What is the treatment protocol for severe bacterial infections using Augmentin (amoxicillin-clavulanate) IV?

Augmentin IV Treatment Protocol for Severe Bacterial Infections

For severe bacterial infections requiring intravenous therapy, administer Augmentin (co-amoxiclav) at 30 mg/kg every 8 hours, with the dose doubled to 60 mg/kg every 8 hours (maximum 4 g/day) in severe infections, particularly for community-acquired pneumonia, intra-abdominal infections, and complicated skin/soft tissue infections. 1

Dosing by Age and Severity

Pediatric Dosing (1 month to 18 years)

• Standard severe infections: 30 mg/kg IV every 8 hours 1
• Life-threatening infections: 60 mg/kg IV every 8 hours (maximum 4 g/day) 1
• Children >3 months with severe infections: Frequency can be increased to every 6 hours (4 times daily) 1

Adult Dosing (12-18 years and older)

• Standard regimen: 1.2 g IV every 8 hours 1
• Severe infections: Can be administered every 6 hours 1

Primary Indications for IV Augmentin

Community-Acquired Pneumonia

• Use when oral therapy is not tolerated or in severe disease with hypoxemia, respiratory rates ≥70 breaths/min in infants, or significant chest recession 1
• Duration: 7-10 days, may extend to 14 days based on clinical response 1

Intra-Abdominal Infections

• Mild to moderate community-acquired IAI: Augmentin provides adequate coverage for mixed aerobic-anaerobic infections 1
• Severe IAI: Consider 30 mg/kg every 6 hours (4 times daily) for enhanced coverage 1
• Duration: 5-7 days after adequate source control 1

Complicated Skin and Soft Tissue Infections

• Particularly effective for polymicrobial infections including animal/human bites and contaminated traumatic wounds 2, 3
• First-line for infections involving axilla or perineum 1

Critical Administration Principles

Timing and Loading

• Sepsis/septic shock: Administer within 1 hour of recognition 1
• Loading dose: Use higher initial doses in critically ill patients due to "third spacing phenomenon" affecting hydrophilic beta-lactams 1

Infusion Strategy

• Extended infusion: Consider prolonged infusion over 3 hours for beta-lactam antibiotics to maximize time above MIC, particularly in severe infections 1
• Standard infusion: Over 30-60 minutes 4

Administration with Food

• When transitioning to oral therapy, administer with meals to reduce gastrointestinal upset 4

Duration of Therapy

Standard Durations

• Respiratory tract infections: 7-10 days, up to 14 days if slow clinical response 1
• Intra-abdominal infections: 3-7 days after adequate source control in stable patients 1
• Bacteremia: 7-14 days depending on source 1

Transition to Oral Therapy

• Switch to oral formulation (same total daily dose) when patient demonstrates clinical improvement, can tolerate oral intake, and hemodynamically stable 1
• Typical transition occurs after 3 days of IV therapy 5

Resistance Considerations and Limitations

Appropriate Use

• Effective against beta-lactamase-producing organisms including H. influenzae, M. catarrhalis, and many Enterobacteriaceae 6
• NOT appropriate for: ESBL-producing organisms (use carbapenems instead), carbapenem-resistant Enterobacteriaceae, or MRSA 1

When to Avoid or Escalate

• Do not use as empirical monotherapy for nosocomial infections in critically ill patients 1
• Escalate to carbapenems if patient has known ESBL colonization within 3 months AND presents with severe sepsis/septic shock 1
• Consider alternatives for hospital-acquired infections with prior third-generation cephalosporin or fluoroquinolone exposure in last 3 months 1

Common Pitfalls to Avoid

Dosing Errors

• Do not underdose: In severe infections, failure to double the standard dose (from 30 to 60 mg/kg) may lead to treatment failure 1
• Maximum daily dose: Do not exceed 4 g/day total amoxicillin component 1

Inappropriate Spectrum

• Avoid for suspected Pseudomonas infections—Augmentin lacks anti-pseudomonal activity 1
• Do not use for vancomycin-resistant enterococci—requires linezolid or daptomycin 1

Duration Mistakes

• Do not continue beyond 5-7 days without reassessing for uncontrolled source or treatment failure 1
• Avoid prolonged courses without documented indication, as this drives resistance 1

Monitoring and De-escalation

Clinical Assessment

• Evaluate for improvement within 48-72 hours 1
• If no improvement by 48 hours, consider diagnostic workup for alternative diagnosis or resistant pathogen 1

Culture-Directed Therapy

• Narrow to targeted therapy once culture results available 1
• Discontinue if cultures negative and clinical improvement evident 1

Adverse Effects and Tolerance

Common Side Effects

• Gastrointestinal upset (vomiting, diarrhea) occurs in minority of patients 5, 7
• Local IV site reactions are rare with proper administration 5, 7
• Overall tolerance is excellent even at high doses up to 1.0 g/day clavulanic acid 8

Serious Reactions

• Monitor for Clostridioides difficile infection if diarrhea develops, especially if severe or persists >2-3 days 4
• Discontinue if allergic reaction occurs (penicillin-class hypersensitivity) 4