High‑Dose Amoxicillin‑Clavulanate for Acute Otitis Media in Children

Dosing Recommendations

For a child weighing approximately 20 kg with acute otitis media, prescribe Augmentin ES‑600 (600 mg amoxicillin / 42.9 mg clavulanate per 5 mL) at 10 mL twice daily for 10 days, delivering 90 mg/kg/day of amoxicillin (American Academy of Pediatrics) 1.
The high‑dose regimen provides 90 mg/kg/day amoxicillin and 6.4 mg/kg/day clavulanate in a 14:1 amoxicillin‑to‑clavulanate ratio, specifically formulated for acute otitis media (American Academy of Pediatrics) 1.

High‑dose amoxicillin‑clavulanate is the preferred first‑line option for children with acute otitis media who have received amoxicillin within the prior 30 days (American Academy of Pediatrics) 1.
It is also recommended for children younger than 2 years with bilateral disease (American Academy of Pediatrics) 1.
The regimen is indicated when purulent conjunctivitis co‑exists (otitis‑conjunctivitis syndrome) (American Academy of Pediatrics) 1.
It provides necessary coverage for β‑lactamase‑producing Haemophilus influenzae and Moraxella catarrhalis (American Academy of Pediatrics) 1.

Duration of therapy: 10 days (American Academy of Pediatrics) 1.
Clinical reassessment: evaluate response at 48–72 hours after initiation (American Academy of Pediatrics) 1.
Failure criteria: lack of improvement or clinical worsening after 48–72 hours should prompt consideration of alternative therapy (e.g., ceftriaxone ≈ 50 mg/kg IM/IV daily for 3 days) (American Academy of Pediatrics) 1.

When a child has taken amoxicillin within the past 30 days or presents with moderate‑to‑severe illness, high‑dose amoxicillin‑clavulanate is specifically indicated over standard‑dose amoxicillin (American Academy of Pediatrics; additional support from a second Pediatrics source) 1, 2.
For children with a true penicillin allergy, recommended alternatives include cefdinir (≈ 14 mg/kg/day) or ceftriaxone (American Academy of Pediatrics) 1.

The World Health Organization recommends amoxicillin 40 mg/kg twice daily for uncomplicated acute otitis media in resource‑limited settings (British Journal of Pharmacology) 3.
Current U.S. guidelines (American Academy of Pediatrics) favor the higher 80–90 mg/kg/day dosing to address rising antimicrobial resistance (Pediatrics) 1.