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

Amoxicillin Dosing for Pediatric Otitis Media

The recommended dose of amoxicillin for treating otitis media in pediatric patients is 80-90 mg/kg/day divided into two doses. 1

First-Line Treatment Regimen

• Dosage: 80-90 mg/kg/day divided into two doses
• Duration: 10 days
• Administration schedule: Every 12 hours (preferred over every 8 hours due to significantly less diarrhea) 1, 2

Age-Specific Considerations

• Neonates and infants <12 weeks (<3 months): 30 mg/kg/day divided every 12 hours 2
• Children ≥12 weeks (≥3 months):
  • For otitis media: 45 mg/kg/day every 12 hours 2
  • For more severe infections: Higher dose (80-90 mg/kg/day) as recommended by guidelines 1
• Children weighing ≥40 kg: Follow adult dosing recommendations 2

Treatment Algorithm

Clinical Scenario	Recommended Treatment
First episode (no amoxicillin use in past 30 days)	Amoxicillin 80-90 mg/kg/day divided twice daily
Recurrent AOM or recent amoxicillin use	Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate
Treatment failure with amoxicillin-clavulanate	Consider ceftriaxone or specialist consultation

Evidence Supporting High-Dose Regimen

The high-dose regimen (80-90 mg/kg/day) is recommended over standard-dose (40-45 mg/kg/day) due to:

1. Excellent coverage against Streptococcus pneumoniae, including resistant strains 1
2. Improved efficacy against non-beta-lactamase producing Haemophilus influenzae 1
3. Better penetration into middle ear fluid, particularly important during viral co-infections 3

Studies have demonstrated that the standard dose of 40 mg/kg/day is inadequate for eradicating resistant S. pneumoniae, particularly during viral coinfection 3. Bacteriologic studies show high-dose amoxicillin achieves eradication in 92% of S. pneumoniae cases, including penicillin-nonsusceptible strains 4.

Administration Schedule

The twice-daily (every 12 hours) regimen is preferred over three times daily because:

1. Clinical trials demonstrate comparable efficacy between twice-daily and three-times-daily dosing 5
2. Twice-daily dosing is associated with significantly less diarrhea (14% vs. 34%) 2
3. Better adherence with twice-daily dosing due to fewer reported difficulties with dosing schedule 5

Special Considerations

• Beta-lactamase producing organisms: If treatment failure occurs with high-dose amoxicillin, consider switching to amoxicillin-clavulanate, as beta-lactamase producing H. influenzae is the predominant pathogen in treatment failures 4
• Penicillin allergy: For non-Type I allergies, consider cefdinir, cefuroxime, or cefpodoxime; for Type I allergies, consider macrolides or clindamycin 1
• Children under 2 years with bilateral otitis media: Require immediate antibiotic therapy rather than observation 1
• Tympanic membrane perforation: Warrants immediate antibiotic therapy regardless of age 1

By following this high-dose amoxicillin regimen, you can optimize treatment outcomes while minimizing side effects and improving adherence in pediatric patients with otitis media.