What is the recommended dosing for Augmentin (amoxicillin-clavulanate) for the treatment of bacterial tonsillitis?

Augmentin Dosing for Tonsillitis

For bacterial tonsillitis (Group A Streptococcal pharyngitis), standard-dose amoxicillin alone is preferred first-line therapy at 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days, while Augmentin (amoxicillin-clavulanate) is reserved for treatment failures or chronic carriers at 40 mg amoxicillin/kg/day divided into three doses (maximum 2,000 mg amoxicillin per day) for 10 days. 1

First-Line Treatment Approach

• Amoxicillin alone is the preferred initial treatment for Group A Streptococcal tonsillopharyngitis, not Augmentin 2, 1
• Penicillin V (250 mg 2-3 times daily for children <27 kg; 500 mg 2-3 times daily for children ≥27 kg and adults) for 10 days is an acceptable alternative 2
• The addition of clavulanate does not improve outcomes for uncomplicated streptococcal pharyngitis and unnecessarily increases cost and side effects 2

When to Use Augmentin for Tonsillitis

Augmentin should be reserved for specific clinical scenarios:

• Treatment failures after initial amoxicillin or penicillin therapy 1
• Chronic carriers of Group A Streptococcus who have failed first-line therapy 1
• Suspected polymicrobial infection or when beta-lactamase producing organisms are a concern 3

Augmentin Dosing Regimens

Pediatric Dosing

• Standard dose: 40 mg amoxicillin/kg/day divided into three doses (maximum 2,000 mg amoxicillin per day) for 10 days 1
• Alternative twice-daily dosing: 45 mg amoxicillin/6.4 mg clavulanate per kg/day divided into two doses for 7-10 days 4
• High-dose formulation (Augmentin ES-600): 90 mg amoxicillin/6.4 mg clavulanate per kg/day divided into two doses (14:1 ratio) - this formulation was developed primarily for otitis media with resistant organisms, not routine tonsillitis 5, 6
• Maximum daily dose: Do not exceed 2,000 mg of amoxicillin component per day, regardless of weight 1

Adult Dosing

• Standard dose: 500 mg three times daily or 875 mg twice daily for 10 days 3
• Duration should be 10 days to ensure adequate eradication and prevent rheumatic fever 2

Important Clinical Considerations

Treatment Duration

• Complete the full 10-day course even if symptoms resolve earlier to prevent recurrence, complications, and rheumatic fever 2, 1
• This differs from sinusitis, where shorter courses (5-7 days in adults) may be acceptable 2

Monitoring and Follow-Up

• Assess response after 72 hours - if symptoms worsen or fail to improve, consider treatment failure 1
• For treatment failures, switch to an alternative agent rather than continuing the same antibiotic 1

Common Pitfalls to Avoid

• Do not use Augmentin as first-line therapy for uncomplicated streptococcal pharyngitis - this promotes unnecessary antibiotic resistance and increases gastrointestinal side effects 2, 1
• Diarrhea is more common with three-times-daily dosing (10.7%) compared to twice-daily dosing (7.2%), so consider twice-daily formulations when appropriate 4
• Do not use macrolides (azithromycin, clarithromycin) in areas with high macrolide resistance - studies show only 14-19% eradication of clarithromycin-resistant Group A Streptococcus 7
• Compliance is better with twice-daily dosing (82.8%) versus three-times-daily dosing (73.3%) 4

Penicillin Allergy Alternatives

If Augmentin cannot be used due to penicillin allergy:

• Cephalexin (narrow-spectrum cephalosporin) for 10 days - avoid in immediate (Type I) hypersensitivity 2, 1
• Clindamycin 20 mg/kg/day divided in 3 doses (maximum 1.8 g/day) for 10 days 2
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 2
• Clarithromycin 15 mg/kg/day divided twice daily (maximum 250 mg twice daily) for 10 days 2

Note that macrolides have higher bacteriologic failure rates (20-25%) and should be used cautiously in areas with known resistance 2, 7