What is the maximum daily dose of Augmentin (amoxicillin/clavulanic acid) for adults with normal renal function and pediatric patients with varying degrees of renal impairment?

Maximum Daily Dose of Augmentin

For adults with normal renal function, the maximum daily dose of Augmentin is 4 grams of amoxicillin component per day (administered as either 2000 mg twice daily using the extended-release formulation or 875 mg three times daily), while pediatric patients should not exceed 90 mg/kg/day of the amoxicillin component. 1, 2

Adult Dosing - Normal Renal Function

Standard formulations:

• Maximum of 875 mg three times daily (2625 mg amoxicillin/day total) for severe infections 1
• Alternative: 500 mg every 8 hours (1500 mg amoxicillin/day) for moderate infections 1

High-dose formulations:

• Extended-release: 2000 mg/125 mg twice daily (4000 mg amoxicillin/day maximum) for drug-resistant respiratory pathogens 3
• This represents the absolute maximum daily dose for adults with normal renal function 2, 3

Pediatric Dosing - Normal Renal Function

For children ≥3 months and weighing <40 kg:

• Maximum: 90 mg/kg/day of amoxicillin component divided into two doses (high-dose formulation) 1, 4
• Standard dosing: 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for severe infections 1
• The high-dose pediatric formulation (90/6.4 mg/kg/day) should not be exceeded 4, 3

For children <3 months:

• Maximum: 30 mg/kg/day divided every 12 hours due to immature renal function 1

Renal Impairment Adjustments

Critical dose reductions are mandatory for renal dysfunction:

• CrCl 30-50 mL/min: Reduce dose by 50% or double the dosing interval 5
• CrCl 10-30 mL/min: 500 mg or 250 mg every 12 hours maximum 1, 5
• CrCl <10 mL/min: 500 mg or 250 mg every 24 hours maximum 1, 5
• Hemodialysis: 500 mg or 250 mg every 24 hours, with additional dose during and after dialysis 1, 5

The 875 mg dose formulation should NOT be used in patients with CrCl <30 mL/min 1

Critical Safety Considerations

Clavulanic acid accumulation:

• Both amoxicillin and clavulanate are renally eliminated, requiring parallel dose adjustments in renal impairment 5
• Clavulanic acid can accumulate in severe renal dysfunction, though it has a favorable safety profile 5

Nephrology consultation is recommended:

• For patients with CrCl <30 mL/min before prescribing 5
• For patients on dialysis or continuous renal replacement therapy 5

Common Dosing Pitfalls to Avoid

Do not confuse formulations:

• The extended-release 2000/125 mg formulation is NOT interchangeable with standard immediate-release tablets 3
• Pediatric high-dose suspension (90/6.4 mg/kg/day) uses a 14:1 ratio specifically designed to minimize clavulanate-related diarrhea 2, 4

Avoid concurrent nephrotoxic agents:

• NSAIDs and aminoglycosides should be used with extreme caution in patients with baseline renal impairment receiving Augmentin 5

Grossly inadequate dosing:

• For a typical 9-year-old child, an 80 mg total daily dose would be completely inadequate and lead to treatment failure—minimum effective dose is approximately 500-750 mg total daily of amoxicillin component 6