What is the appropriate dosing regimen for Augmentin (amoxicillin-clavulanate) for pediatric patients?

Augmentin Dosing for Pediatric Patients

For pediatric patients, Augmentin should be dosed at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses (maximum 4000 mg/day), for most respiratory tract infections and moderate-to-severe infections. 1, 2

Standard Dosing Regimens by Age and Weight

Infants Under 3 Months

• 30 mg/kg/day divided every 12 hours based on the amoxicillin component 3
• Use the 125 mg/5 mL oral suspension (experience with 200 mg/5 mL formulation is limited in this age group) 3

Children 3 Months and Older

High-Dose Regimen (Preferred for Most Infections):

• 90 mg/kg/day of amoxicillin component in 2 divided doses 1, 2
• This provides 6.4 mg/kg/day of clavulanate in the 14:1 ratio formulation 2
• Maximum single dose: 2000 mg per dose 2
• Maximum daily dose: 4000 mg/day 1

Standard-Dose Regimen (For Mild Infections Only):

• 45 mg/kg/day in 2 doses for mild infections 1
• Alternative: 40 mg/kg/day divided every 8 hours 3

Children Weighing ≥40 kg

• Dose according to adult recommendations 3
• For severe respiratory infections: 875 mg/125 mg every 12 hours or 500 mg/125 mg every 8 hours 3

Indication-Specific Dosing

Community-Acquired Pneumonia

• 90 mg/kg/day in 2 divided doses for 10 days 1, 2
• This applies to children under 5 years with presumed bacterial pneumonia 2
• For children with incomplete H. influenzae type b vaccination or concurrent purulent otitis media, use 80-90 mg/kg/day 2, 4

Acute Otitis Media

• 90 mg/kg/day in 2 divided doses for 10 days 1, 3
• High-dose regimen is particularly important for children with risk factors: age <2 years, daycare attendance, recent antibiotic use within 3 months, or moderate-to-severe illness 2

Preseptal Cellulitis

• 80-90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses for 10-14 days 4
• Maximum 2 g per dose 4

β-Lactamase Producing H. influenzae Infections

• Either 45 mg/kg/day in 3 doses OR 90 mg/kg/day in 2 doses 1, 2
• The twice-daily regimen is preferred as it causes significantly less diarrhea 3

Practical Dosing Examples

For a 5.5 kg, 3-month-old infant:

• Mild-moderate pneumonia: 45 mg/kg/day = 1.25 mL of suspension twice daily 1
• Severe infection or high resistance area: 90 mg/kg/day = 2.5 mL twice daily 1

For an 18 kg, 5-year-old child:

• Standard oral dosing: 5 mL of 125/31 suspension three times daily 2
• High-dose regimen: 90 mg/kg/day = approximately 810 mg twice daily 1
• Severe infections requiring IV: 30 mg/kg three times daily IV = 540 mg IV three times daily 2

For a 27 kg child with recent antibiotic exposure:

• High-dose regimen: 90 mg/kg/day in 2 doses for severe infections or areas with high pneumococcal resistance 1

Treatment Duration and Monitoring

Standard Duration

• 10 days for most respiratory infections including pneumonia and acute otitis media 1, 2, 3
• 10-14 days for preseptal cellulitis, with some experts recommending continuation until symptom-free for 7 days 4

Expected Clinical Response

• Clinical improvement should occur within 48-72 hours of starting therapy 1, 2
• If no improvement or worsening after 72 hours, reevaluation and consideration of alternative antibiotics or further investigation is necessary 1, 2, 4

Critical Considerations and Common Pitfalls

Why High-Dose Regimens Matter

• High-dose amoxicillin (80-90 mg/kg/day) exceeds the minimum inhibitory concentration for intermediately resistant S. pneumoniae and many highly resistant serotypes 2
• The 14:1 ratio formulation (90/6.4 mg/kg/day) causes less diarrhea than other preparations while maintaining efficacy 2
• Using standard doses when high-dose therapy is indicated leads to treatment failure with resistant organisms 2

Formulation-Specific Warnings

• Two 250 mg/125 mg tablets should NOT be substituted for one 500 mg/125 mg tablet (both contain 125 mg clavulanate, making them non-equivalent) 3
• The 250 mg/125 mg tablet and 250 mg/62.5 mg chewable tablet are NOT interchangeable (different clavulanate content) 3
• Always verify suspension concentration (125/31 vs 250/62) before calculating volume to avoid dosing errors 2

When High-Dose Therapy is Indicated

• Age <2 years 2
• Daycare attendance 2
• Recent antibiotic use within past 3-4 months 1, 2
• Moderate to severe illness 2
• Incomplete vaccination against H. influenzae type b (less than 3 injections) 2, 4
• Areas with high prevalence of penicillin-resistant S. pneumoniae (>10%) 2
• Concurrent purulent acute otitis media 1, 4

Antibiotic Stewardship Considerations

• Most upper respiratory tract infections are viral and do not benefit from antibiotics 2
• Before prescribing for URTI, ensure criteria for acute bacterial rhinosinusitis are met: persistent symptoms >10 days without improvement, severe symptoms, or "double sickening" 2
• Subtherapeutic doses fail to achieve adequate concentrations and promote antimicrobial resistance 2

Adverse Effects

• Common adverse effects include diarrhea, nausea, vomiting, and rash 2
• The difference in adverse effects between lower and higher doses is generally negligible 2
• The twice-daily regimen is associated with significantly less diarrhea compared to three-times-daily dosing 3