What is the recommended augmented dosing regimen for children with streptococcal (strep) infections who require alternative or increased antibiotic treatment, such as amoxicillin (amoxil) or benzathine penicillin G?

Augmented Dosing for Pediatric Streptococcal Pharyngitis

For children with Group A streptococcal pharyngitis, amoxicillin at 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days is the recommended first-line treatment, with amoxicillin/clavulanate (Augmentin) reserved specifically for treatment failures or chronic carriers at 40 mg/kg/day of the amoxicillin component divided into three doses (maximum 2000 mg/day) for 10 days. 1, 2

First-Line Treatment: Standard Amoxicillin

The Infectious Diseases Society of America (IDSA) establishes amoxicillin as the preferred oral antibiotic for pediatric strep throat, with strong evidence supporting its superiority over penicillin V. 1

Standard Dosing Regimens

• Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 3
• Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 3
• Both regimens demonstrate equivalent efficacy with strong, high-quality evidence 1

Clinical Evidence Supporting Amoxicillin

Research demonstrates that amoxicillin at 40 mg/kg/day achieves significantly higher bacteriologic cure rates (79.3%) compared to standard-dose penicillin V (54.5%), with clinical cure rates of 87.9% versus 70.9% respectively. 4 The improved efficacy likely stems from better compliance with twice-daily dosing and superior pharmacokinetics. 5

When to Use Augmentin (Amoxicillin/Clavulanate)

Augmentin is NOT first-line therapy for uncomplicated strep throat. The American Academy of Family Physicians specifically reserves amoxicillin/clavulanate for two clinical scenarios only: 2

Indications for Augmentin

1. Treatment failures after initial therapy with standard antibiotics 2
2. Chronic Group A Streptococcus carriers who have failed first-line eradication attempts 2

Augmentin Dosing for These Specific Scenarios

• 40 mg/kg/day of amoxicillin component divided into three doses 2
• Maximum daily dose: 2000 mg of amoxicillin component 2
• Duration: 10 days 2
• This represents strong recommendation with moderate-quality evidence 2

Alternative Antibiotics for Penicillin Allergy

For children with documented penicillin allergy, several alternatives exist with varying levels of evidence: 1

First-Generation Cephalosporins (Avoid in Immediate Hypersensitivity)

• Cephalexin: 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days 1
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1
• Both have strong, high-quality evidence 1

For Type I Hypersensitivity Reactions

• Clindamycin: 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 1, 6
  • Alternative dosing: 40 mg/kg/day divided into 3 doses 6
  • Strong recommendation with moderate evidence 1

Macrolides (Use With Caution Due to Resistance)

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
• Clarithromycin: 7.5 mg/kg/dose twice daily (maximum 250 mg/dose) for 10 days 1
• Both carry strong recommendations but only moderate evidence, with known geographic and temporal resistance patterns 1

Critical Clinical Considerations

Mandatory 10-Day Duration

All oral regimens must be completed for 10 full days to prevent acute rheumatic fever, regardless of symptom resolution. 1, 3 This is non-negotiable for Group A Streptococcus infections. 1

Benzathine Penicillin G as Alternative

For situations where compliance cannot be assured (episodic care, poor follow-up, crowded living conditions): 1

• Children <27 kg: 600,000 units intramuscularly as single dose 1
• Children ≥27 kg: 1,200,000 units intramuscularly as single dose 1
• This ensures complete treatment and remains the gold standard for guaranteed compliance 1, 7

Common Pitfalls to Avoid

• Do NOT use Augmentin as first-line therapy - it adds unnecessary cost, side effects (particularly diarrhea), and promotes resistance without improving outcomes in uncomplicated cases 2
• Do NOT use once-daily penicillin V - meta-analysis shows 12 percentage point lower cure rate compared to more frequent dosing 5
• Do NOT prescribe the 875 mg amoxicillin dose for children - pediatric dosing should be weight-based, not fixed-dose tablets 3
• Assess for antibiotic use in previous 4-6 weeks - recent exposure increases risk of resistant organisms 8

Monitoring and Follow-Up

• Evaluate clinical response at 48-72 hours - lack of improvement indicates treatment failure requiring antibiotic change or reevaluation 2, 8
• Consider local resistance patterns when selecting therapy, particularly for macrolides 1, 2
• Treatment should continue minimum 48-72 hours beyond symptom resolution 3