What is the recommended dosage and treatment plan for Augmentin (amoxicillin-clavulanate) for bacterial infections?

Augmentin (Amoxicillin-Clavulanate) Dosing Recommendations

For adults with standard bacterial infections, use Augmentin 875 mg/125 mg twice daily for respiratory, skin, and soft tissue infections, or 500 mg/125 mg three times daily for mild-to-moderate infections, with treatment duration of 5-7 days for most infections and 10 days for streptococcal infections. 1, 2, 3

Standard Adult Dosing Regimens

Twice-Daily Dosing (Most Common)

• 875 mg/125 mg twice daily is the preferred regimen for respiratory tract infections including acute bacterial rhinosinusitis, community-acquired pneumonia, and acute exacerbations of chronic bronchitis 1
• This same dose applies to skin and soft tissue infections, urinary tract infections, and animal or human bites 1, 2
• 500 mg/125 mg twice daily is appropriate for mild-to-moderate infections and specifically recommended for animal or human bites 1, 2

Three-Times-Daily Dosing

• 500 mg/125 mg three times daily provides adequate coverage for mild-to-moderate infections when extended dosing is preferred 1
• This regimen is specifically recommended for acute bacterial rhinosinusitis for 10 days 1
• For recurrent streptococcal pharyngitis in adults with multiple episodes, use 500 mg twice daily for 10 days 1

Critical Warning: Never substitute two 250 mg tablets for one 500 mg tablet, as this results in excessive clavulanate dosing and increased gastrointestinal side effects 1

Pediatric Dosing (Age ≥3 Months and Weight <40 kg)

Standard Infections

• Mild/Moderate infections: 25 mg/kg/day (amoxicillin component) divided every 12 hours OR 20 mg/kg/day divided every 8 hours 3
• Severe infections or lower respiratory tract infections: 45 mg/kg/day divided every 12 hours OR 40 mg/kg/day divided every 8 hours 3

High-Dose Regimen for Resistant Pathogens

• 90 mg/6.4 mg/kg/day (amoxicillin/clavulanate) in two divided doses for acute otitis media with risk factors for resistant organisms, particularly penicillin-resistant Streptococcus pneumoniae 2, 4, 5, 6
• This high-dose formulation (Augmentin ES-600) provides a 14:1 ratio of amoxicillin to clavulanate, minimizing clavulanate-related diarrhea while maximizing efficacy against resistant pathogens 6

Infants <3 Months

• Maximum dose is 30 mg/kg/day divided every 12 hours due to immature renal function 3
• Minimum 10-day treatment for Streptococcus pyogenes to prevent acute rheumatic fever 3

Treatment Duration by Indication

Standard Durations

• Skin and soft tissue infections: 5-7 days after clinical improvement 2
• Animal or human bites: 5-7 days 2
• Acute bacterial rhinosinusitis: 5-7 days in adults 1
• Community-acquired pneumonia: 5-7 days if afebrile for 48 hours and clinically stable 2

Extended Durations

• Any streptococcal infection: Minimum 10 days to prevent acute rheumatic fever 1, 3
• Chronic streptococcal carriers: 10 days with 500 mg twice daily (adults) or 40 mg/kg/day in three divided doses (pediatrics) 1

Special Indications

• Helicobacter pylori triple therapy: 1 gram amoxicillin + 500 mg clarithromycin + 30 mg lansoprazole, all twice daily for 14 days 3
• H. pylori dual therapy: 1 gram amoxicillin + 30 mg lansoprazole, both three times daily for 14 days 3

Intravenous Dosing for Severe Infections

• 1.2 g IV every 8 hours for serious infections including complicated intra-abdominal infections, severe respiratory infections, and severe skin/soft tissue infections 2, 7
• For intra-abdominal infections with adequate source control, treat for 4-7 days 2
• For moderate to severe community-acquired pneumonia requiring hospitalization, continue three-times-daily dosing 2
• Consider increasing to every 6 hours (QID) for critically ill patients or severe sepsis 2

Renal Impairment Dosing

Patients with GFR <30 mL/min should NOT receive the 875 mg dose 3

Adjusted Regimens

• GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours depending on infection severity 3
• GFR <10 mL/min: 500 mg or 250 mg every 24 hours depending on infection severity 3
• Hemodialysis: 500 mg or 250 mg every 24 hours, with an additional dose during and at the end of dialysis 3

Administration Considerations

• Take at the start of a meal to minimize gastrointestinal intolerance 3
• Continue treatment for minimum 48-72 hours beyond symptom resolution or evidence of bacterial eradication 3
• Oral suspension must be shaken well before use and discarded after 14 days; refrigeration is preferable but not required 3

Clinical Decision Algorithm

1. Identify infection type and severity

   • Mild-to-moderate: 500/125 mg formulation
   • Severe or respiratory: 875/125 mg formulation 1

2. Assess patient factors

   • Renal function: Adjust dose if GFR <30 mL/min 3
   • Age: Use weight-based dosing for pediatrics <40 kg 3
   • Risk for resistant pathogens: Consider high-dose formulation (90/6.4 mg/kg/day) in children 5, 6

3. Select dosing frequency

   • Twice daily for most standard infections 1, 2
   • Three times daily for rhinosinusitis or when extended coverage preferred 1

4. Determine duration

   • 5-7 days for most infections 2
   • 10 days mandatory for streptococcal infections 1, 3

Common Pitfalls to Avoid

• Do not use 875 mg dose in patients with severe renal impairment (GFR <30 mL/min) 3
• Do not substitute tablet strengths to achieve desired amoxicillin dose, as this alters clavulanate exposure 1
• Do not shorten treatment duration for streptococcal infections below 10 days, regardless of clinical improvement 1, 3
• Gastrointestinal side effects occur in approximately 9% of patients and are generally less frequent with twice-daily versus three-times-daily dosing 1, 5