Oral Augmentin Dosing for Pediatric Pneumonia
For children with community-acquired pneumonia, prescribe amoxicillin-clavulanate (Augmentin) at 90 mg/kg/day of the amoxicillin component divided into 2 doses, with a maximum of 4 g/day, when β-lactamase-producing organisms (such as Haemophilus influenzae) are suspected or the child is not fully immunized. 1, 2
When to Use Augmentin Instead of Amoxicillin Alone
Amoxicillin alone (90 mg/kg/day in 2 doses) is the definitive first-line treatment for typical bacterial pneumonia in fully immunized children, as it provides excellent coverage for Streptococcus pneumoniae, the most common pathogen, with significantly less diarrhea than amoxicillin-clavulanate. 2, 3
Switch to amoxicillin-clavulanate (amoxicillin component 90 mg/kg/day in 2 doses) when:
- The child is not fully immunized against Haemophilus influenzae type b or Streptococcus pneumoniae, requiring coverage for β-lactamase-producing H. influenzae. 2
- Staphylococcus aureus (MSSA) is suspected based on severe presentation, necrotizing infiltrates, or empyema. 2
- The child has failed initial amoxicillin therapy after 48-72 hours without clinical improvement. 2
Specific Dosing Regimens
Standard high-dose formulation: Amoxicillin-clavulanate 90 mg/kg/day of the amoxicillin component divided into 2 doses (14:1 ratio formulation, also known as Augmentin ES-600 in the U.S.). 2, 4
Alternative standard-dose formulation: Amoxicillin-clavulanate 45 mg/kg/day of the amoxicillin component divided into 3 doses if β-lactamase-producing organisms are confirmed but high-dose therapy is not required. 1, 3
Maximum daily dose: Do not exceed 4 g/day of the amoxicillin component. 2, 3
Treatment Duration
Treat for 7-10 days for most cases of pneumonia, with 10 days being the standard duration for confirmed bacterial pneumonia. 3, 5
Reassess at 48-72 hours: If no clinical improvement occurs, consider hospitalization for parenteral therapy (ampicillin or ceftriaxone) and further diagnostic workup including chest radiography and blood cultures. 2, 3
Critical Dosing Pitfalls to Avoid
Do not underdose the amoxicillin component: Using 40-45 mg/kg/day instead of the recommended 90 mg/kg/day is a common and dangerous error that fails to overcome pneumococcal resistance. 2, 6
Do not use macrolides (azithromycin) as first-line therapy for presumed bacterial pneumonia in children under 5 years, as atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) are uncommon in this age group. 2
Do not use cefixime or other second/third-generation oral cephalosporins as first-line therapy for pneumonia, as they are explicitly not recommended and provide inferior coverage compared to high-dose amoxicillin or amoxicillin-clavulanate. 2
Special Considerations for Severe Pneumonia
Add clindamycin (30-40 mg/kg/day in 3-4 doses orally) to beta-lactam therapy if community-associated MRSA is suspected based on necrotizing infiltrates, empyema, or recent influenza infection, but only if local MRSA clindamycin resistance is <10%. 2, 7
Hospitalize immediately and initiate IV therapy (ampicillin 150-200 mg/kg/day every 6 hours or ceftriaxone 50-100 mg/kg/day) if the child exhibits severe respiratory distress, hypoxemia, inability to tolerate oral intake, or failure to respond to outpatient therapy. 2
Penicillin Allergy Management
For non-severe allergic reactions: Consider oral cephalosporins (cefpodoxime, cefprozil, or cefuroxime) under medical supervision, as cross-reactivity risk is low (1-3%). 2
For severe allergic reactions (anaphylaxis): Use levofloxacin 16-20 mg/kg/day divided twice daily (children 6 months to 5 years) or 8-10 mg/kg once daily (children 5-16 years, maximum 750 mg/day) as the preferred alternative. 2, 3