What is the recommended treatment for an ear infection?

Treatment of Ear Infection

Immediate Treatment Depends on Type of Ear Infection

The treatment for ear infection fundamentally differs based on whether you have acute otitis externa (outer ear canal infection) or acute otitis media (middle ear infection), and your answer must specify which type you're treating.

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For Acute Otitis Externa (Swimmer's Ear)

All topical antibiotic eardrops are equally effective for acute otitis externa, with no consistent advantage of any specific agent. 1

First-Line Treatment

• Prescribe any FDA-approved topical antibiotic eardrop (with or without corticosteroid) for at least 7 days, even if symptoms resolve earlier 1
• All approved eardrops demonstrate equivalent clinical efficacy 1
• Selection factors include cost, dosing frequency, tympanic membrane status, and patient preference 1

Critical Eardrop Administration Technique

• Have someone else administer the drops when possible 1
• Lie with affected ear upward and fill the canal completely 1
• Remain in this position for 3-5 minutes to allow adequate penetration 1

Essential Pain Management

• Provide systemic analgesics (acetaminophen or ibuprofen) immediately, as pain relief is critical in the first 48-72 hours before eardrops become effective 1
• Avoid anesthetic eardrops during active infection as they can mask treatment failure 1

Special Considerations for Eardrop Selection

• If tympanic membrane perforation, prior ear surgery, or tympanostomy tubes are present, use only eardrops approved for middle ear use 1
• Inform your physician if you have diabetes, as this alters management 1

Activity Restrictions

• Avoid inserting anything into the ear canal, including cotton swabs 1
• Cover ear canal opening with petroleum jelly-coated cotton or earplug before showering 1
• Discuss swimming restrictions with your physician 1

Treatment Failure Protocol

• Reassess if no improvement within 48-72 hours 1
• Continue eardrops up to 14 days total if symptoms persist beyond initial 7 days 1

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For Acute Otitis Media (Middle Ear Infection)

High-dose amoxicillin (80-90 mg/kg/day) is the first-line antibiotic for acute otitis media in patients without penicillin allergy. 1, 2, 3

Observation Option (Watchful Waiting)

• Consider observation without immediate antibiotics for:
  • Children 6 months to 2 years with non-severe illness and uncertain diagnosis 1
  • Children ≥2 years without severe symptoms or with uncertain diagnosis 1
• Reassess at 48-72 hours and initiate antibiotics if no improvement 1
• This approach does not worsen recovery but may prolong symptoms by 1-2 days 4

When to Treat Immediately with Antibiotics

• Children <6 months of age 1
• Severe illness (high fever >39°C, moderate-to-severe otalgia) at any age 1
• Bilateral acute otitis media in children <2 years 1
• Bulging tympanic membrane with otorrhea 5

First-Line Antibiotic Regimen

• Amoxicillin 80-90 mg/kg/day divided twice daily for 5-10 days 1, 2, 3
• Duration: 10 days for children <2 years; 5-7 days for children ≥2 years and adults 1
• Take at the start of meals to minimize gastrointestinal intolerance 2

Alternative Antibiotics for Penicillin Allergy

• For non-type I hypersensitivity: Cefdinir, cefpodoxime, or cefuroxime 1
• For type I hypersensitivity: Azithromycin (single 30 mg/kg dose or 10 mg/kg day 1, then 5 mg/kg days 2-5) 6, though efficacy is lower (77-81% vs 90-92% for cephalosporins) 7

Second-Line Treatment for Treatment Failure

• If no improvement at 48-72 hours, switch to amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component) 1
• Alternative: Ceftriaxone IM 50 mg/kg/day for 1-3 days 1, 7
• Consider tympanocentesis for culture if second-line therapy fails 1

Mandatory Pain Management

• Address pain in the first 24 hours regardless of antibiotic use 1
• Use acetaminophen or ibuprofen as primary analgesics 1
• Pain typically improves within 48-72 hours of antibiotic initiation 1

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Critical Pitfalls to Avoid

• Never prescribe antibiotics for isolated tympanic membrane erythema without middle ear effusion, as this commonly occurs with viral pharyngitis 1, 7
• Avoid trimethoprim-sulfamethoxazole or erythromycin-sulfisoxazole as second-line agents due to substantial pneumococcal resistance 7
• Do not use ear candles for any ear infection—they cause harm including tympanic membrane perforation and provide no benefit 1
• Never use systemic corticosteroids for routine acute otitis media treatment 7
• If patient tastes eardrops, this indicates tympanic membrane perforation—notify physician immediately 1