Recommended Dose of Clavulin for a 19kg Boy with Otitis Media
For a 19kg boy with acute otitis media, prescribe high-dose amoxicillin-clavulanate (Clavulin) at 80-90 mg/kg/day of the amoxicillin component, which equals 1520-1710 mg/day total, divided into 2 doses (approximately 760-855 mg twice daily). 1
Dosing Calculation
- Weight-based dosing: 19 kg × 80-90 mg/kg/day = 1520-1710 mg amoxicillin per day 1
- Divided dosing: Give in 2 divided doses (approximately 760-855 mg twice daily) 1
- Clavulanate component: 6.4 mg/kg/day = approximately 122 mg/day total 1
- Duration: 10 days of therapy 1, 2
Rationale for High-Dose Therapy
High-dose amoxicillin-clavulanate is the preferred first-line treatment when coverage for β-lactamase-producing organisms is needed. 1 The AAP/AAFP guidelines specifically recommend 80-90 mg/kg/day dosing to overcome resistance in Streptococcus pneumoniae with intermediate resistance and to cover β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. 1
This high-dose regimen achieves middle ear fluid concentrations sufficient to eradicate penicillin-resistant pneumococci (MICs 2-4 μg/mL), with bacteriologic eradication rates of 91% for resistant strains and 98% overall for S. pneumoniae. 2
When to Use Amoxicillin-Clavulanate vs. Amoxicillin Alone
Use amoxicillin-clavulanate (rather than amoxicillin alone) if the child has: 1
- Received amoxicillin within the previous 30 days
- Concurrent purulent conjunctivitis (otitis-conjunctivitis syndrome)
- Failed initial amoxicillin therapy
- Moderate to severe illness at presentation 1
- Age less than 2 years with risk factors for resistant organisms 1
Practical Formulation Considerations
The 14:1 ratio formulation (amoxicillin to clavulanate) is preferred as it provides adequate clavulanate levels while minimizing gastrointestinal side effects, particularly diarrhea. 1 Twice-daily dosing improves compliance and reduces diarrhea compared to three-times-daily regimens. 3
Clinical Monitoring
Reassess the patient at 48-72 hours. 1 The child should stabilize within 24 hours and begin improving during the second 24-hour period. 1 If no improvement occurs by 48-72 hours, consider treatment failure and switch to an alternative antibiotic such as ceftriaxone (50 mg/kg IM/IV for 3 days). 1
Common Pitfalls to Avoid
- Underdosing: Do not use standard-dose amoxicillin-clavulanate (45 mg/kg/day) for otitis media in the current era of antibiotic resistance 1
- Wrong formulation: Avoid formulations with higher clavulanate ratios (7:1 or 4:1) as they cause more diarrhea without added benefit 1
- Inadequate duration: Complete the full 10-day course even if symptoms resolve earlier 1, 2
Pain Management
Address otalgia regardless of antibiotic use, especially during the first 24 hours. 1 Recommend appropriate analgesics (acetaminophen or ibuprofen) as pain management is a strong recommendation based on clinical trials. 1