What is the treatment for ear infections in adults?

Treatment of Ear Infections in Adults

For uncomplicated otitis externa in adults, prescribe topical antibiotic drops (with or without corticosteroids) as first-line therapy, reserving systemic antibiotics exclusively for acute otitis media or cases with extension beyond the ear canal. 1, 2

Distinguish the Type of Ear Infection First

The critical first step is determining whether you're treating otitis externa (outer ear canal infection) versus acute otitis media (middle ear infection), as management differs fundamentally. 1, 2

Otitis Externa (Most Common in Adults)

• Hallmark sign: Intense tenderness when moving the tragus or pinna, often disproportionate to visual findings 3
• Symptoms: Ear pain, itching, fullness, ear canal swelling/redness, discharge—often following swimming or ear trauma 3, 1
• Pathogens: Predominantly Pseudomonas aeruginosa (20-60%) and Staphylococcus aureus (10-70%), nearly always bacterial (98%) 3, 2

Acute Otitis Media (Less Common in Adults)

• Diagnosis requires: Acute symptom onset, presence of middle ear effusion (confirmed by pneumatic otoscopy), AND signs of middle ear inflammation 4
• Symptoms: Ear pain, hearing loss, fever—but no tragal tenderness 3, 4
• Pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis 2, 4

Assess Modifying Factors That Change Management

Before prescribing, identify these critical factors: 3, 1

• Non-intact tympanic membrane or tympanostomy tubes: Requires non-ototoxic topical preparations (avoid aminoglycosides) 3, 1
• Diabetes or immunocompromised state: High risk for necrotizing otitis externa and fungal infections—may require systemic antibiotics even for otitis externa 3, 1, 2
• Prior radiotherapy: May necessitate systemic antimicrobials 2, 4

First-Line Treatment for Uncomplicated Otitis Externa

Topical antibiotic therapy is superior to systemic antibiotics because it delivers 100-1000 times higher antibiotic concentrations directly to the infection site. 1, 2

Specific Topical Regimen

• Preferred: Topical fluoroquinolone drops (ciprofloxacin or ofloxacin) with or without corticosteroids 3
• Corticosteroid-containing drops may provide faster pain relief 1
• If ear canal is obstructed: Place a wick to facilitate medication delivery, remove after 24-48 hours 3
• Duration: Continue until 48 hours after symptoms resolve, typically 7-10 days total 3

Critical Pitfall to Avoid

Do NOT prescribe oral antibiotics for uncomplicated otitis externa—this increases antibiotic resistance without clinical benefit and exposes patients to unnecessary adverse effects. 1, 2

Pain Management (Essential for All Patients)

Prescribe systemic analgesics based on pain severity for all patients with ear infections. 3, 1

• First-line: Acetaminophen or ibuprofen at adequate doses 1, 4
• Topical analgesics: May reduce ear pain within 10-30 minutes, though evidence quality is limited 1, 2
• Pain management should be addressed immediately, regardless of antibiotic therapy 4

When Systemic Antibiotics ARE Indicated

Systemic antibiotics are appropriate for: 1, 2

1. Confirmed Acute Otitis Media

• First-line: Amoxicillin-clavulanate 1.75g/250mg daily for mild-moderate disease 1, 2, 5
• High-dose: 4g amoxicillin/250mg clavulanate daily for recent antibiotic exposure or moderate disease 2
• Duration: 5-10 days (optimal duration uncertain in adults) 4
• Penicillin allergy: Respiratory fluoroquinolones (levofloxacin, moxifloxacin) with 90-92% efficacy 2

2. Extension Beyond Ear Canal

• Requires systemic antibiotics covering P. aeruginosa and S. aureus 3

3. High-Risk Patients

• Diabetes, immunocompromised state, or prior radiotherapy may require systemic therapy even for otitis externa 3, 1, 2

Expected Timeline and When to Reassess

Symptoms should improve within 48-72 hours of initiating appropriate therapy. 3, 1, 2

If NO Improvement by 48-72 Hours:

• Reassess the diagnosis: Consider alternative causes (dermatologic disorders, fungal infection, necrotizing otitis externa) 3, 1
• Check adherence: Confirm patient is correctly administering drops 3
• Evaluate for obstruction: May need aural toilet or wick placement 3
• Consider culture: Identify resistant bacteria or fungi requiring targeted therapy 3
• Switch antibiotic class: For confirmed treatment failure, change to different agent rather than increasing dose 2, 4

Complete Resolution Timeline

• Most pain resolves within 4-7 days 3
• Complete symptom resolution may take up to 2 weeks 3
• Follow-up warranted if symptoms fail to resolve completely by 2 weeks 3

Critical Red Flags Requiring Specialist Referral

Refer to otolaryngology if: 1

• Symptoms persist beyond 7 days despite appropriate treatment
• Hearing loss develops or persists
• Suspected necrotizing otitis externa (severe pain, granulation tissue, cranial nerve involvement in diabetic/immunocompromised patients) 1, 2
• Recurrent infections
• Excessive cerumen that cannot be safely removed

Missing necrotizing otitis externa in diabetic or immunocompromised patients is a life-threatening error requiring aggressive treatment with IV antibiotics and imaging. 1, 2

Prevention Strategies for Recurrent Otitis Externa

• Remove obstructing cerumen regularly 1
• Use acidifying ear drops (2% acetic acid) before and after swimming 1
• Dry ear canal with hair dryer on low setting after water exposure 1
• Use ear plugs while swimming 1