What is the recommended dosage of Augmentin (amoxicillin-clavulanate) for a pediatric patient with a dog bite?

Pediatric Augmentin Dosing for Dog Bite

For pediatric dog bites, amoxicillin-clavulanate should be dosed at 45 mg/kg/day (based on the amoxicillin component) divided every 12 hours for 5-7 days, with treatment duration extended to 10-14 days for severe infections involving bones or joints. 1, 2

Standard Dosing Regimen

The recommended dose is 45 mg/kg/day of amoxicillin divided every 12 hours (or 40 mg/kg/day divided every 8 hours), which provides optimal coverage against Pasteurella multocida, Staphylococcus aureus, Streptococcus species, Eikenella corrodens, and anaerobic bacteria commonly found in dog bite wounds. 1, 3

Weight-Based Dosing Guidelines

• Children weighing less than 40 kg: Use 45 mg/kg/day divided every 12 hours of the amoxicillin component 1, 3
• Children weighing 40 kg or more: Follow adult dosing of 875 mg/125 mg twice daily 1, 3
• Infants under 12 weeks (3 months): Maximum dose is 30 mg/kg/day divided every 12 hours due to immature renal function 3, 4

Treatment Duration

The typical duration is 5-7 days for uncomplicated dog bites, but should be extended to 10-14 days for more severe infections, particularly those involving bones, joints, or showing signs of osteomyelitis or septic arthritis. 1, 2

High-Risk Indications for Prophylaxis

Preemptive antimicrobial therapy is strongly recommended for pediatric patients with: 1

• Moderate to severe injuries, especially to the hand or face
• Puncture wounds (particularly high-risk with cat bites, but applicable to dog bites)
• Immunocompromised status or asplenia
• Advanced liver disease
• Preexisting or resultant edema of the affected area
• Injuries that may have penetrated the periosteum or joint capsule

Alternative Antibiotics for Penicillin Allergy

For patients with non-anaphylactic penicillin allergy: 2

• Doxycycline 100 mg twice daily (if ≥8 years old)
• Cefuroxime or cefdinir (if no history of immediate Type I hypersensitivity)

For patients with severe/anaphylactic penicillin allergy: 1, 2

• Fluoroquinolones (e.g., ciprofloxacin) plus metronidazole (generally avoided in children but may be considered for severe infections)
• Clindamycin plus trimethoprim-sulfamethoxazole

Critical Pitfalls to Avoid

Do not use first-generation cephalosporins, penicillinase-resistant penicillins (e.g., dicloxacillin), macrolides, or clindamycin alone, as these have poor activity against Pasteurella multocida, which is isolated in 20-30% of dog bite wounds. 1, 5, 6

Do not substitute two 250 mg/125 mg tablets for one 500 mg/125 mg tablet, as they contain different ratios of clavulanic acid and are not equivalent. 3

Administration Recommendations

• Administer at the start of a meal to minimize gastrointestinal intolerance and enhance clavulanate absorption 3, 4
• The every 12-hour regimen is preferred over every 8-hour dosing as it is associated with significantly less diarrhea 3

Additional Management Considerations

Tetanus prophylaxis should be administered if the child has not received vaccination within the past 10 years, with Tdap preferred over Td if not previously given. 1, 2

Evaluate response to treatment within 48-72 hours; if no improvement or worsening occurs, consider alternative antibiotics or reevaluation for complications such as abscess formation, osteomyelitis, or septic arthritis. 1

Wounds should be copiously irrigated with normal saline using a 20-mL or larger syringe, and explored for tendon or bone involvement and possible foreign bodies. 5

Special Populations

For asplenic/hyposplenic patients (including those with functional asplenia), amoxicillin-clavulanate prophylaxis is particularly important due to increased risk of severe sepsis from dog bites, and should be given for 5 days. 7