Various Augmentin oral suspensions and the differences between them
Augmentin (Amoxicillin and Clavulonic acid), sometimes also called Clavamox or Moxiclav is an important medication in a pediatrician’s drug depository. Furthermore, there are quite a few physicians from other fields that tend to use this suspension frequently, as well (such as pediatric respirologists and otolaryngologists).
But there are several important questions that should be addressed when the need to treat with Augmentin comes up and these include:
1. Is Augmentin really necessary? First, the general need for antibiotics needs to be determined and second, one must always remember that Augmentin is usually not the first line of antibiotic treatment, and it is often possible to choose a more narrow-spectrum antibiotic before resorting to Amoxicillin and Clavulonic acid.
2. In most settings, there are 3 different Augmentin suspension dosages that are available in the market, and the purpose of this post is to help parents (and maybe doctors too…) to choose the suitable suspension and dosage depending on the case at hand.
This topic is certainly confusing. I recently came across two cases where children were prescribed a very large dose of Augmentin, but when I looked over the medication pamphlet, I found out that these doses were within the acceptable range. So maybe large doses are allowed and are safe to use, but they are certainly unnecessary. Read more about this below.
What is Augmentin?
Augmentin is a combination of Amoxicillin, an antibiotic that belongs to the penicillin family, and Clavulanic acid. The addition of Clavulanic acid to Amoxicillin gives it the ability to treat bacteria that are not only covered by Amoxicillin, but also those that are resistant to it. Or, in other words, bacteria that have learned to deal with Amoxicillin but cannot handle the combination of Amoxicillin and Clavulanic acid.
And indeed, this is what has led Augmentin to become known for being a “strong antibiotic”. It is one of the most broad-spectrum antibiotics available, that can be given to children by mouth. As you will soon find out, this is both an advantage and a disadvantage.
When should augmentin be used in children?
First of all, let me start with explaining how and the answer to this is – choosing wisely. In my opinion, it is a sin to prescribe Augmentin casually. Both because of its side effects (I will explain more below) and because of its general implications towards the development of antibiotic resistance in the individual person taking it as well as on a community level. Want to learn more about the long-term effects of antibiotics, particularly Augmentin, in children? Click on the link here.
In pediatrics, Augmentin is usually given in severe infections or as second line therapy for infections. I am familiar with all those adults that claim that only Augmentin “works” for them. This is usually not true, but I don’t like to argue with anyone. In children, this isn’t the case. Situations when Augmentin may be used in children (and adults) include:
Ear infections in children: Augmentin is usually second line treatment for children who did not improve with adequate Amoxicillin dosing.
Urinary tract infections (pyelonephritis): or in other words an infection with suspected involvement of the kidneys.
Sinusitis: this is not a common condition in children and usually Amoxicillin is sufficient to treat it.
Augmentin can also be used in abdominal infections.
Skin infections, bone and joint infections and respiratory infections – in my opinion there are better options for these conditions.
What are the side effects of Augmentin?
In addition to being a broad-spectrum antibiotic, that has long term implications and effects on the normal flora of our intestines (the good bacteria that live within us in peace), and being able to cause penicillin-allergy (Augmentin contains Amoxicillin which belongs to the penicillin family), the most common side effects are abdominal pain and diarrhea.
Abdominal pain and diarrhea could be related both to the antibiotic that this medication contains which can change the normal intestinal flora, and to the effects of Clavulanic acid on our system.
Should we all take too much Clavulanic acid, we would all experience abdominal pain. This is the reason behind why it is important for the proportion of Clavulanic acid inside this medication to remain, more or less, constant.
Why do we have three different dosage formulations for augmentin oral suspension?
The three different augmentin oral suspension formulations have different ratios of the drug content for Amoxicillin and Clavulanic acid. Or, simply put, they have almost the same quantity of Clavulanic acid, with larger doses of Amoxicillin.
This allows us to gain the benefit of treatment using larger doses of Amoxicillin, and at the same time give sufficient Clavulanic acid to gain the benefit of its effect, without increasing the clavulanic dose to a level that would cause abdominal pain and diarrhea.
What are the 3 dosage formulations that are available today in most settings?
Augmentin 125 – every 5mL of the medication contains 125mg of amoxicillin and 31.25mg of clavulanic acid. Most countries have discontinued this formulation.
Augmentin 250 – every 5mL of the medication contains 250mg of Amoxicillin and 62.5mg of Clavulanic acid
Augmentin 400 – every 5mL of the medication contains 400mg of Amoxicillin and 57mg of Clavulanic acid.
Augmentin 600 (ES) – ES stands for extra strength. Every 5mL of this medication contains 600mg of Amoxicillin and 42.9mg of Clavulanic acid.
How do these formulations make sense? Note that as the dose of Amoxicillin increases between formulations, the quantity of Clavulanic acid decreases. The decrease in Clavulanic acid allows us to increase the dose of Amoxicillin, without risking the side effects of the Clavulanic acid, such as abdominal pain.
How did we tackle this issue in the past when these formulations did not exist?
In the past, when Augmentin 600 (ES) did not exist, and the specific case required a higher dose of Amoxicillin, we would prescribe the child with Augmentin 400 and ask the parents to give additional Amoxicillin. That is, we would create our own “Augmentin 600”.
What is the logic behind having different Augmentin formulations?
I’m glad you asked. Let’s take a look at these two examples to try and understand this.
Neil has an ear infection that did not improve despite 3 days of adequate treatment with Amoxicillin. The physician that examined him has not noted any improvement and would like to upgrade his antibiotic therapy to the next line of therapy – Augmentin. Since the main bacteria that causes ear infections in children is the bacteria named pneumococcus, which requires a high dose of Amoxicillin, the physician must now prescribe Neil with a relatively high dose of Augmentin and will therefore most probably choose Augmentin 600, at a dose of 80mg/kg body weight/day for Neil.
Lia has a urinary tract infection and fever. A urine sample was sent for culture and the physician would like to start her on Augmentin until the culture results are back. The physician knows that the most common pathogens that cause urinary tract infections are the intestinal bacteria, especially Escherichia coli. Since these intestinal bacteria do not require a high dose of Amoxicillin, the physician will prescribe Lia with Augmentin 400, at a dose of 40mg/kg body weight/day.
And to those of you have made it this far – when the infection involves pneumococcus, the formulation chosen will usually be Augmentin 600, and when pneumococcus isn’t involved, Augmentin 400 is sufficient.
I actually see no reason to ever prescribe Augmentin 250.
What kind of mishaps have I come across?
This part is interesting, but it is reserved for advanced readers/parents only.
In the medication pamphlet of Augmentin 600, it says that the daily dose for children older than 3 months, and weighing less than 40kg, is 90mg of Amoxicillin for every kg body weight, per day, divided into twice daily.
That means that if Neil weighs 38kg, he will need to receive 3420mg (or 3.42g) of Amoxicillin per day, or about 14mL of the oral suspension twice daily (if you do the maths – 14mL in Augmentin 600 will contain 1710mg of Amoxicillin per dose, and this is to be given twice daily).
But, had Neil’s dad (God forbid) suffered from pneumonia, he would be prescribed 500mg of Amoxicillin, 3 times daily, i.e 1.5g per day.
How would it make sense for a child that weighs 38kg to receive twice as much antibiotics as his adult father?
First of all, I’d like to start by pointing out that this dose of antibiotic is safe and approved, and that sometimes, for certain medications, because of the physiological differences in the way the drugs are distributed and eliminated in children as opposed to adults, we do tend to give different doses to children. Amoxicillin can be given in very high doses to children. I have also prescribed such high doses for severe and exceptional cases.
On the other hand, giving such a high dose is a mistake, since, similarly to adults, most children do not need more than 1.5g of Amoxicillin per day. And if they do not need more, then there is certainly no need for them to receive more.
To summarize, I realize that this is one of the more difficult posts I have on this website. It is meant for thinking parents, who want to dig deeper into the topic, understand a little bit more and maybe even ask their medical provider, who is prescribing them these medications, the right questions. And as I have appointed this website a sentinel for all topics that can make the pediatric world a better place, I am pleased with this post and I am happy with its release as is to the public.
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