Maximum Dose of Amoxicillin for Acute Otitis Media
The maximum dose of amoxicillin for acute otitis media is 90 mg/kg/day divided into two doses. 1, 2
First-line Treatment Recommendations
- High-dose amoxicillin (80-90 mg/kg/day divided in 2 doses) is recommended as the first-line treatment for most pediatric patients with acute otitis media (AOM) 1, 2
- This high-dose regimen is effective against common AOM bacterial pathogens, particularly Streptococcus pneumoniae, due to its safety, low cost, acceptable taste, and narrow microbiologic spectrum 2
- 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, 2
Special Populations Requiring Alternative Treatment
- 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, 2, 3
- 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, 2
- 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, 2
Rationale for High-Dose Amoxicillin
- The higher dose (80-90 mg/kg/day) is recommended over the conventional dose (40 mg/kg/day) due to increasing prevalence of penicillin-resistant Streptococcus pneumoniae 1, 4
- Studies have shown that the conventional dosing recommendation of 40 mg/kg/day in three divided doses is inadequate to effectively eradicate resistant S. pneumoniae, particularly during viral coinfection 5
- High-dose amoxicillin has demonstrated superior bacteriologic and clinical efficacy compared to standard dosing, with eradication achieved in 92% of S. pneumoniae infections 4
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, 2
- Alternatively, ceftriaxone (50 mg IM or IV for 3 days) may be used for treatment failures 1, 2
- Beta-lactamase-producing organisms (particularly H. influenzae) are the predominant pathogens isolated from children failing high-dose amoxicillin therapy 4
Common Pitfalls and Caveats
- Inadequate dosing is a common pitfall when treating potentially resistant organisms; ensure the full 80-90 mg/kg/day dose is used 6
- The duration of treatment for a first episode of AOM should be 10 days, particularly in children under 2 years of age 7
- When using amoxicillin-clavulanate, the 14:1 ratio formulation is less likely to cause diarrhea than other amoxicillin-clavulanate preparations 1, 6
- Different formulations of amoxicillin-clavulanate are not interchangeable due to varying amounts of clavulanic acid 8