Amoxicillin Dosing for Acute Otitis Media
For acute otitis media, prescribe amoxicillin at 80-90 mg/kg/day divided into 2 doses, which provides optimal coverage against drug-resistant Streptococcus pneumoniae while maintaining safety and efficacy. 1
Standard Dosing Recommendations
- High-dose amoxicillin (80-90 mg/kg/day) is the first-line treatment for acute otitis media because it provides effective coverage against drug-resistant Streptococcus pneumoniae while maintaining safety, low cost, acceptable taste, and narrow microbiologic spectrum 1
- The American Academy of Pediatrics and American Academy of Family Physicians both recommend this high-dose regimen divided into 2 daily doses 1
- Amoxicillin is recommended as the first-choice antibiotic by the WHO Expert Committee, with amoxicillin-clavulanic acid as second choice 2
Practical Dosing Examples
For a typical child weighing 19.5 kg (43 pounds):
- Total daily dose: 1560-1755 mg/day (based on 80-90 mg/kg/day) 1
- Practical prescription: 800 mg twice daily (approximately 82 mg/kg/day) 1
Treatment Duration
- For children over 2 years with uncomplicated acute otitis media: 5 days of treatment is sufficient 1
- For children under 2 years or those with severe symptoms: 10 days may be warranted 1
- Twice-daily dosing is as effective as three-times-daily administration and improves adherence 2, 3
When to Use Alternative Therapy
Switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate) if: 1
- The child received amoxicillin in the previous 30 days
- Concurrent purulent conjunctivitis is present
- Coverage for beta-lactamase-producing Haemophilus influenzae or Moraxella catarrhalis is needed
Special Considerations
Penicillin Allergy
- If severe penicillin allergy exists, alternative antibiotics outside the beta-lactam class must be used (though specific alternatives are not detailed in the primary guidelines provided) 2
Renal or Hepatic Impairment
- Dose adjustment may be necessary in severe renal impairment, though standard dosing is generally safe in mild-to-moderate dysfunction 4
Obesity Considerations
- For children whose calculated dose exceeds the standard adult dose of 1500 mg/day, prescribe the standard adult dose rather than exceeding it 5
- This represents a practical ceiling dose, as the benefit of exceeding adult dosing is unproven 5
Reassessment and Treatment Failure
- Reassess at 48-72 hours if symptoms fail to improve 1
- 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
- Beta-lactamase-producing Haemophilus influenzae is a common cause of treatment failure 1
Pain Management
- Address pain management concurrently with antibiotic therapy during the first 24 hours 1
- Pain control is a critical component of acute otitis media management alongside antimicrobial therapy 1
Evidence Regarding Standard vs. High-Dose
While one study found no difference between standard-dose (40-45 mg/kg/day) and high-dose amoxicillin in low-risk children 6, current guidelines universally recommend high-dose therapy given the widespread prevalence of drug-resistant Streptococcus pneumoniae and the safety profile of higher dosing 2, 1, 4. The high-dose recommendation accounts for real-world uncertainty about individual patient resistance risk.