Recommended Amoxicillin Dosing for Acute Otitis Media in Pediatric Patients
The recommended dose of amoxicillin for treatment of Acute Otitis Media (AOM) in pediatric patients is 80-90 mg/kg/day divided into two doses (every 12 hours). 1
Dosing Guidelines Based on Age
Infants Under 12 Weeks (<3 Months)
- 30 mg/kg/day divided every 12 hours 2
- Use of 125 mg/5 mL oral suspension is recommended for this age group
Children 12 Weeks (3 Months) and Older
- For AOM: 45 mg/kg/day every 12 hours (90 mg/kg/day total) 2
- Alternative dosing: 40 mg/kg/day every 8 hours (for three times daily dosing) 2
- The twice-daily regimen is preferred as it is associated with significantly less diarrhea
Children Weighing 40 kg or More
- Should be dosed according to adult recommendations 2
- Standard adult dose: 500 mg every 12 hours or 250 mg every 8 hours
- For more severe infections: 875 mg every 12 hours or 500 mg every 8 hours
Rationale for High-Dose Amoxicillin
The American Academy of Family Physicians recommends high-dose amoxicillin (80-90 mg/kg/day) as first-line therapy for AOM because it is:
- Effective against susceptible and intermediate-resistant pneumococci 1
- Safe and well-tolerated
- Inexpensive
- Has acceptable taste for pediatric patients
High-dose amoxicillin is particularly important in areas with high prevalence of drug-resistant Streptococcus pneumoniae. The higher dosage provides adequate coverage against penicillin-resistant S. pneumoniae while maintaining effectiveness against other common pathogens 3.
Duration of Therapy
- The recommended duration of therapy for AOM is 10 days 2
Alternative Antibiotics
For patients with penicillin allergy or treatment failure:
- Non-type I hypersensitivity reactions: cefdinir, cefpodoxime, or cefuroxime 1
- For beta-lactamase-producing organisms: amoxicillin-clavulanate (90 mg/kg/day based on amoxicillin component) 3, 4
Treatment Failure Considerations
- Reassess patients within 48-72 hours if symptoms are not improving 1
- Treatment failure is defined as worsening condition, persistence of symptoms for >48 hours after starting antibiotics, or recurrence within 4 days of completing treatment 1
- Beta-lactamase-producing H. influenzae is the predominant pathogen in children failing high-dose amoxicillin therapy 4
Special Considerations
- For patients with renal impairment, dose adjustment may be necessary 2
- Consider watchful waiting approach for low-risk children ≥2 years with mild symptoms 1
- Immediate antibiotic therapy is recommended for:
- Children under 2 years of age
- Patients with severe symptoms
- Bilateral AOM
- Tympanic membrane perforation with otorrhea 1
Clinical Pearl
While some studies have questioned whether high-dose amoxicillin is necessary in all regions 5, 6, the current consensus from major guidelines supports high-dose amoxicillin (80-90 mg/kg/day) as the first-line treatment for AOM in pediatric patients to ensure coverage against potentially resistant organisms.