What is the appropriate outpatient dose of Amoxicillin (Amoxicillin)-Clavulanate for a stable adult patient and can Ursodeoxycholic acid be given concurrently?

Outpatient Amoxicillin-Clavulanate Dosing and Ursodeoxycholic Acid Use

Recommended Amoxicillin-Clavulanate Dosing

For stable adult outpatients, prescribe amoxicillin-clavulanate 875 mg/125 mg twice daily for respiratory infections or 500 mg/125 mg three times daily for other infections, and yes, ursodeoxycholic acid can be safely co-administered if cholestatic symptoms develop. 1, 2

Standard Adult Dosing Regimens

For respiratory tract infections (pneumonia, sinusitis, bronchitis):

• 875 mg/125 mg twice daily is the preferred dose for moderate-to-severe respiratory infections 1, 3, 2
• Duration: 5-7 days for uncomplicated cases 1, 4
• Take at the start of meals to enhance clavulanate absorption and minimize gastrointestinal side effects 2

For mild-to-moderate non-respiratory infections:

• 500 mg/125 mg three times daily 1, 3, 2
• Alternative: 500 mg/125 mg twice daily for less severe infections 3

For high-risk patients or resistant organisms:

• High-dose formulation: 2000 mg/125 mg twice daily 1, 5
• Indicated for: recent antibiotic use (within 4-6 weeks), moderate-to-severe disease, age >65, immunocompromised status, or areas with >10% penicillin-resistant S. pneumoniae 1

Critical Dosing Considerations

Never substitute two 250 mg/125 mg tablets for one 500 mg/125 mg tablet - this doubles the clavulanate dose unnecessarily and increases diarrhea risk 2

For asplenic/hyposplenic patients with fever:

• Emergency standby dose: 3 g loading dose, then 1 g every 8 hours 6
• Seek immediate medical attention even after starting antibiotics 6

Ursodeoxycholic Acid Co-Administration

Yes, ursodeoxycholic acid (UDCA) can and should be given if cholestatic symptoms develop during amoxicillin-clavulanate therapy. 7

When to Consider UDCA

Initiate UDCA 750 mg/day if the patient develops:

• Jaundice within 2 weeks of starting amoxicillin-clavulanate 7
• Pruritus (itching) 7
• Fatigue with elevated bilirubin 7
• Cholestatic liver enzyme pattern that persists after stopping the antibiotic 7

Evidence for UDCA Use

• UDCA provides prompt and sustained improvement in drug-induced cholestasis from amoxicillin-clavulanate 7
• Effective dose: 750 mg/day (typically divided as 250 mg three times daily) 7
• UDCA reduces serum bilirubin, alkaline phosphatase, and improves symptoms like pruritus 8, 7
• No known drug-drug interactions between amoxicillin-clavulanate and UDCA that would preclude concurrent use 7

Clinical Algorithm

If cholestatic symptoms appear:

1. Stop amoxicillin-clavulanate immediately 7
2. Start UDCA 750 mg/day 7
3. Monitor liver function tests weekly until normalization 7
4. Continue UDCA until complete resolution of cholestasis 7

For prophylactic use: UDCA is not routinely given prophylactically with amoxicillin-clavulanate, only therapeutically if cholestasis develops 7

Common Pitfalls to Avoid

• Don't wait for cholestasis to resolve spontaneously after stopping the drug - UDCA accelerates recovery 7
• Don't use 250 mg/125 mg tablets three times daily when 500 mg/125 mg twice daily is indicated - the clavulanate excess causes more diarrhea 2
• Don't prescribe less than 5 days for respiratory infections - this increases treatment failure risk 1, 4
• Don't use standard doses for high-risk patients - they require the 2000 mg/125 mg formulation for adequate coverage 1, 5