What is the appropriate Augmentin (amoxicillin/clavulanate) dosing for a child weighing approximately 60 lb (≈27 kg)?

Augmentin Dosing for a 60-Pound Child

For a child weighing 60 pounds (27 kg), the recommended Augmentin dose is 1,215 mg twice daily (90 mg/kg/day divided into 2 doses) for most bacterial respiratory infections, or 608 mg twice daily (45 mg/kg/day) for less severe infections without risk factors. 1, 2

Weight-Based Calculation

60 pounds = 27.3 kg

High-Dose Regimen (90 mg/kg/day):

• 27.3 kg × 90 mg/kg = 2,457 mg total daily dose
• Administered as 1,228 mg (approximately 1,215 mg) twice daily 1, 2
• This is the preferred regimen for most bacterial respiratory infections including pneumonia, acute otitis media, and acute bacterial sinusitis 1, 2

Standard-Dose Regimen (45 mg/kg/day):

• 27.3 kg × 45 mg/kg = 1,229 mg total daily dose
• Administered as 614 mg (approximately 608 mg) twice daily 1
• This lower dose is appropriate only for uncomplicated infections in children ≥2 years without risk factors 1

When to Use High-Dose (90 mg/kg/day)

Use the high-dose regimen when ANY of the following risk factors are present:

• Age < 2 years 1, 2
• Daycare attendance 1, 2
• Recent antibiotic use within the past 30 days 1, 2
• Moderate-to-severe illness at presentation 1, 2
• Geographic area with > 10% penicillin-resistant Streptococcus pneumoniae 1
• Incomplete Haemophilus influenzae type b vaccination 2
• Concurrent purulent acute otitis media with pneumonia 2

The high-dose formulation achieves middle-ear and sinus fluid concentrations sufficient to overcome penicillin-resistant S. pneumoniae with MICs up to 2–4 mg/L and provides coverage against β-lactamase-producing H. influenzae and Moraxella catarrhalis 1, 2, 3.

Practical Formulation Selection

For High-Dose Regimen (1,215 mg twice daily):

• Use the 400 mg/57 mg per 5 mL suspension: approximately 15 mL twice daily 4
• This provides the 14:1 ratio (amoxicillin:clavulanate) that minimizes diarrhea while maintaining efficacy 2, 5

For Standard-Dose Regimen (608 mg twice daily):

• Use the 400 mg/57 mg per 5 mL suspension: approximately 7.5 mL twice daily 4
• Or use the 250 mg/62.5 mg chewable tablet: 2.5 tablets twice daily 4

Maximum single dose: 2,000 mg per administration regardless of weight 2, 5

Maximum daily dose: 4,000 mg per day 1, 2

Indication-Specific Dosing

Community-Acquired Pneumonia:

• 90 mg/kg/day in 2 doses for 10 days 1, 2
• This applies to all children ≥3 months with presumed bacterial pneumonia 1

Acute Otitis Media:

• 90 mg/kg/day in 2 doses for 10 days if the child is < 2 years or has any risk factors listed above 2, 3
• 45 mg/kg/day in 2 doses for 10 days only if ≥2 years without risk factors 1

Acute Bacterial Sinusitis:

• 90 mg/kg/day in 2 doses if < 2 years, daycare attendance, or recent antibiotic use 1
• Continue for 7 days after symptom resolution, with a minimum total of 10 days 1

Group A Streptococcal Pharyngitis (Treatment Failure/Chronic Carrier):

• 40 mg/kg/day in 3 doses for 10 days (maximum 2,000 mg/day) 5
• For this 27 kg child: 360 mg three times daily 5
• Plain amoxicillin is preferred for first-line treatment; Augmentin is reserved for treatment failures 1

Treatment Duration and Monitoring

• Standard duration: 10 days for pneumonia, acute otitis media, and most respiratory infections 1, 2
• Clinical improvement should occur within 48–72 hours; if no improvement or worsening, reevaluate and consider switching antibiotics or investigating for complications 1, 2, 5
• Fever typically resolves within 24–48 hours for pneumococcal infections, though cough may persist longer 1

Administration Guidelines

• Administer at the start of meals to enhance clavulanate absorption and minimize gastrointestinal side effects 4
• Complete the full course even if symptoms improve before completion 1
• The twice-daily regimen is associated with significantly less diarrhea than three-times-daily dosing 4, 6

Common Pitfalls to Avoid

• Do not underdose: Using 45 mg/kg/day when 90 mg/kg/day is indicated leads to treatment failure with resistant organisms 1, 2
• Do not substitute formulations incorrectly: Two 250 mg/125 mg tablets are NOT equivalent to one 500 mg/125 mg tablet due to different clavulanate ratios 4
• Verify the indication: Most upper respiratory tract infections are viral and do not require antibiotics 1
• Do not use in children < 3 months without specialist consultation; IV regimens are preferred for this age group 2

Penicillin-Allergic Patients

Non-Anaphylactic Reactions:

• Second- or third-generation cephalosporins (cefdinir, cefuroxime) are safe alternatives with negligible cross-reactivity risk 1

IgE-Mediated (Type I) Reactions:

• Clindamycin: 10–20 mg/kg/day in 3 doses 1
• Azithromycin: 12 mg/kg once daily for 5 days (assess local macrolide resistance patterns first) 1