Amoxicillin-Clavulanate Dosing for Children
For children with respiratory infections requiring amoxicillin-clavulanate, the recommended high-dose regimen is 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two divided doses. 1
Standard Dosing Options
- For children with uncomplicated infections, standard dose is 45 mg/kg/day of amoxicillin with appropriate clavulanate divided into 2-3 doses 2
- For mild to moderate infections, 25 mg/kg/day of amoxicillin in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours 3
- For severe infections, 45 mg/kg/day of amoxicillin in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours 3
High-Dose Regimen Indications
High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two divided doses) is recommended for children with:
- Age under 2 years 2
- Attendance at daycare 4, 2
- Recent antibiotic treatment within previous 30 days 4
- Suspected or confirmed beta-lactamase producing organisms 1
- Areas with high prevalence of penicillin-resistant Streptococcus pneumoniae (>10%) 4
- Moderate to severe infections 2
- Concurrent conjunctivitis 4
- Coverage for Moraxella catarrhalis is desired 4
Special Considerations
Age-Specific Dosing
- 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 3
- For children with severe renal impairment (GFR <30 mL/min): Dose adjustment required 3
Duration of Therapy
- Minimum treatment duration of 10 days for infections caused by Streptococcus pyogenes to prevent acute rheumatic fever 3
- Continue treatment for 48-72 hours beyond resolution of symptoms 3
- For most pediatric infections, a 10-day course is recommended 1
Efficacy and Pharmacokinetics
- High-dose amoxicillin-clavulanate (90/6.4 mg/kg/day) has demonstrated 96% eradication rate for common bacterial pathogens in acute otitis media 5
- Even for penicillin-resistant S. pneumoniae (MICs 2-4 μg/ml), high-dose regimen achieved 91% eradication 5
- Standard amoxicillin dosing (40 mg/kg/day) may be inadequate for resistant organisms, particularly during viral coinfection 6
- Twice-daily dosing has similar efficacy to three-times-daily dosing and may improve compliance 7
Adverse Effects
- Most common adverse effects include diarrhea, nausea, vomiting, and rash 1
- Diarrhea is generally less frequent with twice-daily than with three-times-daily treatment 8
- The 14:1 ratio of amoxicillin to clavulanate in the high-dose formulation is less likely to cause diarrhea than other amoxicillin-clavulanate preparations 4
Clinical Pearl
When using amoxicillin-clavulanate suspension, it's important to:
- Reconstitute properly according to package instructions 3
- Shake well before each use 3
- Store in refrigerator when possible 3
- Discard any unused portion after 14 days 3
The high-dose formulation (90/6.4 mg/kg/day) is particularly valuable for treating infections likely caused by resistant organisms, and should be considered first-line when risk factors for resistance are present 8, 5.