Recommended Dose of Augmentin for Pediatric Acute Otitis Media
For pediatric patients with acute otitis media, prescribe high-dose amoxicillin-clavulanate (Augmentin) at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses daily, using the 14:1 ratio formulation. 1, 2, 3
When to Use Augmentin Instead of Amoxicillin Alone
Augmentin is indicated as first-line therapy (rather than amoxicillin alone) in the following specific situations:
- Recent antibiotic exposure: Child received amoxicillin within the previous 30 days 4, 1, 3
- Concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome) 4, 1, 3
- Treatment failure: No improvement or worsening symptoms after 48-72 hours of amoxicillin therapy 1, 2, 3
- History of recurrent AOM unresponsive to amoxicillin 2
Dosing Calculation and Administration
Calculate the total daily dose by multiplying the child's weight in kilograms by 90 mg (amoxicillin component), then divide into 2 equal doses given approximately 12 hours apart. 1, 3
For example, a 15 kg child would receive:
- 15 kg × 90 mg/kg = 1,350 mg amoxicillin daily
- Divided into 2 doses = 675 mg twice daily 1
Critical formulation requirement: Use only the 14:1 ratio formulation (90 mg/kg amoxicillin with 6.4 mg/kg clavulanate), as older formulations with higher clavulanate ratios cause significantly more diarrhea and should be avoided. 3
The maximum single dose of amoxicillin is 2000 mg. 3
Treatment Duration by Age
- Children under 2 years: 10 days of treatment 1, 2
- Children 2-5 years with severe symptoms or bilateral disease: 10 days 1
- Children over 2 years with uncomplicated AOM: 5-7 days may be sufficient 1
Clinical Response and Treatment Failure
Reassess at 48-72 hours if symptoms fail to improve or worsen. 1, 2, 3 Clinical improvement should be evident within this timeframe. 3
If treatment failure occurs with Augmentin:
- Switch to ceftriaxone 50 mg/kg IM/IV daily 3
- Confirm diagnosis with proper tympanic membrane visualization 2
Evidence Supporting High-Dose Augmentin
High-dose amoxicillin-clavulanate achieves superior bacterial eradication compared to alternatives, with 96% eradication of Streptococcus pneumoniae versus 80.4% for azithromycin. 3 This formulation provides effective coverage against penicillin-intermediate and resistant S. pneumoniae strains, as well as β-lactamase-producing H. influenzae and M. catarrhalis. 3, 5
A head-to-head comparison demonstrated that 10 days of high-dose amoxicillin-clavulanate achieved an 86.5% cure rate compared to 71.0% for cefdinir (p = 0.001). 6
Compliance and Tolerability
Twice-daily dosing improves compliance compared to three-times-daily regimens (82.8% vs 73.3% compliance). 7 The 14:1 ratio formulation causes less diarrhea (7.2%) compared to three-times-daily formulations (10.7%). 7, 8
Common Pitfalls to Avoid
- Using incorrect formulation: Always prescribe the 14:1 ratio (90/6.4 mg/kg/day) formulation, not older 7:1 or 4:1 ratios that cause excessive gastrointestinal side effects 1, 3
- Underdosing: Failure to use 90 mg/kg/day of the amoxicillin component leads to treatment failures against resistant organisms 1, 3
- Incorrect weight-based calculation: Always recalculate based on current weight, not age-based estimates 1
- Inadequate follow-up: Must reassess at 48-72 hours if symptoms persist or worsen 1, 2
- Forgetting pain management: Always address pain concurrently with antibiotics during the first 24 hours using acetaminophen or ibuprofen 1, 2