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

Amoxicillin Dosing for Acute Otitis Media in Children

For children with Acute Otitis Media (AOM), high-dose amoxicillin at 80-90 mg/kg/day divided into two doses is the recommended first-line treatment. 1

First-Line Treatment Recommendations

• Standard dosing regimen:
  • Dose: 80-90 mg/kg/day (high-dose)
  • Frequency: Divided into two doses daily
  • Duration:
    • 10 days for children under 2 years or with severe symptoms
    • 7 days for children 2-5 years with mild/moderate AOM
    • 10 days for children 6 years and older 1

Treatment Algorithm

Clinical Scenario	Recommended Treatment
First episode of AOM (no amoxicillin in past 30 days)	Amoxicillin 80-90 mg/kg/day divided in two doses
Recurrent AOM or recent amoxicillin use	Amoxicillin-clavulanate
Treatment failure with amoxicillin-clavulanate	Consider ceftriaxone or specialist consultation

Special Considerations

• For patients with recent amoxicillin use or concurrent conjunctivitis: Use high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) 1

• For penicillin allergies:

  • Non-Type I allergies: cefdinir, cefuroxime, or cefpodoxime
  • Type I allergies: macrolides or clindamycin 1

Rationale for High-Dose Amoxicillin

The recommendation for high-dose amoxicillin (80-90 mg/kg/day) rather than standard-dose (40-45 mg/kg/day) is based on the need to overcome drug-resistant Streptococcus pneumoniae. Studies have shown that:

• The standard 40 mg/kg/day dosing is inadequate to effectively eradicate resistant S. pneumoniae, particularly during viral coinfection 2
• High-dose amoxicillin achieves better middle ear fluid penetration, with concentrations reaching approximately 9.5 μg/ml 2
• Bacteriologic efficacy studies show that high-dose amoxicillin (80 mg/kg/day) successfully eradicates 92% of S. pneumoniae isolates in middle ear fluid 3

Monitoring Treatment Response

• Assess response to therapy within 48-72 hours
• If no improvement occurs within this timeframe:
  • Confirm diagnosis
  • Consider switching to amoxicillin-clavulanate
  • Consider referral to ENT specialist, especially with tympanic membrane perforation 1

Important Clinical Pearls

• Treatment indications:

  • Children under 2 years with bilateral otitis media require immediate antibiotic therapy
  • Presence of tympanic membrane perforation warrants immediate antibiotic therapy regardless of age 1

• Common pitfalls to avoid:

  • Isolated redness of the tympanic membrane with normal landmarks is not an indication for antibiotic therapy 1
  • Beta-lactamase-producing H. influenzae is the predominant pathogen in children failing high-dose amoxicillin therapy, accounting for 64% of bacteriologic failures 3

• Preventive measures:

  • Pneumococcal vaccination
  • Breastfeeding for at least 6 months
  • Avoiding supine bottle feeding
  • Limiting pacifier use after 6 months of age 1