Avloclav BID 50ml Suspension – Co-amoxiclav 400+57mg/5ml Twice-Daily

1. About Avloclav BID Suspension (7:1 Ratio Co-amoxiclav)

Avloclav BID Suspension is the high-strength twice-daily paediatric formulation of Co-amoxiclav (Amoxicillin 400mg + Clavulanic Acid 57mg per 5ml), manufactured by ACI Limited, Bangladesh. This formulation uses the 7:1 amoxicillin:clavulanate ratio — compared to the standard 4:1 ratio in conventional co-amoxiclav suspension (125+31.25mg/5ml). The key advantages: (1) Higher amoxicillin dose per administration — better coverage of drug-resistant S. pneumoniae; (2) Lower clavulanate dose relative to amoxicillin — reduced diarrhoea compared to 4:1 formulations; (3) Twice-daily dosing (BID) — significantly improved adherence vs TDS. The 7:1 BID formulation is the paediatric equivalent of the adult 875+125mg BD tablet.

2. Why the 7:1 Ratio Matters Clinically

The amoxicillin:clavulanate ratio fundamentally affects both efficacy and tolerability. Standard 4:1 suspension (125+31.25mg/5ml): 4 parts amoxicillin to 1 part clavulanate — the original paediatric formulation. 7:1 BID formulation (400+57mg/5ml): 7 parts amoxicillin to 1 part clavulanate. Clinical implications: (1) For every unit of amoxicillin delivered, the 7:1 formulation delivers less clavulanate — this is clinically significant because clavulanate causes GI side effects (diarrhoea, nausea) through direct effects on gut motility receptors (motilin agonism); (2) Higher amoxicillin dose (45–90mg/kg/day achievable with BID formulation) enables coverage of drug-resistant S. pneumoniae — important for recurrent AOM, treatment-failure AOM, AOM in young children; (3) The BID schedule reduces total daily clavulanate exposure compared to giving equivalent amoxicillin dose as 4:1 TDS, substantially decreasing diarrhoea risk. This formulation is recommended in several paediatric guidelines specifically for high-dose co-amoxiclav situations.

3. Indications

• Acute otitis media (AOM) — high-dose indication: failed first-line therapy, young children (<2 years), daycare attendees, recent antibiotic exposure, or severe AOM
• Acute bacterial sinusitis — high-dose co-amoxiclav as first-line in guidelines requiring high-dose therapy
• Lower respiratory tract infection with suspected drug-resistant S. pneumoniae
• Recurrent respiratory infections where previous standard co-amoxiclav was associated with significant diarrhoea
• Skin and soft tissue infections requiring co-amoxiclav where TDS adherence is problematic

4. Dosage

Standard dose (amoxicillin component): 45mg/kg/day in 2 divided doses (BD) for standard indications; up to 90mg/kg/day BD for high-dose (drug-resistant pneumococcal) indications. Using 400mg/5ml suspension: for a 20kg child at 45mg/kg/day = 900mg/day ÷ 2 = 450mg per dose = 5.6ml BD. For 90mg/kg/day (high-dose): same child = 1800mg/day ÷ 2 = 900mg per dose — exceeds suspension concentration; would require large volumes. The maximum recommended amoxicillin dose is typically 4g/day in adults; adjust paediatric max dose as appropriate. Dosing table should be calculated by prescribing clinician based on current weight. Take with food to reduce GI side effects and optimise clavulanate absorption.

5. Reconstitution Instructions

Add cooled boiled water to the dry powder in two steps — add approximately half the required volume, shake vigorously, then add remainder to the 50ml mark and shake again. Refrigerate reconstituted suspension at 2–8°C; use within 7 days. Shake well before each dose. Measure each dose with the supplied oral syringe — not a household teaspoon. Discard remaining suspension after 7 days regardless of volume remaining. Do not freeze. The 50ml bottle is designed for shorter treatment courses or smaller children — parents should confirm with the prescriber whether additional bottles are needed for the full course.

6. Tolerability Advantages vs Standard TDS Suspension

A primary clinical rationale for the 7:1 BID formulation over standard 4:1 TDS formulation (when equivalent or higher amoxicillin dose is required): (1) Lower total clavulanate per day: For 45mg/kg/day amoxicillin in a 20kg child — 7:1 BID gives 900/7 × 2 = 257mg clavulanate/day vs 4:1 TDS for equivalent dose would give more clavulanate; (2) BID adherence: Twice-daily is demonstrably better adhered to than TDS, particularly for school-age children who are at school at midday dose time; (3) Reduced diarrhoea: Studies comparing 7:1 BID to 4:1 TDS show significantly lower diarrhoea incidence with the 7:1 formulation — a key driver of treatment discontinuation and apparent treatment failure in paediatric AOM.

Frequently Asked Questions (FAQ)

Q1: What is the difference between Avloclav BID suspension and regular Avloclav suspension?

Key differences: Avloclav BID (400+57mg/5ml) — 7:1 amoxicillin:clavulanate ratio, twice-daily dosing, higher amoxicillin concentration per 5ml, lower clavulanate relative to amoxicillin, lower diarrhoea incidence, better adherence, preferred for high-dose therapy, 50ml bottle. Regular Avloclav Suspension (125+31.25mg/5ml) — 4:1 ratio, three-times-daily dosing, lower concentration, higher relative clavulanate, 100ml bottle. The BID formulation is the preferred choice when high-dose co-amoxiclav is needed or when the child had significant diarrhoea on standard TDS suspension. For straightforward first-episode infections where standard dosing is sufficient, either formulation can be used.

Q2: Why does Avloclav BID cause less diarrhoea than regular co-amoxiclav suspension?

Co-amoxiclav-associated diarrhoea is primarily caused by clavulanate, not amoxicillin. Clavulanate acts as a motilin agonist (stimulates gut motility receptors similar to erythromycin), causing increased intestinal contractions and loose stools. The 7:1 BID formulation delivers less clavulanate per mg of amoxicillin compared to the 4:1 TDS formulation — so for the same amoxicillin dose, the child receives less gut-stimulating clavulanate per day. Additionally, twice-daily dosing means fewer clavulanate exposures per day than three-times-daily. The combination of lower clavulanate ratio and reduced dosing frequency significantly reduces diarrhoea incidence — clinical studies show approximately 30–50% reduction in diarrhoea with 7:1 BID vs 4:1 TDS formulations.

Q3: How do I give Avloclav BID suspension to my child — does it need to be refrigerated?

Before first use: add cooled boiled water to the dry powder (see label for exact volume), shake well, and refrigerate immediately. Each time you give a dose: remove from refrigerator, shake the bottle well, measure the prescribed volume using the oral dosing syringe (not a teaspoon), and give with or just before food. Replace the bottle in the refrigerator immediately after each dose — do not leave at room temperature for extended periods. The reconstituted suspension remains stable for 7 days in the refrigerator — mark the discard date on the bottle when you first mix it. If you forget to refrigerate and the suspension has been at room temperature for several hours, contact your pharmacist.

Q4: Can Avloclav BID suspension be used in children under 2 years old?

Avloclav BID suspension can be used in children from 3 months of age (the standard minimum age for co-amoxiclav). For infants under 3 months: limited pharmacokinetic data — co-amoxiclav should only be used under specialist guidance if the benefit clearly outweighs risk. For infants 3–24 months: this age group is actually a priority indication for high-dose co-amoxiclav in AOM — children under 2 years have: higher AOM recurrence rates, higher rates of non-typeable H. influenzae (which is commonly beta-lactamase-producing), higher rates of treatment failure with standard-dose amoxicillin. The 7:1 BID formulation is particularly appropriate in this age group when co-amoxiclav is indicated, provided dosing is calculated accurately by weight. Ear drops and decongestants should be avoided; adequate analgesia (paracetamol/ibuprofen) is important for comfort.