Amoxicillin-Clavulanate Syrup Dosing in Pediatric Patients
For most pediatric patients aged 3 months and older, use standard-dose amoxicillin-clavulanate at 45 mg/kg/day of the amoxicillin component divided into 2 doses, but escalate to high-dose therapy (90 mg/kg/day with 6.4 mg/kg/day clavulanate in 2 divided doses) for children under 2 years, those attending daycare, recent antibiotic exposure within 30 days, or moderate-to-severe infections. 1, 2
Standard Dosing Regimen
For uncomplicated infections in children ≥3 months and weighing <40 kg: Use 45 mg/kg/day of amoxicillin component divided into 2 doses (or 25 mg/kg/day divided into 3 doses for mild infections). 1, 3
Maximum single dose: 2 grams per dose regardless of weight. 4
The standard formulation provides adequate coverage for β-lactamase producing organisms like Haemophilus influenzae and Moraxella catarrhalis. 1
High-Dose Regimen Indications
Use high-dose amoxicillin-clavulanate (90 mg/kg/day amoxicillin with 6.4 mg/kg/day clavulanate in 2 divided doses) for children with specific risk factors: 4, 1, 2
- Age <2 years - higher risk of resistant pathogens 4
- Daycare attendance - increased exposure to resistant organisms 4, 1, 2
- Recent antibiotic use (within previous 30 days) - selects for resistant bacteria 4, 2
- Moderate to severe illness - requires more aggressive coverage 4, 2
- Geographic areas with >10% penicillin-resistant Streptococcus pneumoniae 4, 1, 2
- Concurrent purulent conjunctivitis - suggests M. catarrhalis involvement 2
- Treatment failure with standard-dose amoxicillin 2, 5
Age-Specific Considerations
For infants <3 months (12 weeks): 3
- Maximum dose is 30 mg/kg/day divided every 12 hours due to immature renal function
- Do not exceed this dose in this age group
For children ≥3 months: 3
- Standard dose: 45 mg/kg/day divided every 12 hours OR 25 mg/kg/day divided every 8 hours
- High dose: 90 mg/kg/day divided every 12 hours for severe infections or resistant organisms
Formulation Advantages
The 14:1 ratio formulation (used in high-dose regimens) causes less diarrhea than other amoxicillin-clavulanate preparations, making it better tolerated. 2
The high-dose formulation achieves middle ear fluid concentrations adequate to overcome penicillin-resistant S. pneumoniae based on acute otitis media data. 4
Duration of Therapy
- Most pediatric respiratory infections: 10 days of treatment 1
- Acute bacterial sinusitis: 10-14 days for children (compared to 5-7 days for adults) 2
- Continue therapy for 7 days after symptom resolution as an alternative approach 1
- Minimum duration: 48-72 hours beyond clinical improvement or bacterial eradication 3
Administration Instructions
- Give at the start of meals to minimize gastrointestinal side effects 3
- Shake suspension well before each use 3
- After reconstitution, discard unused suspension after 14 days 3
- Refrigeration is preferable but not required 3
Common Pitfalls to Avoid
Do NOT use the 875 mg tablet formulation in children with severe renal impairment (GFR <30 mL/min) - use 500 mg or 250 mg dosing instead 3
Do NOT underdose in high-risk situations - using standard doses when high-dose therapy is indicated leads to treatment failure with resistant organisms 4, 5
Avoid confusion between total daily dose and per-dose amount - the 90 mg/kg/day is divided into 2 doses, meaning 45 mg/kg per individual dose 1