What is the recommended dose of Amoxicillin (Amox)-Clavulanate (Clav) for a child?

Amoxicillin-Clavulanate Dosing for Children

For most pediatric infections, use 45 mg/kg/day of amoxicillin divided into 2 doses, but increase to 80-90 mg/kg/day (high-dose) divided into 2 doses for children with risk factors including age <2 years, daycare attendance, recent antibiotic use, or resistant organism concerns. 1, 2

Standard Dosing Regimen

• For children ≥3 months with uncomplicated infections: 45 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses 1
• For neonates and infants <3 months: 30 mg/kg/day divided every 12 hours based on the amoxicillin component 3
• Maximum single dose is 2 grams regardless of weight 2

High-Dose Regimen (80-90 mg/kg/day)

High-dose amoxicillin-clavulanate is indicated when any of the following risk factors are present:

• Age under 2 years 2
• Daycare attendance 1, 2
• Recent antibiotic treatment within the previous 30 days 1, 2
• Areas with high prevalence (>10%) of penicillin-resistant Streptococcus pneumoniae 1, 2
• Moderate to severe illness 2
• Concurrent purulent conjunctivitis (suggests Moraxella catarrhalis) 1
• Pneumonia not responding to amoxicillin alone 1
• Incomplete vaccination against Haemophilus influenzae type b (less than 3 injections) 4

Dosing by Specific Infection

Acute Otitis Media

• Standard risk: 45 mg/kg/day divided into 2 doses 1
• With risk factors: 80-90 mg/kg/day divided into 2 doses 1, 2
• Treatment duration: 10 days 3

Community-Acquired Pneumonia

• Children <3 years: Start with amoxicillin alone at 80-100 mg/kg/day in 3 divided doses 4
• Add clavulanate (80 mg/kg/day amoxicillin component) only if: incomplete H. influenzae type b vaccination OR concurrent purulent otitis media 4
• Children >3 years with presumed bacterial pneumonia: 90 mg/kg/day in 2 doses 2
• Treatment duration: 10 days for bacterial pneumonia 4

Acute Bacterial Sinusitis

• Standard: 45 mg/kg/day divided into 2 doses 1
• With risk factors: 80-90 mg/kg/day divided into 2 doses 1
• Treatment duration: 5-7 days 1

Important Clinical Considerations

• The high-dose formulation provides a 14:1 ratio of amoxicillin to clavulanate, which significantly reduces diarrhea compared to older formulations 1, 2, 5
• The every 12-hour regimen (2 doses daily) is preferred over every 8-hour dosing as it is associated with significantly less diarrhea 3
• Serum amoxicillin levels increase linearly with dose, and the difference in adverse effects between standard and high-dose is generally negligible 2
• Using standard doses when high-dose therapy is indicated leads to treatment failure with resistant organisms 2

Common Pitfalls to Avoid

• Do not substitute two 250 mg/125 mg tablets for one 500 mg/125 mg tablet - they contain different amounts of clavulanate and are not equivalent 3
• Do not use 250 mg/125 mg tablets until the child weighs at least 40 kg due to incorrect amoxicillin:clavulanate ratios 3
• For children weighing ≥40 kg, use adult dosing recommendations 3
• The current recommendation of 40 mg/kg/day is inadequate for resistant S. pneumoniae, particularly during viral coinfection 6