What is the treatment for an ear infection?

Treatment of Ear Infections

For acute otitis media (AOM) in children under 2 years, immediate antibiotic therapy with amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil for 8-10 days is recommended, while children over 2 years and adults can receive a 5-day course or observation with pain control depending on symptom severity. 1, 2

Age-Based Treatment Algorithm

Children Under 2 Years

• Immediate antibiotic therapy is recommended for all cases of AOM 1
• Treatment duration: 8-10 days 1, 2
• First-line options: amoxicillin-clavulanate, cefpodoxime-proxetil, or cefuroxime-axetil 1, 2

Children Over 2 Years and Adults

• Observation with pain control is reasonable unless marked symptoms (high fever, intense earache) are present 1
• If observation chosen, reassess after 48-72 hours of symptomatic therapy 1
• Treatment duration when antibiotics prescribed: 5 days 1, 2
• First-line options: amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil 1, 2

Specific Clinical Scenarios

Febrile Painful Otitis (Likely Pneumococcal)

• Amoxicillin, cefuroxime-axetil, or cefpodoxime-proxetil are appropriate choices 1
• High probability of Streptococcus pneumoniae infection 1

Otitis with Purulent Conjunctivitis (Likely H. influenzae)

• Use cefixime, cefpodoxime-proxetil, amoxicillin-clavulanate, or cefuroxime-axetil 1
• Strong probability of Haemophilus influenzae infection 1

Beta-Lactam Allergy

• Erythromycin-sulfafurazole is the alternative 1
• Macrolides and doxycycline are additional options 1, 2
• Important caveat: These alternatives have bacteriologic failure rates of 20-25% due to increasing resistance 2

Ear Infections with Tympanostomy Tubes

With Visible Drainage

• Topical antibiotic ear drops alone (ofloxacin or ciprofloxacin-dexamethasone) are the best treatment 1
• Place drops in ear canal twice daily for up to 10 days 1
• "Pump" the tragus several times after placing drops to help entry 1
• Oral antibiotics are unnecessary unless the child is very ill or infection persists after ear drops 1
• Clinical cure rates with topical therapy: 77-96% versus only 30-67% with oral antibiotics 1

Without Visible Drainage

• Verify the tube is open and functioning 1
• If tube is open, infection should resolve without antibiotics 1
• If tube is blocked, treat as if no tube present 1

Pain Management

• Pain relief is essential regardless of antibiotic decision 3
• Use acetaminophen or ibuprofen as needed 1, 3
• Continue analgesics as long as needed 3

Critical Pitfalls to Avoid

Do NOT Prescribe Antibiotics For:

• Isolated tympanic membrane redness with normal landmarks 1, 2
• Otitis media with effusion (unless persisting >3 months) 1
• When tympanic membrane cannot be adequately visualized due to cerumen 1

When Visualization is Inadequate:

• Do not prescribe antibiotics without proper examination 1
• Consider ENT referral if ear canal cannot be cleaned 1
• In children over 2 years without earache, AOM diagnosis is highly improbable 1

Treatment Failure Management

• Reassess if symptoms persist >48 hours or worsen 1, 3
• Switch to second-line agent (typically amoxicillin-clavulanate if amoxicillin was used first) 2
• Consider tympanocentesis for bacteriological evaluation in infants <6 months or immunocompromised children 4

Special Considerations

• Ceftriaxone IM should only be used in exceptional circumstances 1, 2
• NSAIDs and corticosteroids have not demonstrated efficacy for AOM treatment 2
• Decongestants and nasal steroids do not hasten clearance of middle ear fluid 5
• Antibiotic resistance is increasing, particularly with S. pneumoniae, H. influenzae, and M. catarrhalis 2, 5