What antibiotics are recommended for a patient experiencing ear pain due to a bacterial ear infection?

Treatment of Ear Pain with Antibiotics

For ear pain due to acute otitis externa (swimmer's ear), topical antibiotic drops—not oral antibiotics—are the definitive first-line treatment, achieving cure rates of 65-90% within 7-10 days. 1

Critical First Step: Distinguish the Type of Ear Infection

Before prescribing antibiotics, you must differentiate between:

• Acute otitis externa (AOE): Inflammation of the ear canal with tenderness when moving the tragus or pinna, canal edema, erythema, and otorrhea 2
• Acute otitis media (AOM): Middle ear infection with middle ear effusion, bulging tympanic membrane, and acute symptoms 3

This distinction is essential because topical antibiotics are used for otitis externa, while oral antibiotics are used for otitis media 1, 3.

For Acute Otitis Externa (Outer Ear Canal Infection)

First-Line Treatment: Topical Antibiotic Drops

Topical antibiotics deliver drug concentrations 100-1000 times higher than oral antibiotics and achieve superior outcomes (77-96% cure rate vs. 30-67% for oral antibiotics). 1

Choice of topical agent depends on tympanic membrane integrity:

• If tympanic membrane is intact or certain: Any FDA-approved topical preparation is acceptable, including neomycin/polymyxin B/hydrocortisone or fluoroquinolones 2, 1
• If tympanic membrane is perforated, uncertain, or patient has tympanostomy tubes: Use ONLY non-ototoxic fluoroquinolones (ofloxacin 0.3% or ciprofloxacin 0.2%) 2, 1

Essential Pre-Treatment Step: Aural Toilet

Before administering any drops, the ear canal MUST be cleared of debris, cerumen, and inflammatory material through gentle suction, dry mopping, or irrigation to ensure medication reaches infected tissues. 1 If severe canal edema prevents drop entry, place a compressed cellulose wick to facilitate drug delivery 1.

Proper Drop Administration Technique

• Warm the bottle in hands for 1-2 minutes to prevent dizziness 1
• Have someone else administer drops if possible (only 40% of patients self-administer correctly) 1
• Lie with affected ear upward, fill canal completely with drops 1
• Maintain position for 3-5 minutes, apply gentle tragal pumping to eliminate trapped air 1

Treatment Duration and Pain Management

• Continue drops for minimum 7 days, even if symptoms resolve earlier 1
• Pain typically improves within 48-72 hours of starting topical therapy 2, 1
• Prescribe acetaminophen or NSAIDs for pain control; NSAIDs significantly reduce pain compared to placebo 2, 1

When Oral Antibiotics ARE Indicated for Otitis Externa

Oral antibiotics should NOT be prescribed as initial therapy for uncomplicated otitis externa. 2 Reserve systemic antibiotics for:

• Extension of infection beyond the ear canal 2, 1
• Diabetes mellitus or immunocompromised state 2, 1
• When topical therapy cannot reach the infected area 2, 1
• Treatment failure after 48-72 hours 1

When systemic antibiotics are needed, use fluoroquinolones (e.g., ciprofloxacin) for coverage against Pseudomonas aeruginosa and Staphylococcus aureus, which cause 98% of cases 1.

For Acute Otitis Media (Middle Ear Infection)

First-Line Treatment: Oral Amoxicillin

High-dose amoxicillin (80-90 mg/kg/day in 2 divided doses for children; 1.5-4 g/day for adults) is the first-line antibiotic for acute otitis media. 3, 4 Amoxicillin is effective against Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, which cause approximately 70% of AOM cases 3, 4.

When to Use Amoxicillin-Clavulanate Instead

Use amoxicillin-clavulanate (90 mg/kg/day of amoxicillin with 6.4 mg/kg/day of clavulanate) as first-line when: 3

• Patient received amoxicillin in previous 30 days 3
• Concurrent purulent conjunctivitis 3
• Need for coverage of beta-lactamase-producing organisms 3

Treatment Duration for AOM

• Children <2 years or severe symptoms: 10-day course 3
• Children 2-5 years with mild-moderate symptoms: 7-day course 3
• Children ≥6 years with mild-moderate symptoms: 5-7 day course 3

Observation Without Immediate Antibiotics (Selected Cases Only)

For children ≥6 months with non-severe AOM and reliable follow-up within 48-72 hours, observation without immediate antibiotics is appropriate: 3

• Children 6-23 months with non-severe unilateral AOM 3
• Children ≥24 months with non-severe AOM 3

Initiate antibiotics immediately if symptoms worsen or fail to improve within 48-72 hours. 3

Pain Management for AOM

Pain control must be addressed immediately in every patient with AOM, regardless of antibiotic decision. 3 Prescribe acetaminophen or ibuprofen, especially during the first 24 hours 3.

Common Pitfalls to Avoid

• Prescribing oral antibiotics for uncomplicated otitis externa (occurs inappropriately in 20-40% of cases) 1
• Using ototoxic preparations (aminoglycosides) when tympanic membrane integrity is uncertain 2, 1
• Failing to perform aural toilet before administering drops (medication cannot penetrate debris) 1
• Inadequate pain management (pain can be severe and underappreciated) 2, 1
• Using neomycin-containing drops in patients with eczema or chronic otitis externa (causes contact sensitivity in 13-30% of patients) 1

Reassessment Criteria

If no improvement occurs within 48-72 hours, reassess to confirm diagnosis and consider: 2, 1

• Inadequate drug delivery due to canal obstruction 1
• Poor adherence to therapy 1
• Allergic contact dermatitis from topical agents (especially neomycin) 1
• Fungal co-infection (otomycosis) 1
• Incorrect diagnosis 1

For AOM treatment failure, switch to amoxicillin-clavulanate or ceftriaxone IM 3.