Co-Amoxiclav Dosing for Pneumonia
For pediatric community-acquired pneumonia, use amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component divided into 2 doses (maximum 4000 mg/day), while for adults, use the pharmacokinetically enhanced formulation of 2000/125 mg twice daily for 7-10 days. 1, 2
Pediatric Dosing
Standard High-Dose Regimen
- The American Academy of Pediatrics recommends 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate divided into 2 doses for all children with community-acquired pneumonia. 1, 2
- This provides a 14:1 ratio of amoxicillin to clavulanate, which is the preferred formulation for respiratory infections. 1
- The maximum daily dose is 4000 mg of amoxicillin per day regardless of weight. 1
Age-Specific Considerations
- Children under 5 years with presumed bacterial pneumonia should receive 90 mg/kg/day in 2 divided doses. 2
- Children 5 years and older should receive the same 90 mg/kg/day in 2 divided doses (maximum 4 g/day). 2
- For children with incomplete Haemophilus influenzae type b vaccination or concurrent purulent otitis media, amoxicillin-clavulanate with 80-90 mg/kg/day of the amoxicillin component is indicated. 1
Practical Suspension Dosing by Age
- Children 1-12 months: 2.5 ml of 125/31 suspension three times daily. 1
- Children 1-6 years: 5 ml of 125/31 suspension three times daily. 1
- Children 7-12 years: 5 ml of 250/62 suspension three times daily. 1
- Adolescents 12-18 years: 1 tablet (250/125) three times daily. 1
Critical pitfall: Always verify the suspension concentration (125/31 vs 250/62) before calculating volume to avoid dosing errors. 1
Treatment Duration
- The Infectious Diseases Society of America recommends 10 days of treatment for bacterial pneumonia in children. 1, 2
- Clinical improvement should occur within 48-72 hours; if not, reassess the diagnosis and consider alternative antibiotics. 3, 2
Adult Dosing
Outpatient Community-Acquired Pneumonia
- For adults with CAP requiring amoxicillin-clavulanate, the pharmacokinetically enhanced formulation of 2000/125 mg twice daily is superior to standard dosing. 4, 5
- This formulation achieves higher serum concentrations of amoxicillin over the 12-hour dosing interval to eradicate Streptococcus pneumoniae with MICs up to 4 mg/L. 4, 5
- Standard dosing of 875/125 mg three times daily is an alternative but provides lower amoxicillin exposure. 4
Treatment Duration
- Treat for 7-10 days based on clinical response. 4, 5
- The pharmacokinetically enhanced formulation demonstrated 94.7% clinical success at follow-up compared to 88.8% with standard dosing. 4
Evidence Supporting High-Dose Formulations
- The 2000/125 mg twice-daily formulation was at least as effective clinically as 875/125 mg three times daily, with clinical success rates of 91.5% vs 93.0%. 5
- This formulation successfully treated penicillin-resistant S. pneumoniae (PRSP) with amoxicillin MICs of 8 mg/L in all three cases studied. 4
- Twice-daily dosing improves adherence compared to three-times-daily regimens. 3
Important Clinical Considerations
When Co-Amoxiclav is NOT First-Line
- The American Thoracic Society/IDSA guidelines recommend amoxicillin alone (1 g every 8 hours) as first-line for adults without comorbidities, NOT co-amoxiclav. 6
- Co-amoxiclav is reserved for patients with comorbidities or when β-lactamase-producing organisms (H. influenzae, M. catarrhalis) are suspected. 6, 2
Monitoring and Safety
- Both pediatric and adult formulations are well tolerated, with diarrhea being the most common adverse effect (8.6% in adults, similar rates in children). 1, 7
- The 14:1 ratio formulation causes less diarrhea than other amoxicillin-clavulanate preparations while maintaining efficacy. 1
- Complete the full prescribed course even if symptoms improve before completion. 3, 2