What is the recommended dosage of Augmentin (amoxicillin-clavulanate) for pediatric patients with preseptal cellulitis?

Pediatric Dosing of Augmentin for Preseptal Cellulitis

For mild preseptal cellulitis in children (eyelid <50% closed), use high-dose amoxicillin-clavulanate at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into two doses (maximum 2000 mg amoxicillin per dose), with daily follow-up until definite improvement is noted. 1

Dosing Regimen

Standard high-dose formulation:

• 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day of clavulanate (14:1 ratio) 1
• Divide into two doses given every 12 hours 1
• Maximum dose: 2000 mg amoxicillin per dose (or 4000 mg/day total) 1
• This high-dose regimen provides comprehensive coverage against penicillin-resistant Streptococcus pneumoniae and other common pathogens causing preseptal cellulitis 1

Duration of Therapy

• Continue treatment until the patient is well for 7 days, typically resulting in a 10-14 day total course 1
• Daily follow-up is mandatory until definite improvement is documented 1
• If no improvement within 24-48 hours or if infection is progressive, hospitalization for intravenous antimicrobial therapy is appropriate 1

Clinical Decision Algorithm

Assess severity at presentation:

Mild preseptal cellulitis (outpatient management):

• Eyelid swelling <50% closed 1
• No proptosis, impaired visual acuity, or painful/impaired extraocular mobility 1
• Treatment: High-dose oral amoxicillin-clavulanate as above 1

Moderate to severe preseptal cellulitis (hospitalization indicated):

• Eyelid swelling ≥50% closed 1
• Presence of proptosis, impaired visual acuity, or impaired/painful extraocular mobility 1
• Altered mental status or severe headache 1
• Treatment: Intravenous antibiotics (vancomycin to cover methicillin-resistant S. pneumoniae) 1
• Obtain contrast-enhanced CT scan 1
• Consult otolaryngology, ophthalmology, and infectious disease 1

Alternative Regimens for Penicillin Allergy

For immediate Type I hypersensitivity reactions to β-lactams:

• Clindamycin 30-40 mg/kg/day divided into 3 doses (maximum 40 mg/kg/day) 1, 2
• Note: Clindamycin has limited effectiveness against major pathogens and bacterial failure rates of 20-25% are possible 1

For non-immediate penicillin allergies (e.g., rash):

• Second or third-generation cephalosporins may be used: cefdinir, cefuroxime, or cefpodoxime 1, 2
• Cefdinir is preferred due to high patient acceptance 1

Common Pitfalls and Caveats

Critical monitoring points:

• Never use TMP-SMX, azithromycin, clarithromycin, or erythromycin as first-line therapy - these have limited effectiveness against major pathogens of preseptal cellulitis with bacterial failure rates of 20-25% 1
• Do not use first-generation cephalosporins or macrolides alone - they have poor activity against many causative pathogens 2

Risk factors requiring heightened vigilance:

• Preseptal cellulitis is most commonly secondary to acute ethmoiditis in otherwise healthy young children 1
• Sinusitis is the most common predisposing factor (present in approximately 50% of cases) 3, 4
• Other risk factors include odontogenic infections, insect bites, and periocular trauma 3, 4

When to escalate care:

• Failure to improve within 24-48 hours mandates hospital admission 1
• Any signs of postseptal (orbital) involvement require immediate hospitalization, imaging, and specialist consultation 1
• Recent retrospective data shows clindamycin and ceftriaxone are commonly used in hospitalized children, though amoxicillin-clavulanate remains the most frequently prescribed antibiotic overall 3, 5