What is the recommended antibiotic treatment for a ruptured eardrum (tympanic membrane perforation) due to infection?

Antibiotic Treatment for Ruptured Eardrum

Treatment Depends on the Clinical Context

For acute otitis media with spontaneous tympanic membrane perforation (purulent drainage from infected middle ear), use topical fluoroquinolone eardrops as first-line therapy—specifically ofloxacin or ciprofloxacin-dexamethasone drops twice daily for up to 10 days. 1

Acute Otitis Media with Perforation and Drainage

When a ruptured eardrum occurs in the context of acute otitis media with visible purulent drainage:

• Topical antibiotic eardrops alone are the best treatment for acute otitis media with tympanic membrane perforation and visible ear drainage 1
• Use ofloxacin or ciprofloxacin-dexamethasone drops in the ear canal twice daily for up to 10 days 1
• After placing drops, "pump" the tragus (flap of skin in front of the ear canal) several times to help drops enter through the perforation 1
• Oral antibiotics are unnecessary for most cases unless the patient is severely ill, has another indication for systemic antibiotics, or the infection fails to resolve with topical therapy 1

Critical distinction: The fluoroquinolones used topically (ofloxacin, ciprofloxacin) are appropriate here because they target Pseudomonas aeruginosa and Staphylococcus aureus, the predominant pathogens in acute tympanic membrane otorrhea, especially after water exposure 1. These are external auditory canal pathogens, not the typical middle ear pathogens.

If Systemic Antibiotics Are Required

When oral antibiotics are necessary (severe illness, treatment failure with topical therapy, or no visible drainage but confirmed middle ear infection):

• High-dose amoxicillin-clavulanate (90 mg/kg/day of amoxicillin component with 6.4 mg/kg/day clavulanate in 2 divided doses) is the appropriate choice 1
• This covers beta-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis, as well as resistant Streptococcus pneumoniae 1
• For penicillin allergy, use cefdinir, cefuroxime, or cefpodoxime 1

Treatment Duration

• Children under 2 years: 10 days of therapy 1
• Children over 2 years and adults: 5-7 days may be sufficient 1

Traumatic Perforation Without Active Infection

For traumatic tympanic membrane perforations without signs of acute infection:

• Oral antibiotics significantly improve closure rates (94.5% with antibiotics vs 76% without, p=0.023) 2
• Use amoxicillin-clavulanate 1000 mg twice daily for 7 days 2
• Keep the ear dry to prevent secondary infection 3
• Most traumatic perforations heal spontaneously, but antibiotics accelerate healing 2

Special Populations

Neonates (first 10 days of life) with spontaneous perforation:

• Require parenteral antibiotics due to high prevalence of Pseudomonas aeruginosa 4
• Use ampicillin-ceftazidime for 10 days 4
• Oral antibiotics are inadequate for neonatal cases 4

Critical Pitfalls to Avoid

• Do not use oral fluoroquinolones (ofloxacin, ciprofloxacin) for acute otitis media, as they lack adequate pneumococcal coverage 5
• Do not prescribe antibiotics without visualizing the tympanic membrane to confirm the diagnosis 6, 5
• Avoid prolonged topical antibiotic use (>10 days) to prevent yeast infections of the ear canal 1
• Do not use azithromycin as first-line therapy—it has inferior efficacy compared to amoxicillin-clavulanate for eradicating S. pneumoniae and H. influenzae 1, 7

When to Refer to ENT

• Perforation persists beyond 6-8 weeks despite appropriate treatment 3
• Continuous pain, vertigo, or facial paralysis 3
• Ear drainage continues for more than 7 days despite topical antibiotics 1
• Multiple treatment failures requiring tympanocentesis 6
• Suspected cholesteatoma or chronic middle ear infection 3