What is the treatment for an ear infection?

Treatment of Ear Infection

The treatment of ear infection depends critically on the type and location: for acute otitis media (middle ear infection) in children, amoxicillin is the first-line oral antibiotic when treatment is indicated, while for otitis externa (outer ear canal infection), topical antibiotic drops (ofloxacin or ciprofloxacin-dexamethasone) are superior to oral antibiotics and should be used as first-line therapy. 1, 2, 3

Acute Otitis Media (Middle Ear Infection)

When to Treat vs. Observe

Age-based approach is essential:

• Children under 2 years: Antibiotic therapy is recommended immediately 1
• Children over 2 years: Observation with symptomatic treatment for 48-72 hours is reasonable unless marked symptoms (high fever, intense earache) are present 1
• Pain management is mandatory regardless of antibiotic decision - use acetaminophen or ibuprofen 1, 2

First-Line Antibiotic Treatment

Amoxicillin is the drug of choice for uncomplicated acute otitis media 3, 4, 5, 6

• Standard dosing per FDA labeling: continue for minimum 48-72 hours beyond symptom resolution 3
• Take at the start of meals to minimize gastrointestinal intolerance 3
• Covers the most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis 1, 6

Second-Line Options

If treatment fails or beta-lactamase-producing organisms suspected:

• Amoxicillin-clavulanate is the reference second-line therapy 1
• Alternative options include cefuroxime-axetil, cefpodoxime-proxetil, or cefixime 1
• For beta-lactam allergy: erythromycin-sulfisoxazole 1, 4

Clinical clues for pathogen-directed therapy:

• Otitis with purulent conjunctivitis suggests H. influenzae - use cefixime, cefpodoxime-proxetil, or amoxicillin-clavulanate 1
• Febrile painful otitis suggests pneumococcal infection - amoxicillin, cefuroxime-axetil, or cefpodoxime-proxetil 1

Treatment Duration

• 8-10 days for children under 2 years 1
• 5 days for children over 2 years 1

Otitis Externa (Outer Ear Canal Infection)

Topical antibiotic drops are vastly superior to oral antibiotics - achieving 77-96% clinical cure rates versus only 30-67% with systemic antibiotics 1

First-Line Treatment

Use topical antibiotic drops alone:

• Ofloxacin OR ciprofloxacin-dexamethasone 1
• Apply 2 times daily for up to 10 days 1
• Proper administration technique: "Pump" the tragus several times after placing drops to help them enter the ear canal 1, 2

Topical therapy delivers 100-1000 times higher antimicrobial concentration at the infection site compared to systemic antibiotics 2

When Systemic Antibiotics ARE Needed

Oral antibiotics are unnecessary for most otitis externa UNLESS:

• Extension of infection outside the ear canal 2
• Patient is very ill 1
• Infection does not resolve after topical drops 1

Ear Infections in Children with Tympanostomy Tubes

With Visible Drainage

Topical antibiotic drops alone are the best treatment:

• Ofloxacin or ciprofloxacin-dexamethasone drops, 2 times daily for up to 10 days 1
• Oral antibiotics are unnecessary unless child is very ill or infection persists despite drops 1
• Superior outcomes: 77-96% cure rate with topical therapy vs. 30-67% with oral antibiotics 1

Without Visible Drainage

• Verify tube is open and functioning - if so, infection should resolve without antibiotics 1
• Use acetaminophen or ibuprofen for pain during first few days 1
• If tube is blocked, treat as if tube were not present 1

Critical Follow-Up Indicators

Call for specialist referral if:

• Ear drainage continues more than 7 days despite treatment 1, 2
• Symptoms worsen or don't improve within 48-72 hours on observation approach 1, 2
• Hearing loss or continued ear pain develops 1
• Frequent recurrent infections occur 1

Common Pitfalls to Avoid

• Don't prescribe antibiotics for isolated tympanic membrane redness with normal landmarks - this is not acute otitis media 1
• Don't use oral antibiotics for otitis externa - topical therapy is far more effective 1, 2
• Don't use topical antibiotic drops for more than 10 days to avoid yeast infections 1
• Don't prescribe antibiotics for otitis media with effusion unless it persists beyond 3 months 1
• Don't use fluoroquinolones inactive on pneumococci (ofloxacin, ciprofloxacin) for systemic treatment of middle ear infections 1