Augmentin Dosing for Adult Ear Infections
For adults with acute otitis media, prescribe Augmentin (amoxicillin-clavulanate) 875 mg/125 mg orally twice daily for 5-10 days, reserving this as second-line therapy after amoxicillin failure or as first-line in high-risk patients with recent antibiotic exposure. 1, 2
When to Use Augmentin vs. Plain Amoxicillin
Amoxicillin alone (1.5-4 g/day) should be first-line for uncomplicated acute otitis media due to its effectiveness, safety, cost, and narrow spectrum. 1 However, Augmentin is preferred as initial therapy in the following situations:
- Recent antibiotic use (within the past 4-6 weeks) 3, 1
- Treatment failure after 72 hours of amoxicillin therapy 3, 1
- Moderate to severe infection with high fever (≥39°C/102°F) or systemic toxicity 3
- High-risk patients: age >65 years, diabetes, chronic cardiac/hepatic/renal disease, immunocompromised 3
- Geographic areas with high resistance rates (>10% penicillin-nonsusceptible S. pneumoniae) 3
- Close contact with healthcare environments or daycare facilities 3
Specific Dosing Regimens
Standard-Dose Augmentin
- 875 mg/125 mg orally twice daily (preferred for respiratory infections) 2
- Alternative: 500 mg/125 mg orally three times daily 2
High-Dose Augmentin (for resistant pathogens)
- 2000 mg/125 mg (Augmentin XR) orally twice daily for patients at high risk of resistant organisms 3, 4
- This high-dose formulation provides enhanced coverage against penicillin-nonsusceptible S. pneumoniae 3, 4
Important caveat: Two 250 mg/125 mg tablets should NOT be substituted for one 500 mg/125 mg tablet, as both contain the same amount of clavulanic acid (125 mg), making them non-equivalent. 2
Treatment Duration
- 5-7 days for uncomplicated cases in adults 3
- 10 days is the traditional duration studied in most trials 3, 1
- Reassess at 48-72 hours if no clinical improvement occurs 3, 1
The shorter 5-7 day course shows equivalent efficacy to 10-14 day courses in systematic reviews, with similar resolution rates. 3
Penicillin Allergy Alternatives
For patients with non-type I penicillin allergy:
- Cefdinir 300 mg twice daily or 600 mg once daily 1
- Cefuroxime axetil 500 mg twice daily 1
- Cefpodoxime proxetil 1
For patients with immediate Type I hypersensitivity:
- Doxycycline 3
- Respiratory fluoroquinolones (levofloxacin or moxifloxacin) 3
- Note: Macrolides have limited effectiveness due to >40% resistance rates in S. pneumoniae 3
Renal Impairment Adjustments
- GFR <30 mL/min: Do NOT use 875 mg/125 mg dose 2
- GFR 10-30 mL/min: 500 mg/125 mg or 250 mg/125 mg every 12 hours 2
- GFR <10 mL/min: 500 mg/125 mg or 250 mg/125 mg every 24 hours 2
- Hemodialysis: 500 mg/125 mg or 250 mg/125 mg every 24 hours, with additional dose during and after dialysis 2
When to Switch Therapy
Change antibiotics if symptoms worsen or fail to improve after 48-72 hours of initial therapy. 3, 1 This indicates either:
- Resistant pathogen requiring broader coverage 3
- Non-bacterial etiology requiring diagnostic reevaluation 3
- Need for high-dose formulation if not already prescribed 3
Adjunctive Therapies
Recommended adjuncts:
- Intranasal saline irrigation (physiologic or hypertonic) 3
- Intranasal corticosteroids, especially in patients with allergic rhinitis history 3
NOT recommended:
Common Pitfalls to Avoid
- Do not routinely cover MRSA in initial empiric therapy—current data does not support this approach 3
- Avoid macrolides and trimethoprim-sulfamethoxazole as first-line due to high resistance rates (>40% and 50% respectively) 3
- Monitor for gastrointestinal side effects, particularly diarrhea, which is more common with Augmentin than amoxicillin alone but rarely requires discontinuation 4, 5
- Ensure adequate dosing in viral coinfection scenarios, as viral presence may reduce middle ear fluid antibiotic penetration 6