Amoxicillin Dosing for Pediatric Otitis Media
The recommended dose of amoxicillin for pediatric patients with acute otitis media is 80-90 mg/kg per day in 2 divided doses. 1
First-line Treatment
- High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is the recommended first-line treatment for most pediatric patients with acute otitis media (AOM) 1
- This dosing recommendation is based on amoxicillin's effectiveness against common AOM bacterial pathogens, particularly Streptococcus pneumoniae, as well as its safety, low cost, acceptable taste, and narrow microbiologic spectrum 1
- High-dose amoxicillin achieves middle ear fluid levels that exceed the minimum inhibitory concentration (MIC) of intermediately resistant S. pneumoniae and many highly resistant serotypes for a longer period of the dosing interval 1
Special Considerations
- For children who have taken amoxicillin in the previous 30 days, those with concurrent conjunctivitis, or those for whom coverage for Moraxella catarrhalis is desired, therapy should be initiated with high-dose amoxicillin-clavulanate 1
- The recommended dose for amoxicillin-clavulanate is 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate (amoxicillin to clavulanate ratio of 14:1) in 2 divided doses 1
- For penicillin-allergic children, alternative treatments include cefdinir (14 mg/kg/day in 1 or 2 doses), cefuroxime (30 mg/kg/day in 2 divided doses), or cefpodoxime (10 mg/kg/day in 2 divided doses) 1
Treatment Duration
- The duration of therapy studied and recommended for acute otitis media is 10 days 2
- If a patient fails to respond to the initial treatment within 48-72 hours, the clinician should reassess the patient to confirm AOM and consider changing the antibiotic 1
Treatment Failure Management
- If initial treatment with amoxicillin fails after 48-72 hours, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1
- Alternatively, ceftriaxone (50 mg IM or IV for 3 days) may be used for treatment failures 1
- Beta-lactamase-producing organisms (particularly Haemophilus influenzae) are the predominant pathogens isolated from children with AOM failing high-dose amoxicillin therapy 3
Clinical Pearls and Pitfalls
- The standard adult dose of amoxicillin (1500 mg/day) may be exceeded when using weight-based dosing in overweight children. In such cases, some clinicians cap the dose at the standard adult maximum, while others maintain the weight-based dosing 4
- In areas with low prevalence of non-susceptible S. pneumoniae, standard-dose amoxicillin (40-45 mg/kg/day) may be sufficient for uncomplicated AOM, but high-dose remains the recommended approach in most guidelines 5
- Viral co-infection in AOM may reduce the antibacterial efficacy of antibiotics and may require higher dosing of amoxicillin 6
- Observation without antibiotics is an option for selected children based on diagnostic certainty, age, illness severity, and assurance of follow-up 1
High-dose amoxicillin remains the cornerstone of AOM treatment in pediatric patients due to its proven efficacy against resistant pathogens and favorable safety profile 1, 7.