What is the recommended pediatric dosing for Augmentin (amoxicillin-clavulanate)?

Pediatric Dosing for Augmentin (Amoxicillin-Clavulanate)

For most pediatric infections, 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 (maximum 4000 mg/day), which provides the optimal 14:1 ratio formulation. 1

Standard Dosing Regimens

High-Dose Regimen (Preferred for Most Infections)

• 90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate in 2 divided doses is the recommended high-dose regimen for children with respiratory tract infections, acute otitis media, and acute bacterial rhinosinusitis 1
• This high-dose formulation achieves middle ear fluid concentrations adequate to overcome penicillin-resistant Streptococcus pneumoniae 1
• The 14:1 ratio formulation causes less diarrhea than other amoxicillin-clavulanate preparations while maintaining efficacy 1

Standard-Dose Alternative

• 45 mg/kg/day in 3 doses OR 90 mg/kg/day in 2 doses for β-lactamase producing H. influenzae 1
• Maximum single dose is 2 grams regardless of weight 1

Age-Based Dosing for Standard Infections

When using conventional formulations (125/31 or 250/62 suspensions):

• Less than 1 year (1-12 months): 2.5 ml of 125/31 suspension three times daily 1
• 1-6 years: 5 ml of 125/31 suspension three times daily 1
• 7-12 years: 5 ml of 250/62 suspension three times daily 1
• 12-18 years: 1 tablet (250/125) three times daily 1

Specific Clinical Indications

Acute Otitis Media & Acute Bacterial Rhinosinusitis

• High-dose regimen (90 mg/kg/day divided BID) is first-line therapy for acute bacterial rhinosinusitis and recurrent/persistent acute otitis media 1
• Indicated when risk factors are present: age <2 years, daycare attendance, recent antibiotic use (within 3 months), incomplete H. influenzae type b vaccination, moderate to severe illness, or geographic area with high pneumococcal resistance 1, 2
• Treatment duration: 10 days for acute otitis media 1
• Treatment duration: 10-14 days for acute bacterial rhinosinusitis 1

Community-Acquired Pneumonia

• Children <5 years with presumed bacterial pneumonia: 90 mg/kg/day of amoxicillin component in 2 doses 1
• Children ≥5 years: 90 mg/kg/day in 2 doses (maximum 4000 mg/day) 1
• Children <3 years without risk factors: Consider amoxicillin alone at 80-100 mg/kg/day in 3 divided doses first; add clavulanate if incomplete H. influenzae type b vaccination or concurrent purulent otitis media 1
• Treatment duration: 10 days 1

Intravenous Dosing for Severe Infections

• 30 mg/kg three times daily IV for all pediatric ages with severe infections requiring parenteral therapy 1

Treatment Duration and Monitoring

• Standard duration: 10 days for most respiratory infections including pneumonia and acute otitis media 1, 2
• Expected clinical improvement: Within 48-72 hours of starting therapy 1
• If no improvement after 72 hours: Reevaluate diagnosis, consider atypical pathogens, evaluate for complications, and consider switching antibiotics 1

Critical Dosing Considerations and Common Pitfalls

Avoid Underdosing

• Using standard doses when high-dose therapy is indicated leads to treatment failure with resistant organisms 1
• Subtherapeutic doses fail to achieve adequate serum and tissue concentrations and promote antimicrobial resistance 1

Verify Suspension Concentration

• Always verify the suspension concentration (125/31 vs 250/62) before calculating volume to avoid dosing errors 1
• The 250/62 formulation is specifically indicated for children over 6 years of age 1

Ensure Appropriate Indication

• Most upper respiratory tract infections are viral and do not benefit from antibiotics 1
• Before prescribing, ensure the child meets criteria for bacterial infection (persistent symptoms >10 days without improvement, severe symptoms, or "double sickening") 1

Adverse Effects

• Common adverse effects include diarrhea, nausea, vomiting, and rash 1, 2
• The difference in adverse effects between lower and higher doses is generally negligible 1
• Diarrhea occurs less frequently with twice-daily dosing compared to three-times-daily dosing 3, 4
• The high-dose formulation (90/6.4 mg/kg/day) shows similar tolerability to conventional twice-daily formulations 3