Can augmentin (amoxicillin‑clavulanate) be prescribed at 50 mg/kg per day for a child with mild‑to‑moderate acute otitis media?

Augmentin 50 mg/kg/day is Inadequate for Mild-to-Moderate AOM

No, you should not prescribe augmentin at 50 mg/kg/day for a child with mild-to-moderate acute otitis media—this dose is substantially below the recommended high-dose regimen of 90 mg/kg/day (amoxicillin component) divided twice daily, which is the standard of care for AOM in children. 1, 2

Recommended Dosing for AOM

First-Line Therapy

• High-dose amoxicillin at 80–90 mg/kg/day divided into two doses for 10 days is the standard first-line treatment for most children with AOM, including those under 2 years of age. 1, 2
• This dosing achieves middle ear fluid concentrations that exceed the minimum inhibitory concentration for approximately 87% of Streptococcus pneumoniae isolates, including intermediately resistant strains. 1

When to Use Amoxicillin-Clavulanate Instead of Amoxicillin Alone

Switch to high-dose amoxicillin-clavulanate (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate, divided BID) when:

• The child received amoxicillin within the prior 30 days 1, 2
• Concurrent purulent conjunctivitis is present 1
• The child attends daycare (higher risk of β-lactamase-producing organisms) 1
• The child is under 2 years with severe presentation 3

Why 50 mg/kg/day is Insufficient

Pharmacodynamic Failure

• A dose of 50 mg/kg/day falls far short of the 80–90 mg/kg/day needed to overcome resistant S. pneumoniae, the predominant pathogen in AOM. 1, 2
• Standard-dose amoxicillin (40–45 mg/kg/day) covers only 83% of S. pneumoniae isolates, compared to 87% with high-dose therapy—and 50 mg/kg/day sits in a therapeutic "no man's land" that is inadequate for resistant organisms. 1

Clinical Consequences of Underdosing

• Subtherapeutic doses fail to achieve adequate middle ear fluid concentrations, leading to treatment failure and promoting antimicrobial resistance. 1
• The FDA-approved clinical trial for AOM in children compared 45 mg/kg/day (divided every 12 hours) versus 40 mg/kg/day (divided every 8 hours), both of which are still below current guideline recommendations—neither used 50 mg/kg/day. 4

Practical Dosing Algorithm

For a child with mild-to-moderate AOM:

1. Calculate weight-based dose: 90 mg/kg/day × child's weight (kg) = total daily amoxicillin dose 1
2. Divide into two equal doses given 12 hours apart 1
3. If using amoxicillin-clavulanate (Augmentin), prescribe the 14:1 ratio formulation (90 mg/kg/day amoxicillin + 6.4 mg/kg/day clavulanate) to minimize diarrhea 1, 3
4. Treat for 10 days in children under 6 years 1, 2

Example Calculation

For a 20 kg child:

• Total daily dose: 90 mg/kg/day × 20 kg = 1,800 mg/day
• Per-dose amount: 900 mg twice daily (every 12 hours) 1

Monitoring and Treatment Failure

Expected Response

• Clinical improvement should be evident within 48–72 hours (reduced pain, fever, irritability). 1, 3

If No Improvement After 48–72 Hours

1. First, reassess the diagnosis of AOM 1
2. If initially on amoxicillin alone, switch to high-dose amoxicillin-clavulanate (90/6.4 mg/kg/day divided BID) 1, 2
3. If already on amoxicillin-clavulanate, consider ceftriaxone 50 mg/kg IM or IV for three days 1

Common Pitfalls to Avoid

• Do not use 50 mg/kg/day—it is neither standard-dose nor high-dose and will likely result in treatment failure 1, 2
• Verify the suspension concentration (e.g., 125/31 mg/5 mL vs. 250/62 mg/5 mL) before calculating volume to avoid dosing errors 3
• The 14:1 ratio formulation causes significantly less diarrhea (14% vs. 34%) than older 7:1 formulations while maintaining efficacy 1, 4
• Do not prescribe amoxicillin-clavulanate in children under 3 months of age unless specialist consultation is obtained 3

Evidence Quality Note

The American Academy of Pediatrics guidelines consistently recommend 80–90 mg/kg/day across multiple recent publications, and this is reinforced by FDA-approved dosing studies showing that even 45 mg/kg/day (higher than your proposed 50 mg/kg/day) was studied only in comparison to 40 mg/kg/day—both below current standards. 1, 2, 4 There is no high-quality evidence supporting 50 mg/kg/day as an effective dose for AOM.