Augmentin Pediatric Dose for Acute Otitis Media
For acute otitis media in children, prescribe high-dose amoxicillin-clavulanate (Augmentin) at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses daily, using the 14:1 ratio formulation. 1, 2, 3
When to Use Augmentin vs. Amoxicillin Alone
Use high-dose amoxicillin-clavulanate as first-line therapy when:
- The child received amoxicillin within the previous 30 days 1, 3
- Concurrent purulent conjunctivitis is present 1, 3
- The child is younger than 2 years old 4
- The child attends daycare 4
- Coverage for β-lactamase-producing Moraxella catarrhalis or Haemophilus influenzae is specifically desired 1, 3
Use high-dose amoxicillin alone (80-90 mg/kg/day in 2 divided doses) for uncomplicated cases without these risk factors. 2, 3
Specific Dosing Calculation
Calculate the dose as follows:
- Multiply the child's weight in kg by 90 mg for the amoxicillin component 1, 3
- Divide the total daily dose into 2 equal doses given 12 hours apart 1, 5, 6
- Maximum single dose is 2000 mg of amoxicillin 4
- For example, a 20 kg child receives 1800 mg amoxicillin daily (900 mg twice daily) with 128 mg clavulanate daily (64 mg twice daily) 1
The 14:1 ratio formulation (amoxicillin to clavulanate) is critical because it significantly reduces diarrhea compared to older formulations. 1, 7 The older 4:1 ratio formulations cause substantially more gastrointestinal side effects and should be avoided 7.
Treatment Duration and Monitoring
Standard treatment duration is 10 days. 1, 2
Assess clinical response at 48-72 hours:
- If symptoms improve, continue the full 10-day course 1, 2
- If no improvement or worsening occurs, consider treatment failure and switch to ceftriaxone (50 mg/kg IM/IV) 4, 3
Efficacy Evidence
High-dose amoxicillin-clavulanate demonstrates superior bacterial eradication compared to alternatives:
- 96% eradication rate for S. pneumoniae versus 80.4% with azithromycin 1
- Effective against penicillin-intermediate and resistant S. pneumoniae strains 8
- Covers all β-lactamase-producing H. influenzae and M. catarrhalis 4, 8
Twice-daily dosing is as effective as three-times-daily dosing with better compliance (82.8% vs. 73.3%) and less diarrhea (7.2% vs. 10.7%). 5, 7, 6
Critical Pitfalls to Avoid
Do not underdose the amoxicillin component. Using standard-dose amoxicillin-clavulanate (45 mg/kg/day) instead of high-dose (90 mg/kg/day) leads to treatment failures against resistant S. pneumoniae 1, 2. This is the most common prescribing error.
Do not use older formulations with higher clavulanate ratios. The 14:1 ratio formulation causes significantly less diarrhea than the 4:1 or 7:1 ratios 1, 7. Prescribe specifically "Augmentin ES-600" or equivalent 14:1 ratio products.
Do not continue ineffective therapy beyond 48-72 hours. If symptoms persist or worsen, switch antibiotics rather than extending the same regimen 1, 2.
Always manage pain concurrently with acetaminophen or ibuprofen during the first 24 hours. 2 Pain control is as important as antibiotic therapy for acute symptom relief.
Penicillin Allergy Alternatives
For true penicillin allergies, use:
- Cefdinir 14 mg/kg/day in 1-2 doses 2, 3
- Cefuroxime 30 mg/kg/day in 2 divided doses 2, 3
- Cefpodoxime 10 mg/kg/day in 2 divided doses 2, 3
Recent evidence shows the risk of cross-reactivity between penicillins and second/third-generation cephalosporins is negligible 4.