What is the recommended dose of amoxicillin (amoxicillin) for the treatment of otitis media?

Amoxicillin for Otitis Media: Dosing and Treatment Guidelines

High-dose amoxicillin (80-90 mg/kg per day in 2 divided doses) is the recommended first-line treatment for acute otitis media due to its effectiveness against common bacterial pathogens, safety, low cost, and narrow microbiologic spectrum. 1

First-Line Treatment Options

• Amoxicillin at 80-90 mg/kg per day in 2 divided doses is the recommended first-line treatment for most patients with acute otitis media 1
• The high-dose recommendation is based on the need to overcome resistant strains of Streptococcus pneumoniae, which is a common pathogen in otitis media 2, 3
• For children who have taken amoxicillin in the previous 30 days, those with concurrent conjunctivitis, or when coverage for Moraxella catarrhalis is desired, high-dose amoxicillin-clavulanate should be used instead 1
• Amoxicillin-clavulanate should be dosed at 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in a 14:1 ratio, given in 2 divided doses 1, 4

Alternative Treatment Options for Penicillin Allergy

• For patients with non-type I hypersensitivity to penicillin, alternative options include:
  • Cefdinir (14 mg/kg per day in 1 or 2 doses) 1
  • Cefuroxime (30 mg/kg per day in 2 divided doses) 1
  • Cefpodoxime (10 mg/kg per day in 2 divided doses) 1
• Recent data suggest that cross-reactivity between penicillins and second/third-generation cephalosporins is lower than historically reported 1

Treatment After Initial Antibiotic Failure

• If the patient fails to respond to initial treatment within 48-72 hours, reassessment is necessary to confirm the diagnosis and exclude other causes 1
• For patients who fail initial amoxicillin therapy, options include:
  • Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses) 1
  • Ceftriaxone (50 mg IM or IV for 3 days) 1

Important Clinical Considerations

• Pain management should be addressed regardless of antibiotic use, especially during the first 24 hours 1
• The World Health Organization recommends amoxicillin as first choice and amoxicillin-clavulanate as second choice for otitis media 1
• The predominant pathogens isolated from children with AOM failing high-dose amoxicillin therapy are typically beta-lactamase-producing organisms 3

Common Pitfalls and Caveats

• Standard-dose amoxicillin (40 mg/kg/day) is inadequate to effectively eradicate resistant Streptococcus pneumoniae, particularly during viral coinfection 2
• For obese children, there is debate about whether to cap the dose at the standard adult dose (1500 mg/day) or continue with the weight-based dosing 5
• In areas with low prevalence of non-susceptible S. pneumoniae, standard-dose amoxicillin may be sufficient, but this requires local microbiological surveillance 6
• Fluoroquinolones should be avoided for otitis media as they have poor activity against S. pneumoniae 4

Treatment Duration

• The optimal duration of therapy for patients with AOM is typically 10 days, especially for younger children 3
• During treatment, patients may worsen slightly initially but should stabilize within 24 hours and begin improving during the second 24-hour period 1