What is the maximum daily dose of amoxicillin (Amoxicillin) for children with Acute Otitis Media (AOM)?

Maximum Dose of Amoxicillin for Children with Acute Otitis Media

The maximum daily dose of amoxicillin for children with acute otitis media (AOM) is 90 mg/kg/day, typically administered in two divided doses. 1, 2

First-Line Treatment Recommendations

Standard Approach

• High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses) is the recommended first-line treatment for AOM in children 2, 1
• This dosing is effective against susceptible and intermediately resistant Streptococcus pneumoniae, which is a common pathogen in AOM 2
• The high-dose regimen provides middle ear fluid levels that exceed the minimum inhibitory concentration (MIC) of resistant pneumococcal strains for a longer period of the dosing interval 2

Special Circumstances

For children who have:

• Taken amoxicillin in the previous 30 days
• Concurrent conjunctivitis
• Need for coverage against β-lactamase-producing H. influenzae and M. catarrhalis

High-dose amoxicillin-clavulanate should be used instead:

• 90 mg/kg/day of amoxicillin component
• 6.4 mg/kg/day of clavulanate component
• Given in 2 divided doses (14:1 ratio of amoxicillin to clavulanate) 2, 1

Treatment Duration

• 10 days for children under 2 years or those with severe symptoms
• 7 days for children 2-5 years with mild/moderate symptoms 1

Alternative Options for Penicillin Allergy

For children with non-type I penicillin allergy:

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

Treatment Failure Management

If symptoms worsen or fail to improve within 48-72 hours:

1. Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate)
2. Consider ceftriaxone (50 mg IM or IV per day for 3 days) for further failures 2, 1

Clinical Considerations

Efficacy Evidence

• High-dose amoxicillin has demonstrated superior efficacy in eradicating S. pneumoniae from the middle ear compared to standard dosing 3
• A study by Hoberman et al. showed superior efficacy of high-dose amoxicillin-clavulanate in eradicating S. pneumoniae (96%) from the middle ear compared with azithromycin 2

Common Pitfalls to Avoid

1. Using standard-dose amoxicillin (40-45 mg/kg/day) - This is inadequate for resistant organisms 1, 4
2. Ignoring recent antibiotic use - Children who have taken amoxicillin in the past 30 days should receive amoxicillin-clavulanate instead 1
3. Overlooking pain management - Pain relief should be addressed regardless of antibiotic use 1
4. Continuing antibiotics for asymptomatic middle ear effusion - Persistent middle ear effusion without symptoms after successful antibiotic treatment does not require additional antibiotics 1

Bacterial Resistance Considerations

• Beta-lactamase-producing H. influenzae is a common cause of treatment failure with amoxicillin alone 3
• Current data show that approximately 83% and 87% of S. pneumoniae isolates are susceptible to regular and high-dose amoxicillin, respectively 2

Remember that the maximum dose of 90 mg/kg/day should not be exceeded, as this is the upper limit recommended by clinical guidelines for treating AOM in children.