Recommended Amoxicillin Dosing for Pediatric Acute Otitis Media
The recommended dose of amoxicillin for pediatric patients with acute otitis media is 80-90 mg/kg/day divided into 2 doses, as endorsed by the American Academy of Pediatrics and American Academy of Family Physicians. 1, 2
Dosing Algorithm by Weight
- Calculate the total daily dose: Multiply the child's weight in kg by 80-90 mg 1, 2
- Divide into twice-daily dosing: Split the total daily dose into 2 equal administrations 1, 2, 3
- Practical example: For a 19.5 kg child, prescribe approximately 800 mg twice daily (82 mg/kg/day total) 1
Rationale for High-Dose Therapy
High-dose amoxicillin (80-90 mg/kg/day) is specifically chosen to overcome drug-resistant Streptococcus pneumoniae while maintaining safety, low cost, acceptable taste, and narrow microbiologic spectrum. 1
- High-dose therapy achieves middle ear fluid concentrations that exceed the minimum inhibitory concentration for intermediately resistant S. pneumoniae for longer periods during the dosing interval 2
- Approximately 87% of S. pneumoniae isolates remain susceptible to high-dose amoxicillin, compared to only 83% for standard-dose therapy 2
- The regimen effectively covers the three predominant pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 2
Treatment Duration by Age
- Children under 2 years: Treat for 10 days 2
- Children over 2 years with uncomplicated AOM: 5-7 days is sufficient 1
When to Switch to Amoxicillin-Clavulanate
Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate) in these specific scenarios: 1, 2
- The child received amoxicillin within the previous 30 days 1, 2
- Concurrent purulent conjunctivitis is present 1, 2
- Coverage for β-lactamase-producing H. influenzae or M. catarrhalis is specifically needed 1, 2
- No clinical improvement occurs within 48-72 hours of starting amoxicillin 1, 2
Use the 14:1 ratio formulation of amoxicillin to clavulanate, as it causes less diarrhea than other ratios. 2
Critical Monitoring Points
- Reassess at 48-72 hours if symptoms fail to improve 1, 2
- Treatment failure is defined as worsening condition, persistence of symptoms beyond 48 hours, or recurrence within 4 days of completing therapy 1
- If treatment fails, switch to amoxicillin-clavulanate or consider ceftriaxone 1, 2
Important Clinical Caveats
Address pain management concurrently during the first 24 hours regardless of antibiotic choice. 1, 2
- Twice-daily dosing is as effective as three-times-daily administration and improves adherence by reducing family-perceived scheduling difficulties 3
- In heavier or obese children, some clinicians cap the dose at the standard adult maximum of 1500 mg/day, though guideline committee members remain divided on this practice 4
- Children attending daycare have higher rates of drug-resistant S. pneumoniae carriage (29% vs 14%) and may particularly benefit from high-dose therapy 5