In a 5‑year‑old female weighing 27 kg with 2 days of fever and a productive cough producing green sputum, what is the likely diagnosis and what are the appropriate doses of amoxicillin‑clavulanate suspension (250 mg/5 ml) twice daily for 7 days and paracetamol?

Diagnosis and Treatment of a 5-Year-Old with Fever and Productive Cough

Most Likely Diagnosis

This clinical presentation is most consistent with community-acquired pneumonia (CAP), given the 2-day history of fever with productive cough and greenish sputum in a 5-year-old child. 1 The green phlegm suggests bacterial infection, though this alone does not definitively distinguish bacterial from viral etiology. 1

---

Antibiotic Selection and Dosing

Co-Amoxiclav (Amoxicillin-Clavulanate) Dosing

For this 27 kg child with presumed bacterial pneumonia, the recommended dose is 90 mg/kg/day of the amoxicillin component divided into 2 doses (BID) for 7-10 days. 1, 2

Calculation:

• Total daily dose: 27 kg × 90 mg/kg = 2,430 mg/day
• Per dose (BID): 2,430 mg ÷ 2 = 1,215 mg per dose
• Using 250 mg/5 mL suspension: 1,215 mg ÷ 50 mg/mL = 24.3 mL per dose
• Practical dosing: Give 24 mL twice daily (morning and evening, 12 hours apart) 2, 3

The high-dose regimen (90 mg/kg/day) is specifically indicated for children ≥5 years with community-acquired pneumonia to provide adequate coverage against penicillin-resistant Streptococcus pneumoniae and β-lactamase-producing organisms. 1, 2

---

Treatment Duration

Complete a full 7-10 day course of therapy; for pneumonia specifically, 10 days is preferred. 1, 2, 3 Continue treatment for at least 48-72 hours after complete resolution of fever and respiratory symptoms. 2

---

Paracetamol (Acetaminophen) Dosing

For fever management, give paracetamol 15 mg/kg per dose every 6 hours (maximum 60 mg/kg/day). 4

Calculation for 27 kg child:

• Per dose: 27 kg × 15 mg/kg = 405 mg per dose
• Practical dosing: Give 400 mg every 6 hours as needed for fever or discomfort
• Maximum daily dose: 27 kg × 60 mg/kg = 1,620 mg/day (do not exceed)

---

Clinical Monitoring and Expected Response

Clinical improvement should be evident within 48-72 hours of starting appropriate antibiotic therapy. 1, 2 Specifically:

• Fever should resolve within 24-48 hours for pneumococcal pneumonia 2, 5
• Cough may persist longer and does not indicate treatment failure 5
• If no improvement or worsening occurs after 48-72 hours, reevaluation is mandatory and may require:
  • Consideration of atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae) and addition of a macrolide 1, 5
  • Further diagnostic imaging 1
  • Possible hospitalization 1, 5

---

Critical Considerations and Pitfalls

Why High-Dose Co-Amoxiclav?

The 90 mg/kg/day regimen is essential because it achieves adequate tissue concentrations to overcome penicillin-resistant S. pneumoniae (the most common bacterial pathogen in pediatric CAP) and covers β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis. 1, 2, 3

When to Consider Alternative Therapy

If the child is ≥5 years old and shows no improvement after 48-72 hours on high-dose amoxicillin-clavulanate, add a macrolide (azithromycin 10 mg/kg on day 1, then 5 mg/kg daily for days 2-5) to cover atypical pathogens. 1, 5

Common Dosing Errors to Avoid

• Do not use standard-dose amoxicillin-clavulanate (45 mg/kg/day) for pneumonia in this age group—it provides inadequate coverage for resistant organisms 2, 3
• Verify the suspension concentration before dispensing (250 mg/5 mL vs. other formulations) to avoid calculation errors 3
• Do not continue the same antibiotic beyond 72 hours without clinical improvement—this constitutes treatment failure requiring intervention 5

Adverse Effects

Common side effects of high-dose amoxicillin-clavulanate include diarrhea (occurs in approximately 25% of patients) and abdominal discomfort. 3, 6 These are generally mild and do not require discontinuation unless severe.

---

When to Seek Urgent Care

Immediate medical reevaluation is required if:

• Respiratory rate >50 breaths/min, oxygen saturation ≤92%, grunting, or cyanosis 5
• Inability to tolerate oral intake or signs of dehydration 5
• No improvement after 5 days of appropriate high-dose therapy 5
• Clinical deterioration at any point during treatment 1, 5