Antibiotics for an ear infection, such as amoxicillin, amoxicillin-clavulanate, cefdinir, or ceftriaxone, may be prescribed to treat bacterial acute otitis media. These medicines help eliminate bacteria that can infect the middle ear, such as Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.
Not all ear infections need antibiotics, as some cases can improve on their own with observation and symptom relief. Antibiotics are usually considered when symptoms are more severe, do not improve, or when there is a higher risk of complications.
The best antibiotic depends on age, symptom severity, previous antibiotic use, allergies, and whether there is ear drainage from a perforated eardrum or ear tubes. Antibiotics should only be used when prescribed by a doctor, as incorrect use can increase side effects and antibiotic resistance.
List of antibiotics
Antibiotics that a doctor may prescribe for an ear infection include:
1. Amoxicillin
Amoxicillin is usually considered the first-line antibiotic for uncomplicated acute otitis media in children and many adults. It is commonly used when there has been no recent amoxicillin use and there is no significant penicillin allergy.
Dosing: Children: 80 to 90 mg/kg/day divided into 2 doses, usually for 5 to 10 days depending on age and severity. Adults: commonly 875 mg twice daily or 500 mg three times daily for 5 to 10 days, as prescribed.
Side effects: Diarrhea, nausea, vomiting, abdominal discomfort, rash, urticaria, oral or vaginal candidiasis, and, rarely, anaphylaxis.
Contraindications: Serious hypersensitivity to penicillin or other beta-lactam antibiotics. Use with caution in significant kidney impairment and in people with mononucleosis, as rash is more common.
2. Amoxicillin-clavulanate
Amoxicillin-clavulanate is often prescribed when broader coverage is needed, such as after recent amoxicillin use, treatment failure, recurrent ear infection, or ear infection with purulent conjunctivitis. The clavulanate component helps treat bacteria that produce beta-lactamase, such as some Haemophilus influenzae and Moraxella catarrhalis strains.
Dosing: Children: 90 mg/kg/day of the amoxicillin component with 6.4 mg/kg/day of clavulanate, divided twice daily, usually for 5 to 10 days. Adults: commonly 875/125 mg twice daily or 2000/125 mg twice daily with extended-release formulations when indicated.
Side effects: Diarrhea, nausea, vomiting, abdominal discomfort, rash, itching, urticaria, oral thrush, vaginal candidiasis, cholestatic hepatitis, jaundice, severe hypersensitivity reactions, Stevens-Johnson syndrome, and Clostridioides difficile-associated diarrhea.
Contraindications: Previous amoxicillin-clavulanate-associated cholestatic jaundice or liver dysfunction. It is also contraindicated in people with serious penicillin or beta-lactam allergy and should be used with caution in liver disease or kidney impairment.
3. Cefdinir
Cefdinir is an oral third-generation cephalosporin that may be used when amoxicillin is not suitable, especially in some people with non-anaphylactic penicillin allergy. It is also used as a non-first-line option in some cases of acute otitis media.
Dosing: Children 6 months to 12 years: 7 mg/kg every 12 hours for 5 to 10 days, or 14 mg/kg once daily for 10 days, up to 600 mg/day. Older children, adolescents, and adults: commonly 300 mg twice daily or 600 mg once daily for 5 to 10 days.
Side effects: Diarrhea, nausea, vomiting, abdominal pain, rash, headache, candidiasis, and, rarely, C. difficile colitis.
Contraindications: Serious hypersensitivity to cephalosporins. Use with caution in people with severe penicillin allergy, and dose adjustment may be needed when creatinine clearance is below 30 mL/min.
4. Cefuroxime
Cefuroxime is an oral cephalosporin that may be prescribed as an alternative for ear infections when amoxicillin cannot be used. It has activity against common bacteria involved in acute otitis media, including some beta-lactamase-producing strains.
Dosing: Children: often 30 mg/kg/day divided twice daily for 5 to 10 days. Adults: up to 500 mg twice daily for 5 to 10 days, depending on severity and medical guidance.
Side effects: Diarrhea, nausea, vomiting, abdominal pain, rash, urticaria, and temporary liver enzyme changes.
Contraindications: Hypersensitivity to cephalosporins. Use with caution in people with immediate-type penicillin allergy, and dose adjustment may be needed in kidney impairment.
5. Cefpodoxime
Cefpodoxime is another oral cephalosporin option that may be used for acute otitis media when first-line treatment is not appropriate. It may be considered for children or adults who need an alternative to amoxicillin but do not have a high-risk anaphylactic beta-lactam allergy.
Dosing: Children: commonly 10 mg/kg/day divided twice daily, up to 400 mg/day, for about 5 to 10 days. Adults: often 200 mg twice daily, depending on severity and the doctor’s prescription.
Side effects: Diarrhea, nausea, vomiting, abdominal pain, rash, urticaria, and transient liver enzyme elevations.
Contraindications: Hypersensitivity to cephalosporins. Use with caution in true immediate-type penicillin allergy, and dose adjustment may be needed in kidney impairment.
6. Ceftriaxone
Ceftriaxone is an injectable third-generation cephalosporin that may be used when oral antibiotics are not possible, such as with vomiting, or when initial oral treatment fails. It is usually reserved for more severe, refractory, or selected recurrent cases of acute otitis media.
Dosing: Children: commonly 50 mg/kg IM or IV once daily for 1 to 3 days, with a maximum of 1 to 2 g/day depending on the protocol. Adults: commonly 1 to 2 g IM or IV daily for 1 to 3 days, as directed by local guidance.
Side effects: Injection-site pain, induration, tenderness, diarrhea, nausea, rash, eosinophilia, transient liver enzyme elevation, biliary sludge or pseudolithiasis, rare immune-mediated hemolytic anemia, and severe hypersensitivity reactions.
Contraindications: Hypersensitivity to ceftriaxone or cephalosporins. It is contraindicated in neonates receiving calcium-containing IV solutions and should be used with caution in significant combined kidney and liver dysfunction.
7. Azithromycin
Azithromycin is a macrolide antibiotic with a limited role in ear infections because of resistance concerns and lower effectiveness against some Streptococcus pneumoniae strains. It is generally reserved for special cases when no beta-lactam antibiotic can be safely used.
Dosing: Children: commonly 10 mg/kg on day 1, followed by 5 mg/kg once daily on days 2 to 5, or 10 mg/kg once daily for 3 days. Adults: commonly 500 mg on day 1, followed by 250 mg once daily on days 2 to 5, when prescribed.
Side effects: Diarrhea, nausea, abdominal pain, headache, rash, transient liver enzyme elevation, QT-interval prolongation, arrhythmia risk, rare severe hypersensitivity reactions, and rare hepatotoxicity.
Contraindications: Allergy to azithromycin or other macrolides. Use with caution in people with QT prolongation, electrolyte abnormalities, liver disease, or those taking other medications that prolong the QT interval.
8. Ofloxacin ear drops
Ofloxacin ear drops may be prescribed when there is ear drainage related to tympanostomy tubes or a perforated eardrum. Topical ear antibiotics can reach high concentrations in the ear while causing fewer systemic side effects than oral antibiotics.
Dosing: Ofloxacin otic solution is typically used twice daily for about 7 to 10 days. The dose varies by age and product, such as 5 drops in the affected ear twice daily in children or 10 drops twice daily in adults.
Side effects: Local burning, stinging, ear discomfort, itching, dizziness, and abnormal taste.
Contraindications: Hypersensitivity to quinolones or any ingredient in the formulation. Systemic fluoroquinolone side effects are less relevant with ear drops because systemic absorption is minimal.
9. Ciprofloxacin ear drops
Ciprofloxacin ear drops, sometimes combined with a steroid, may be used for ear infections with drainage through ear tubes or a perforated eardrum. These drops are generally preferred over systemic antibiotics in these situations because they act directly in the ear.
Dosing: Ciprofloxacin-containing otic drops are commonly used for 7 to 10 days, depending on the specific product and prescription. The exact number of drops and frequency should follow the product label and the doctor’s instructions.
Side effects: Local ear discomfort, burning, stinging, itching, dizziness, and abnormal taste.
Contraindications: Hypersensitivity to quinolones or any component of the ear-drop formulation. Use should be guided by a doctor, especially if there is severe pain, worsening drainage, or concern for complications.