What is the recommended dose and frequency of Augmentin (amoxicillin/clavulanate) for bacterial pharyngitis?

Augmentin Dosing for Bacterial Pharyngitis

Augmentin (amoxicillin/clavulanate) is NOT a first-line agent for bacterial pharyngitis and should only be used for chronic Group A Streptococcus carriers who have failed standard therapy, at a dose of 40 mg/kg/day of the amoxicillin component divided into three doses (maximum 2000 mg amoxicillin per day) for 10 days. 1

Why Augmentin is NOT First-Line

• Penicillin or amoxicillin alone remains the drug of choice for acute Group A Streptococcal pharyngitis due to proven efficacy, narrow spectrum, safety, and low cost 1, 2, 3
• No documented penicillin resistance in Group A Streptococcus has ever been reported anywhere in the world 3
• The addition of clavulanate provides no benefit for acute pharyngitis since Group A Streptococcus does not produce beta-lactamase 1
• Augmentin has a broader antimicrobial spectrum than necessary, which unnecessarily increases selection pressure for antibiotic-resistant flora 4

When Augmentin IS Indicated: Chronic Carriers Only

Augmentin should be reserved exclusively for chronic Group A Streptococcus carriers who have failed standard penicillin or amoxicillin therapy. 1

Dosing for Chronic Carriers:

• Pediatric patients: 40 mg amoxicillin per kg per day divided into three doses (maximum 2000 mg amoxicillin per day) for 10 days 1
• Adults: This translates to approximately 875 mg twice daily or 500 mg three times daily for 10 days (based on the 40 mg/kg amoxicillin component guideline) 1

Correct First-Line Treatment for Acute Pharyngitis

For Non-Allergic Patients:

• Amoxicillin: 500 mg twice daily for adults OR 50 mg/kg once daily (maximum 1000 mg) for children for 10 days 1, 2, 3
• Penicillin V: 500 mg twice daily OR 250 mg four times daily for adults for 10 days 1, 2

For Penicillin-Allergic Patients:

• Non-immediate allergy: Cephalexin 500 mg twice daily for adults (20 mg/kg per dose twice daily for children, maximum 500 mg per dose) for 10 days 1, 4, 2
• Immediate/anaphylactic allergy: Clindamycin 300 mg three times daily for adults (7 mg/kg per dose three times daily for children, maximum 300 mg per dose) for 10 days 1, 4, 2
• Alternative for immediate allergy: Azithromycin 500 mg once daily for 5 days for adults (12 mg/kg once daily for children, maximum 500 mg) 1, 4, 2

Critical Treatment Duration

• A full 10-day course is essential for all antibiotics except azithromycin to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent acute rheumatic fever 1, 4, 2, 3
• Azithromycin requires only 5 days due to its prolonged tissue half-life 1, 4, 2
• Shortening the course by even a few days results in appreciable increases in treatment failure rates 4

Common Pitfalls to Avoid

• Do not prescribe Augmentin for acute pharyngitis - it provides no advantage over amoxicillin alone and has broader spectrum with more gastrointestinal side effects 1, 5
• Do not use shorter courses than recommended (except azithromycin's 5-day regimen) as this increases treatment failure and rheumatic fever risk 4, 2
• Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to up to 10% cross-reactivity risk 1, 4
• Do not use macrolides as first-line - macrolide resistance is 5-8% in the United States and varies geographically 4