What is the recommended dose of amoxicillin-clavulanate (Augmentin) for preseptal cellulitis in children?

Recommended Dose of Amoxicillin-Clavulanate for Preseptal Cellulitis in Children

For pediatric preseptal cellulitis, use high-dose amoxicillin-clavulanate at 80-90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses (maximum 2000 mg per dose), for 10-14 days. 1

Dosing Specifics by Age

Neonates and Infants <12 Weeks

• Use 30 mg/kg/day divided every 12 hours based on the amoxicillin component 2
• The 125 mg/5 mL oral suspension is recommended for this age group 2

Infants and Children ≥12 Weeks (3 Months) and Older

• High-dose regimen: 80-90 mg/kg/day of amoxicillin component in 2 divided doses 1
• This translates to 45 mg/kg/day every 12 hours using the 200 mg/5 mL or 400 mg/5 mL formulations 2
• Maximum dose: 2000 mg amoxicillin per dose 1
• The every 12-hour regimen is preferred as it causes significantly less diarrhea 2

Children Weighing ≥40 kg

• Dose according to adult recommendations: 875 mg/125 mg tablet every 12 hours 2
• Do not use the 250 mg/125 mg tablets until the child weighs at least 40 kg due to different amoxicillin-to-clavulanate ratios 2

Rationale for High-Dose Formulation

The high-dose formulation is critical because it provides adequate coverage against beta-lactamase producing organisms, particularly Moraxella catarrhalis and resistant Haemophilus influenzae, which are common causative pathogens in preseptal cellulitis. 1

• Standard-dose amoxicillin alone should NOT be used for preseptal cellulitis as it lacks coverage against beta-lactamase producing organisms 1
• The high-dose formulation (14:1 ratio of amoxicillin to clavulanate) provides enhanced activity while minimizing gastrointestinal side effects from clavulanate 3

High-Risk Populations Requiring High-Dose Therapy

High-dose amoxicillin-clavulanate is particularly important for: 1

• Children <2 years of age
• Children attending daycare
• Children with recent antibiotic use within the past 4-6 weeks
• Moderate to severe infections

Duration of Treatment

• Continue treatment for 10-14 days total 1
• Some experts recommend continuing until the patient has been symptom-free for 7 days 4
• Assess clinical response after 48-72 hours 1

Alternative Regimens for Special Situations

For Children Unable to Tolerate Oral Medication

• Give a single dose of ceftriaxone 50 mg/kg IV or IM initially 1
• Follow with oral amoxicillin-clavulanate to complete the course 1

For True Penicillin Allergy

• Clindamycin 30-40 mg/kg/day divided into 3-4 doses 1
• For severe infections with MRSA concerns, consider linezolid or infectious disease consultation 1

For Young Children with Upper Respiratory Symptoms

• Children <36 months with associated upper respiratory tract infections and otitis are at higher risk for Haemophilus influenzae bacteremia 5
• These patients require antibiotic coverage for Haemophilus and should receive high-dose amoxicillin-clavulanate 5

Administration Recommendations

• Administer at the start of meals to enhance clavulanate absorption and minimize gastrointestinal intolerance 2
• May be taken without regard to meals, but starting with meals is preferred 2

Monitoring and Red Flags

Evaluate for clinical improvement within 48-72 hours of starting therapy. 1

Watch for signs indicating progression to orbital cellulitis requiring immediate hospitalization and IV antibiotics: 1

• Proptosis (eye bulging)
• Limited eye movement
• Vision changes
• Ophthalmoplegia

If symptoms worsen or fail to improve after 72 hours: 1

• Consider CT imaging to rule out complications or orbital involvement
• Reassess diagnosis and consider alternative pathogens

Common Pitfalls and Caveats

Critical Dosing Errors to Avoid

Underdosing the amoxicillin component is the most common mistake in treating preseptal cellulitis. 1

• Do NOT substitute two 250 mg/125 mg tablets for one 500 mg/125 mg tablet—they contain the same amount of clavulanate but different amounts of amoxicillin 2
• The 250 mg/125 mg tablet and 250 mg/62.5 mg chewable tablet are NOT interchangeable 2
• Standard-dose amoxicillin (40-50 mg/kg/day) is inadequate for preseptal cellulitis 1

Regional Resistance Patterns

• Be aware of local antibiotic susceptibility patterns when selecting therapy 1
• In regions with high penicillin resistance in invasive pneumococcal strains, consider alternative agents 4

Age-Specific Considerations

• For children <5 years who are inadequately vaccinated against Haemophilus influenzae type b, high-dose amoxicillin-clavulanate or second/third-generation cephalosporins are justified 4
• Young children with preseptal cellulitis and concurrent purulent otitis media require high-dose therapy 4