What is the recommended dose of Augmentin (amoxicillin/clavulanate) for pediatric periorbital cellulitis?

Augmentin Dosing for Pediatric Periorbital Cellulitis

For pediatric periorbital cellulitis, use high-dose amoxicillin-clavulanate at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses daily, for 10-14 days. 1, 2

Standard High-Dose Regimen

• The recommended dosing is 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in two divided doses, which provides the optimal 14:1 ratio formulation 1, 2
• Maximum single dose should not exceed 2 grams per dose regardless of weight 2
• This high-dose regimen is specifically designed to overcome beta-lactamase producing organisms commonly implicated in periorbital cellulitis, including Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis 2, 3

Treatment Duration and Monitoring

• Treatment duration should be 10-14 days for periorbital cellulitis 2, 4
• Clinical improvement should be evident within 48-72 hours of initiating therapy 1, 2
• If no improvement or worsening occurs after 72 hours, reevaluate the diagnosis, consider imaging (CT scan), and assess for complications such as orbital abscess or subperiosteal abscess 1, 4

Age-Specific Dosing Considerations

For children ≥3 months:

• Use the 200 mg/28.5 mg per 5 mL or 400 mg/57 mg per 5 mL suspension formulations 5
• Calculate the volume based on 90 mg/kg/day divided into 2 doses 1, 2

For children <3 months:

• Use 30 mg/kg/day divided every 12 hours based on the amoxicillin component 5
• The 125 mg/5 mL oral suspension is recommended for this age group 5

For children weighing ≥40 kg:

• Dose according to adult recommendations: 875 mg/125 mg every 12 hours 5

Clinical Context for Periorbital Cellulitis

• Periorbital cellulitis most commonly arises from sinusitis (22-43% of cases), trauma (25%), or upper respiratory tract infections 4, 6, 7
• Staphylococcus aureus is the most frequently isolated pathogen (74% of positive cultures) 6
• The high-dose formulation achieves adequate tissue concentrations to overcome intermediately resistant Streptococcus pneumoniae and beta-lactamase producing organisms 2, 3

Administration Guidelines

• Administer at the start of meals to enhance clavulanate absorption and minimize gastrointestinal intolerance 5
• The 14:1 ratio formulation (90/6.4 mg/kg/day) causes significantly less diarrhea than other amoxicillin-clavulanate preparations while maintaining efficacy 2, 8

Critical Pitfalls to Avoid

• Never use standard-dose amoxicillin-clavulanate (45 mg/kg/day) for periorbital cellulitis, as this leads to treatment failure with resistant organisms and inadequate tissue penetration 2
• Do not substitute two 250 mg/125 mg tablets for one 500 mg/125 mg tablet, as they contain different amounts of clavulanic acid and are not equivalent 5
• Verify suspension concentration (125/31 vs 250/62 vs 400/57) before calculating volume to avoid dosing errors 2
• Ensure patients complete the full 10-14 day course even if symptoms improve earlier, as premature discontinuation increases recurrence risk 4, 6

When to Consider Alternative Management

• If no improvement after 72 hours of appropriate antibiotic therapy, obtain CT imaging to evaluate for orbital abscess or subperiosteal abscess requiring surgical drainage 4, 7
• Surgical intervention is indicated in approximately 7-12% of cases, typically for abscess formation 4
• Consider daily outpatient IV ceftriaxone (50 mg/kg/day, max 2g) with daily physician reassessment as an alternative in select cases without systemic illness 7