What Augmentin (amoxicillin‑clavulanate) dose should be given to a child with acute otitis media and streptococcal pharyngitis?

Augmentin Dosing for Acute Otitis Media and Streptococcal Pharyngitis in Children

For acute otitis media, prescribe high-dose amoxicillin-clavulanate (Augmentin) at 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided into 2 doses daily (14:1 ratio formulation), for 10 days in children under 2 years or 7 days in children 2-5 years with mild-moderate disease. 1, 2 For streptococcal pharyngitis, amoxicillin-clavulanate is NOT first-line therapy; it is reserved only for recurrent or treatment-failure cases at 40 mg/kg/day (amoxicillin component) in 3 divided doses for 10 days. 3

Acute Otitis Media: When to Use Augmentin vs. Plain Amoxicillin

First-Line Therapy Decision

Plain high-dose amoxicillin (80-90 mg/kg/day divided twice daily) remains first-line for most children with acute otitis media. 1, 4 However, Augmentin should be prescribed as first-line therapy in the following specific situations:

• Recent antibiotic exposure: The child received amoxicillin within the past 30 days 1, 2
• Concurrent purulent conjunctivitis: This strongly suggests Haemophilus influenzae infection, which commonly produces beta-lactamase 1, 2
• High-risk settings: Children under 2 years attending daycare or in areas with high prevalence of beta-lactamase-producing organisms [1, @14@]
• Treatment failure: Symptoms persist or worsen 48-72 hours after starting plain amoxicillin 1, 4

Precise Augmentin Dosing for Otitis Media

Calculate the dose using the 14:1 ratio formulation (Augmentin ES-600): 2, 5

• Amoxicillin component: 90 mg/kg/day
• Clavulanate component: 6.4 mg/kg/day
• Frequency: Divide into 2 equal doses given 12 hours apart
• Maximum single dose: 2000 mg of amoxicillin [2, @14@]

Example calculation for a 15 kg child:

• Total daily amoxicillin: 15 kg × 90 mg = 1350 mg/day
• Per dose: 1350 mg ÷ 2 = 675 mg twice daily 2

Treatment Duration by Age

• Children under 2 years: 10 days regardless of severity 1, 5
• Children 2-5 years: 7 days for mild-moderate disease; 10 days for severe disease (moderate-to-severe otalgia or fever ≥39°C) 1, 5
• Children 6 years and older: 5-7 days for mild-moderate disease; 10 days for severe disease 1

Critical Advantage of Twice-Daily Dosing

The twice-daily Augmentin regimen (90/6.4 mg/kg/day) causes significantly less diarrhea than three-times-daily dosing (40/10 mg/kg/day)—approximately 10% vs. 27-34% incidence—while maintaining equivalent clinical efficacy. 5, 6 This improved tolerability directly enhances compliance. 7, 6

Streptococcal Pharyngitis: Limited Role for Augmentin

First-Line Therapy (NOT Augmentin)

For uncomplicated streptococcal pharyngitis, plain amoxicillin is first-line: 3

• Dose: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose)
• Duration: 10 days
• Strength of recommendation: Strong, high-quality evidence 3

Plain amoxicillin is preferred because strep throat does NOT involve beta-lactamase-producing organisms, making the clavulanate component unnecessary and exposing the child to additional side effects without benefit. 3

When Augmentin IS Indicated for Strep Throat

Augmentin should be used for streptococcal pharyngitis ONLY in these specific scenarios: 3

• Recurrent treatment failures: Multiple culture-positive episodes despite appropriate therapy
• Suspected chronic carrier state with recurrent symptomatic episodes

Dosing for recurrent strep pharyngitis: 3

• Children: 40 mg/kg/day (amoxicillin component) in 3 equally divided doses
• Duration: 10 days
• Strength of recommendation: Strong, moderate-quality evidence 3

Management of Treatment Failure

Otitis Media Treatment Failure Algorithm

If symptoms worsen or fail to improve within 48-72 hours: 1, 4

1. If initially treated with plain amoxicillin: Switch to high-dose Augmentin (90/6.4 mg/kg/day twice daily) 1, 4

2. If Augmentin fails: Administer intramuscular ceftriaxone 50 mg/kg once daily for 3 consecutive days (superior to single-dose regimen) 1, 2

3. After multiple failures: Consider tympanocentesis with culture and susceptibility testing 1

Strep Pharyngitis Treatment Failure

For recurrent strep pharyngitis unresponsive to standard therapy, Augmentin at 40 mg/kg/day in 3 divided doses for 10 days is one evidence-based option alongside clindamycin or combination regimens with rifampin. 3

Critical Pitfalls to Avoid

Dosing Errors

• Underdosing Augmentin: Using the older 40/10 mg/kg/day formulation instead of the high-dose 90/6.4 mg/kg/day formulation for otitis media leads to treatment failures against resistant S. pneumoniae 2, 8, 9
• Wrong ratio formulation: Two 250 mg tablets are NOT equivalent to one 500 mg tablet because both contain 125 mg clavulanate; always verify the 14:1 ratio for pediatric otitis media 3, 2
• Incorrect weight-based calculation: Always recalculate based on current weight, not age-based estimates 4

Inappropriate Use

• Using Augmentin for uncomplicated strep throat: This exposes children to unnecessary clavulanate-related diarrhea without clinical benefit, as Group A Streptococcus does not produce beta-lactamase 3
• Treating isolated tympanic membrane redness: This is not acute otitis media and does not require antibiotics 1
• Failing to address pain: Analgesics (acetaminophen or ibuprofen) must be initiated immediately for otitis media, as antibiotics provide no symptomatic relief in the first 24 hours 1, 4

Follow-Up Failures

• Not reassessing at 48-72 hours: Early recognition of treatment failure is essential to switch therapy before complications develop 1, 4
• Treating post-treatment effusion: 60-70% of children have middle ear effusion 2 weeks after successful otitis media treatment; this requires monitoring but NOT antibiotics unless it persists beyond 3 months with hearing loss 1

Concurrent Infections: Practical Approach

If a child presents with BOTH acute otitis media AND confirmed streptococcal pharyngitis:

• Use high-dose Augmentin (90/6.4 mg/kg/day twice daily) for 10 days to treat the otitis media, which will simultaneously treat the strep throat 1, 2
• This approach is justified because the otitis media requires the higher amoxicillin dose and potential beta-lactamase coverage, which will provide more than adequate coverage for the streptococcal pharyngitis 3, 1
• The 10-day duration satisfies requirements for both conditions 3, 1

Pain management is mandatory: Initiate weight-based acetaminophen or ibuprofen immediately for the otalgia, as antibiotics will not relieve ear pain in the first 24 hours. 1, 4