What is the recommended dose of Augmentin (amoxicillin-clavulanate) for pediatric patients?

Augmentin Dosing for Pediatric Patients

For most pediatric respiratory tract infections, use high-dose amoxicillin-clavulanate at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses daily (maximum 4000 mg/day), which provides the 14:1 ratio formulation that optimally covers β-lactamase-producing organisms and penicillin-resistant Streptococcus pneumoniae. 1

Standard High-Dose Regimen (Preferred for Most Infections)

The high-dose regimen is now considered standard therapy rather than exceptional, particularly in areas with >10% prevalence of penicillin-resistant S. pneumoniae and for children with specific risk factors. 1

• Dosing: 90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate in 2 divided doses 1, 2
• Maximum single dose: 2 grams regardless of weight 1, 2
• Formulation advantage: The 14:1 ratio causes significantly less diarrhea than older formulations while maintaining superior efficacy 1

High-Dose Indications (Use This for Most Patients)

High-dose therapy is indicated for children with ANY of these risk factors:

• Age <2 years 1, 2
• Daycare attendance 1, 2
• Recent antibiotic use (within past 30 days) 1, 2
• Moderate to severe illness 1, 2
• Incomplete Haemophilus influenzae type b vaccination (<3 injections) 1
• Geographic areas with high penicillin-resistant S. pneumoniae prevalence (>10%) 1

Alternative Standard-Dose Regimen (Limited Use)

Use this lower dose ONLY for mild infections in fully vaccinated children >2 years without recent antibiotic exposure:

• Dosing: 45 mg/kg/day amoxicillin component in 3 divided doses 1, 2
• Critical warning: This dose is inadequate for β-lactamase-producing organisms and resistant S. pneumoniae, leading to treatment failure 1

Age-Based Volume Dosing for Oral Suspension

When using pre-mixed suspensions (less precise than weight-based dosing):

• <1 year (1-12 months): 2.5 mL of 125/31 suspension three times daily 1, 2
• 1-6 years: 5 mL of 125/31 suspension three times daily 1, 2
• 7-12 years: 5 mL of 250/62 suspension three times daily 1, 2
• 12-18 years: 1 tablet (250/125) three times daily 1, 2

Critical pitfall: Always verify suspension concentration (125/31 vs 250/62) before calculating volume to avoid dangerous dosing errors. 1

Specific Infection-Based Dosing

Community-Acquired Pneumonia

• Children <5 years (outpatient): 90 mg/kg/day amoxicillin component in 2 doses 1, 2
• Children <3 years with incomplete Hib vaccination OR concurrent purulent otitis media: 80-100 mg/kg/day amoxicillin component in 3 divided doses 1
• Duration: 10 days for bacterial pneumonia 1, 2

β-Lactamase-Producing H. influenzae

• Dosing: 45 mg/kg/day in 3 doses OR 90 mg/kg/day in 2 doses 3, 1
• Rationale: The clavulanate component specifically inhibits β-lactamase enzymes, making this the definitive choice over amoxicillin alone 3

Severe Infections Requiring IV Therapy

• All pediatric ages: 30 mg/kg three times daily IV 1, 2
• Example: For an 18 kg child, this equals 540 mg IV three times daily 1

Treatment Duration

• Most pediatric infections: 10 days 1
• Alternative approach: Continue for 7 days after patient becomes symptom-free 1
• Bacterial pneumonia: 10 days (firm recommendation) 1, 2

Critical Pharmacokinetic Considerations

The high-dose regimen achieves middle ear fluid concentrations of approximately 9.5 mcg/mL, which exceeds the MIC for penicillin-intermediate S. pneumoniae (MIC ≤2 mg/L). 4, 5

• Amoxicillin serum levels increase linearly with dose 1, 2
• The difference in adverse effects between standard and high-dose is negligible 1, 2
• Twice-daily dosing improves compliance (82.8% vs 73.3% for three-times-daily) and reduces diarrhea (7.2% vs 10.7%) 6

Common Pitfalls to Avoid

1. Underdosing catastrophe: Using 40-45 mg/kg/day when high-dose is indicated leads to inevitable treatment failure with resistant organisms and promotes antimicrobial resistance 1

2. Viral infection mismanagement: Most upper respiratory tract infections are viral and do not require antibiotics at all—ensure bacterial infection criteria are met before prescribing 1

3. Viral co-infection reduces efficacy: Amoxicillin MEF penetration is significantly lower during viral co-infection (geometric mean 2.7 mcg/mL vs 5.7 mcg/mL for bacterial-only infection), making high-dose therapy even more critical 5

4. Suspension concentration errors: Always verify whether you're using 125/31 or 250/62 suspension before calculating volume 1

Adverse Effects Profile

• Most common: Diarrhea, nausea, vomiting, rash 1
• Incidence: Low overall adverse event rate of 3.6% in large postmarketing studies 4
• Formulation advantage: The 14:1 ratio high-dose formulation causes less diarrhea than older preparations 1
• Tolerability: High-dose (90/6.4 mg/kg/day) shows similar tolerability to standard-dose (45/6.4 mg/kg/day) in controlled trials 4