Can you write a prescription for amoxicillin oral suspension for a 30 kg child with acute otitis media, including the dose, 10‑day duration, and instructions to switch to high‑dose amoxicillin‑clavulanate if there is no improvement within 48‑72 hours?

Amoxicillin Prescription for Acute Otitis Media in a 30 kg Child

For a 30 kg child with acute otitis media, prescribe amoxicillin oral suspension 2700 mg/day (90 mg/kg/day) divided into two doses of 1350 mg every 12 hours for 10 days, with instructions to switch to high-dose amoxicillin-clavulanate if no improvement occurs within 48-72 hours. 1, 2

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Prescription Details

Medication: Amoxicillin oral suspension (400 mg/5 mL concentration recommended for ease of dosing)

Dose Calculation:

• Weight-based dose: 90 mg/kg/day = 2700 mg/day for 30 kg child 1, 2
• Divided into 2 doses: 1350 mg every 12 hours 1, 2
• Volume per dose: 16.9 mL of 400 mg/5 mL suspension (or 27 mL of 250 mg/5 mL suspension) 3

Duration: 10 days 1, 2

Instructions:

• Administer every 12 hours (twice daily) 1, 2
• May be taken with or without food 3
• Shake suspension well before each use 3
• Refrigerate suspension after reconstitution 3

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Rationale for High-Dose Amoxicillin

High-dose amoxicillin (80-90 mg/kg/day) is the preferred first-line therapy because it achieves middle ear fluid concentrations that exceed the minimum inhibitory concentration for drug-resistant Streptococcus pneumoniae, with 87% of isolates susceptible to high-dose versus only 83% to standard dosing. 1, 2

• Amoxicillin is the most active oral β-lactam against streptococci, including pneumococci, due to its intrinsic activity and excellent bioavailability 4
• The 10-day duration is specifically recommended for children under 6 years or those with severe symptoms 1
• Serum levels of amoxicillin increase linearly with dose, and the difference in adverse effects between lower and higher doses is negligible 4

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Failure Protocol: When to Switch

If the child shows no improvement or worsening symptoms within 48-72 hours, switch to high-dose amoxicillin-clavulanate. 1, 2

Second-Line Prescription:

• Amoxicillin-clavulanate oral suspension (14:1 ratio formulation)
• Dose: 90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate 1, 2, 3
• For 30 kg child: 2700 mg amoxicillin/192 mg clavulanate per day
• Divided into 2 doses: 1350 mg/96 mg every 12 hours 1, 2
• Use the 600 mg amoxicillin/42.9 mg clavulanate per 5 mL suspension (ES-600 formulation) 3, 5
• Volume per dose: 11.25 mL every 12 hours
• Continue for 10 days 1, 2

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Clinical Monitoring

Reassess the patient at 48-72 hours to evaluate for clinical improvement, defined as reduction in fever, ear pain, and irritability. 1, 2

• Persistent fever or worsening symptoms after 48-72 hours indicates treatment failure and requires switching to amoxicillin-clavulanate 1, 2
• If failure persists after amoxicillin-clavulanate, consider intramuscular ceftriaxone 50 mg/kg/day for 3 days 1, 2
• Address pain management with analgesics regardless of antibiotic choice 1

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Important Caveats

Do not use amoxicillin-clavulanate as first-line therapy unless the child has received amoxicillin within the prior 30 days, has concurrent purulent conjunctivitis, or attends daycare—situations that increase risk of β-lactamase-producing organisms. 1

• The addition of clavulanate preserves amoxicillin activity against β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis but does not enhance activity against S. pneumoniae 4
• The twice-daily regimen is associated with significantly less diarrhea compared to three-times-daily dosing 3, 6
• Persistent middle ear effusion without acute symptoms after treatment (present in 60-70% at 2 weeks, 40% at 1 month) does not require additional antibiotics 1