Amoxicillin is the first-line antibiotic for middle ear infections in children, while adults are typically started on amoxicillin-clavulanate. Outer ear infections (swimmer’s ear) are treated differently, with antibiotic ear drops rather than oral medications. The specific choice depends on your age, allergy history, and how severe the infection is.
Middle Ear Infections in Children
For children with acute otitis media, the standard treatment is high-dose amoxicillin at 80 to 90 mg/kg per day, split into two doses. This higher dose became the recommendation because it’s more effective against resistant bacteria than the older, lower-dose regimen. It remains first-line for kids who aren’t allergic to penicillin and haven’t taken amoxicillin in the past 30 days.
Not every ear infection needs antibiotics right away, though. Current guidelines from the American Academy of Pediatrics use age and severity to decide whether to treat immediately or wait 48 to 72 hours to see if the infection clears on its own:
- Treat immediately if the child has a fever of 102.2°F or higher, moderate to severe ear pain, symptoms lasting 48 hours or more, or drainage from the ear
- Under 6 months: always treat immediately
- 6 to 23 months: treat immediately if both ears are infected; observation is an option if only one ear is affected
- 2 years and older: observation for 48 to 72 hours is reasonable for both unilateral and bilateral infections, as long as symptoms are mild
With the observation approach, your child’s doctor may write a “safety-net” prescription you can fill if symptoms don’t improve within two to three days. This avoids unnecessary antibiotic use while still giving you quick access to treatment if needed.
How Long Children Take Antibiotics
The course length varies by age and severity. Children under 2 typically get a full 10-day course. Kids aged 2 to 5 with non-severe symptoms can often do 7 days. Children 6 and older with mild infections may only need 5 to 7 days. Any child with severe signs (high fever, significant pain, symptoms lasting over 48 hours) gets the full 10 days regardless of age.
Middle Ear Infections in Adults
Adults are generally started on amoxicillin-clavulanate rather than plain amoxicillin. The clavulanate component helps the antibiotic work against bacteria that have developed resistance. The standard adult dose is 875 mg of the amoxicillin component twice daily. Adults over 65, those with weakened immune systems, or people who’ve recently used antibiotics may need a higher-dose formulation.
If you can’t take amoxicillin-clavulanate, several alternatives exist. For people without a severe penicillin allergy, cephalosporin-class antibiotics like cefdinir, cefpodoxime, or cefuroxime are common substitutes. These are related to penicillin but are tolerated by most people with mild penicillin allergies.
For a confirmed severe penicillin allergy, the options shift to unrelated drug classes like doxycycline or a fluoroquinolone. If none of those work, azithromycin or clarithromycin can be used, though they’re less effective against some of the bacteria that commonly cause ear infections.
Outer Ear Infections (Swimmer’s Ear)
Outer ear infections are a completely different situation. The infection is in the ear canal rather than behind the eardrum, and it’s treated with antibiotic ear drops, not oral antibiotics. The most common prescription is a combination of ciprofloxacin (an antibiotic) and dexamethasone (a steroid that reduces swelling, redness, and itching). The typical regimen is 4 drops in the affected ear twice a day for 7 days.
These drops work directly at the site of infection, which means they’re effective at lower doses and cause fewer side effects than oral antibiotics. Keeping the ear dry during treatment speeds recovery.
Managing Pain While Antibiotics Work
Antibiotics don’t relieve ear pain immediately. It usually takes 48 to 72 hours before you start to feel noticeably better. In the meantime, over-the-counter pain relievers like ibuprofen and acetaminophen are effective. Some people find that alternating between the two provides better relief than either one alone, since they work through different mechanisms.
Over-the-counter numbing ear drops containing benzocaine might seem like a good idea, but they’re generally not recommended. The numbing effect is very brief, and the drops can sometimes sting and make pain worse.
When the First Antibiotic Doesn’t Work
If symptoms haven’t improved after 48 to 72 hours on amoxicillin, the usual next step is switching to amoxicillin-clavulanate or a cephalosporin. This broader coverage targets bacteria that produce enzymes capable of breaking down plain amoxicillin. One study comparing the two found that about 52% of patients treated with amoxicillin-clavulanate were free of fluid buildup at 10 days, compared with 32% on amoxicillin alone. By four weeks, though, both groups had similar outcomes, suggesting that amoxicillin-clavulanate may speed up initial recovery even if long-term results are comparable.
Recurrent ear infections, defined as three or more episodes in six months or four in a year, sometimes require a different approach. Your doctor may use a broader-spectrum antibiotic, investigate underlying causes like allergies or enlarged adenoids, or discuss whether ear tubes could help prevent future episodes.