What is the recommended dosing of Augmentin (amoxicillin/clavulanate) for acute otitis media in children?

Augmentin Dosing for Acute Otitis Media in Children

For acute otitis media in children, high-dose amoxicillin-clavulanate (Augmentin) should be dosed at 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate, divided into two doses daily for 10 days. 1

First-Line Treatment Options

Standard Cases

• First episode with no recent antibiotic use:
  • Amoxicillin alone: 80-90 mg/kg/day divided twice daily 2, 1

Special Circumstances (requiring amoxicillin-clavulanate)

• When to use Augmentin instead of amoxicillin alone:
  • Children who have taken amoxicillin in the previous 30 days
  • Children with concurrent conjunctivitis
  • When coverage for beta-lactamase-producing organisms is desired
  • Recurrent AOM episodes 2, 1

Dosing Formulations

• For children <40 kg:

  • High-dose amoxicillin-clavulanate: 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (14:1 ratio) divided into two doses daily 2
  • This formulation is designed to overcome resistance while minimizing diarrhea compared to other amoxicillin-clavulanate preparations 2

• For children ≥40 kg:

  • Follow adult dosing recommendations 3
  • 875 mg/125 mg tablet every 12 hours or 500 mg/125 mg tablet every 8 hours 3

Age-Specific Considerations

Infants <12 weeks (<3 months)

• 30 mg/kg/day divided every 12 hours (based on amoxicillin component)
• Use 125 mg/5 mL oral suspension 3

Children 12 weeks (3 months) and older

• For otitis media: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 3
• The twice-daily regimen is preferred as it is associated with significantly less diarrhea 3, 4

Treatment Duration

• 10 days is the recommended duration for acute otitis media in children 2, 3

Clinical Considerations

Bacterial Coverage

• High-dose amoxicillin-clavulanate provides excellent coverage against:
  • S. pneumoniae (including 92% of penicillin-resistant strains)
  • H. influenzae (including beta-lactamase-producing strains)
  • M. catarrhalis 5

Efficacy

• High-dose amoxicillin-clavulanate has demonstrated superior bacteriologic eradication rates compared to other antibiotics, with clinical success rates of approximately 90% 5
• Bacteriologic eradication rates with high-dose amoxicillin-clavulanate: 94.2% overall, 96% for S. pneumoniae, and 89.7% for H. influenzae 5

Side Effects Management

• The most common adverse effect is diarrhea
• Twice-daily dosing has fewer gastrointestinal side effects than three-times-daily dosing 4
• Recent research suggests that reduced clavulanate concentrations (2.85 mg/kg/day) may result in less diarrhea while maintaining clinical efficacy 6

Treatment Algorithm

Clinical Scenario	Recommended Treatment
First episode, no recent antibiotics	Amoxicillin 80-90 mg/kg/day divided twice daily
Recent amoxicillin use (within 30 days)	Amoxicillin-clavulanate 90/6.4 mg/kg/day divided twice daily
Recurrent AOM	Amoxicillin-clavulanate 90/6.4 mg/kg/day divided twice daily
Treatment failure with amoxicillin	Amoxicillin-clavulanate 90/6.4 mg/kg/day divided twice daily
Concurrent conjunctivitis	Amoxicillin-clavulanate 90/6.4 mg/kg/day divided twice daily

Important Clinical Pearls

• The twice-daily regimen improves compliance and reduces gastrointestinal side effects compared to three-times-daily dosing 4
• Children under 2 years with bilateral otitis media require immediate antibiotic therapy rather than observation 1
• For patients with penicillin allergy, alternative treatments include cefdinir, cefuroxime, or cefpodoxime for non-Type I allergies, and macrolides or clindamycin for Type I allergies 1
• Tympanic membrane perforation warrants immediate antibiotic therapy regardless of the child's age 1