What is the recommended antibiotic dosage for a child with a bacterial upper respiratory tract infection (URTI)?

Antibiotic Dosage Recommendations for Pediatric Upper Respiratory Tract Infections

Amoxicillin is the first-line antibiotic for bacterial upper respiratory tract infections in children, with a recommended dosage of 45 mg/kg/day divided into two doses or 40 mg/kg/day divided into three doses for mild to moderate infections, and 90 mg/kg/day for severe infections or when drug-resistant pathogens are suspected. 1

First-Line Treatment Options

Amoxicillin Dosing

• For children weighing less than 40 kg with mild/moderate ear, nose, throat, skin, or genitourinary infections: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours 2
• For severe infections or lower respiratory tract infections: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 2
• For areas with high prevalence of penicillin-resistant S. pneumoniae: High-dose amoxicillin (90 mg/kg/day) is recommended 1, 3
• For children under 3 years with suspected bacterial pneumonia: 80-100 mg/kg/day in three daily doses 3

Duration of Therapy

• For acute otitis media: 5 days for uncomplicated cases 1
• For acute bacterial rhinosinusitis: 5-8 days 1
• For streptococcal pharyngitis: Minimum of 10 days to prevent acute rheumatic fever 2

Special Considerations

Age-Specific Recommendations

• For children less than 12 weeks (3 months): Maximum dose of 30 mg/kg/day divided every 12 hours due to incompletely developed renal function 2
• For children 3 months to 5 years: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours 1
• For children over 5 years: Similar dosing as younger children, but with attention to maximum daily doses 3

When to Consider Alternative Antibiotics

• For patients who have received antibiotics in the previous 4-6 weeks: High-dose amoxicillin (90 mg/kg/day) or amoxicillin-clavulanate 1, 3
• For children with insufficient vaccination against H. influenzae type b or with coexistent purulent acute otitis media: Consider amoxicillin-clavulanate (80-90 mg/kg/day of amoxicillin component) 3, 1
• For beta-lactam allergic patients: Alternatives include macrolides (azithromycin 10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5), clindamycin, or cephalosporins if not severely allergic 3, 1

Specific Infections

Acute Otitis Media

• First-line: Amoxicillin 40-45 mg/kg/day divided twice daily 1, 4
• For treatment failure or high-risk cases: Amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 4, 5

Acute Bacterial Rhinosinusitis

• First-line: Amoxicillin 45 mg/kg/day divided twice daily 4, 6
• For high-risk children or treatment failure: High-dose amoxicillin (90 mg/kg/day) or amoxicillin-clavulanate 5, 6

Streptococcal Pharyngitis

• First-line: Penicillin V or amoxicillin 7, 4
• Dosage: Amoxicillin 50-75 mg/kg/day in 2 doses for 10 days 3, 7

Clinical Monitoring

• Evaluate response to therapy after 48-72 hours; lack of improvement may indicate treatment failure requiring change in antibiotic or reevaluation 1, 3
• Treatment should continue for a minimum of 48-72 hours beyond the time that the patient becomes asymptomatic 2

Important Considerations for Administration

• To minimize gastrointestinal intolerance, amoxicillin should be taken at the start of a meal 2
• For oral suspension, shake well before using and refrigeration is preferable but not required 2
• Any unused portion of reconstituted suspension must be discarded after 14 days 2

Dosage Adjustments for Renal Impairment

• For children with severe renal impairment (GFR 10-30 mL/min): 500 mg or 250 mg every 12 hours, depending on infection severity 2
• For children with very severe renal impairment (GFR less than 10 mL/min): 500 mg or 250 mg every 24 hours 2

Remember that many upper respiratory tract infections are viral in origin and do not require antibiotic therapy. Judicious use of antibiotics is essential to prevent the development of antibiotic resistance 3, 7.