For most middle ear infections, amoxicillin is the first-choice antibiotic for both children and adults. It’s effective against the bacteria most commonly responsible, it’s inexpensive, and it has a long safety track record. But the best antibiotic depends on the type of ear infection you have, your age, allergy history, and how severe your symptoms are. In some cases, you may not need an antibiotic at all.
Middle Ear Infections: First-Line Treatment
A middle ear infection, called acute otitis media, is the type most people mean when they say “ear infection.” It causes pain, pressure, and sometimes fluid behind the eardrum. The bacteria most often responsible are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
Amoxicillin covers these bacteria well and remains the standard starting point. For children, treatment typically lasts 10 days for those under two years old and 7 days for older children. Adults are generally treated for 7 to 10 days depending on severity. If symptoms haven’t improved after two to three days on amoxicillin, your doctor will likely switch to a stronger option.
When a Stronger Antibiotic Is Needed
Amoxicillin-clavulanate (commonly known by the brand name Augmentin) is the usual step up. The added ingredient, clavulanate, disables a defense mechanism that some bacteria use to resist amoxicillin. This combination covers all three of the most common ear infection bacteria more reliably, which is why it’s preferred when the first round of amoxicillin fails or when symptoms are severe from the start.
Your doctor may also go straight to amoxicillin-clavulanate if you’ve taken amoxicillin recently (within the past 30 days), since the bacteria present may already be partially resistant. About 2 in 5 pneumococcal infections now show reduced susceptibility to at least one antibiotic, according to CDC surveillance data, so resistance is a real consideration.
Options If You’re Allergic to Penicillin
Since amoxicillin is a penicillin-type drug, it’s off the table if you have a true penicillin allergy. What you take instead depends on how severe your allergy is.
If your reaction to penicillin was mild (a rash days into treatment, for example), third-generation cephalosporins like cefdinir or cefpodoxime are commonly used. The cross-reactivity between penicillin and these newer cephalosporins is low, so most people tolerate them without problems.
If you have a history of a serious allergic reaction to penicillin, such as hives, throat swelling, or anaphylaxis, your doctor will avoid the entire family of related drugs. For adults, the alternatives include doxycycline or a fluoroquinolone like levofloxacin or moxifloxacin. Azithromycin and clarithromycin are also options, though they’re less ideal because pneumococcal bacteria have developed high rates of resistance to these drugs.
Outer Ear Infections Use Different Treatment
An outer ear infection, often called swimmer’s ear, affects the ear canal rather than the space behind the eardrum. It feels different: the pain tends to worsen when you tug on your ear or press on the small flap in front of it, and you may notice itching, drainage, or a feeling of fullness.
Oral antibiotics aren’t the standard treatment here. Instead, antibiotic ear drops applied directly to the canal are far more effective. A common prescription is ciprofloxacin combined with dexamethasone (an anti-inflammatory steroid). The typical course is 4 drops in the affected ear twice a day for 7 days. Ofloxacin drops are another widely used option. Because the medication goes right to the infection site, these drops work faster and cause fewer body-wide side effects than oral antibiotics.
When Antibiotics Can Wait
Not every middle ear infection requires immediate antibiotics. For children 6 months and older with mild symptoms, a “watchful waiting” approach is often appropriate. The American Academy of Pediatrics outlines specific criteria for when observation is reasonable:
- Children 6 to 23 months with a one-sided infection, no fever above 102.2°F (39°C), and only mild ear pain lasting less than 48 hours can be observed before starting antibiotics.
- Children 2 years and older qualify for watchful waiting with either one-sided or two-sided infections, as long as symptoms remain mild by the same measures.
Watchful waiting means managing pain with over-the-counter pain relievers and rechecking within 48 to 72 hours. If symptoms worsen or don’t improve, antibiotics are started at that point. This approach works because many middle ear infections, particularly in older children, are caused by viruses and resolve on their own.
Adults are handled differently. Because middle ear infections are less common in adults and complications can be more significant, most clinicians treat all adult cases with antibiotics rather than waiting.
Side Effects to Expect
Antibiotics cause side effects in up to 1 in 5 children who take them. The most common issues are diarrhea, stomach pain, nausea, and rashes. Most of these are mild and resolve once the course is finished.
Rashes deserve a closer look. A rash that appears several days into treatment is often not a true allergy. However, hives (raised red welts) that show up soon after the first dose suggest a genuine allergic reaction and should be reported to your doctor right away. This distinction matters because being incorrectly labeled as penicillin-allergic can limit your treatment options for years.
Risks of Skipping Treatment
When antibiotics are genuinely needed, leaving a bacterial ear infection untreated carries real risks. The infection can spread to nearby tissues, and repeated or prolonged infections can cause hearing loss. In young children, even temporary hearing loss during critical developmental windows can delay speech and language skills.
Rarely, an untreated middle ear infection can progress to mastoiditis, an infection of the bone behind the ear that may require hospitalization. Serious spread to other tissues in the skull is even rarer but possible. These complications are uncommon precisely because most ear infections are caught and treated early, which is why following through on a prescribed antibiotic course matters even after symptoms start to improve.