember that observation without antibiotics is an option for selected children with uncomplicated AOM, particularly those ≥2 years with non-severe symptoms 1