Amoxicillin is the go-to antibiotic for most middle ear infections, and it has been for decades. It’s effective against the bacteria that commonly cause ear infections, it’s inexpensive, and it has a relatively mild side-effect profile. But the right antibiotic depends on the type of ear infection you have, whether you’ve taken antibiotics recently, and whether you’re allergic to penicillin.
Middle Ear Infections: The Most Common Type
A middle ear infection (acute otitis media) is what most people picture when they think “ear infection.” It develops behind the eardrum, often after a cold, and causes ear pain, muffled hearing, and sometimes fever. In children, it’s the single most common reason for antibiotic prescriptions.
Amoxicillin remains the first-choice antibiotic for uncomplicated middle ear infections. It works well against the main bacteria responsible, particularly Streptococcus pneumoniae, and it’s well tolerated. For adults at higher risk of resistant infections, including people over 65, those with weakened immune systems, or anyone who has taken antibiotics in the past month, doctors often prescribe a higher dose or switch to a broader-spectrum option.
When amoxicillin alone isn’t enough, the next step up is amoxicillin-clavulanate (brand name Augmentin). Some bacteria produce an enzyme that breaks down amoxicillin before it can work. The clavulanate component blocks that enzyme, restoring amoxicillin’s effectiveness. This combination is specifically indicated for ear infections caused by resistant strains of Haemophilus influenzae and Moraxella catarrhalis, two of the most common culprits alongside S. pneumoniae. Your doctor may start with this combination if you’ve had a recent antibiotic course that failed or if your symptoms are severe from the start.
Options If You’re Allergic to Penicillin
Both amoxicillin and amoxicillin-clavulanate are penicillin-type drugs, so they’re off the table if you have a penicillin allergy. The alternatives depend on how severe your allergy is.
For a mild or non-severe penicillin allergy (think rash rather than throat swelling), doctors can prescribe certain cephalosporin antibiotics, including cefdinir, cefuroxime, or cefpodoxime. These are in a related drug family but are generally safe for people whose penicillin reactions were not life-threatening. Another option is ceftriaxone, given as an injection.
For a severe penicillin allergy, such as a history of anaphylaxis, the choices narrow further. Levofloxacin, a fluoroquinolone antibiotic, can be considered in these cases. Your doctor will weigh the risks carefully since fluoroquinolones carry their own side-effect concerns and are typically reserved for situations where safer options aren’t available.
Not Every Ear Infection Needs Antibiotics Right Away
For children six months and older with mild symptoms in one ear, guidelines from the American Academy of Pediatrics support a “watchful waiting” approach. This means managing pain for 48 to 72 hours and only starting antibiotics if symptoms worsen or don’t improve. Many ear infections, particularly mild ones, resolve on their own.
Antibiotics should be prescribed right away when a child has severe symptoms: moderate to severe ear pain, pain lasting 48 hours or longer, or a fever of 102.2°F (39°C) or higher. Bilateral infections (both ears) in children six months and older also call for immediate treatment. For younger infants, the threshold for prescribing is lower because of the higher risk of complications.
In adults, the decision is more straightforward. Most adults with a confirmed middle ear infection receive antibiotics, partly because adult ear infections are less common and can sometimes signal an underlying issue worth investigating. Adults who experience recurring ear infections or persistent fluid behind the eardrum for more than six weeks may need referral to an ear, nose, and throat specialist.
How Long You’ll Take Them
The standard antibiotic course for a middle ear infection is 10 days, but shorter courses can work well depending on the patient’s age. Research published in American Family Physician found that shorter antibiotic courses (as few as a few days beyond the initial two-day mark) were as effective as seven or more days for children with ear infections, with the added benefit of fewer side effects like diarrhea and rash.
In practice, children under two and those with severe infections are still typically prescribed a full 10-day course. Older children and adults with mild to moderate infections may receive a 5- to 7-day course. Your prescriber will factor in age, severity, and infection history when deciding on duration.
When You Should Feel Better
Once antibiotics are started, improvement comes relatively quickly. Fever typically resolves within 48 hours. Ear pain should noticeably improve by day two and be gone by day three. If symptoms aren’t improving after two to three days on antibiotics, that’s a signal to call your doctor. It may mean the bacteria aren’t responding to the chosen antibiotic and a switch is needed.
Pain management matters in the meantime. Over-the-counter pain relievers like ibuprofen or acetaminophen are the primary tools for managing ear pain while waiting for the antibiotic to take effect. Treating the pain is considered a core part of managing any ear infection, not just an afterthought.
Swimmer’s Ear Is Treated Differently
Outer ear infections (otitis externa), commonly called swimmer’s ear, affect the ear canal rather than the space behind the eardrum. They feel different too: the pain worsens when you tug on your outer ear or press on the small flap in front of the ear canal, and the canal itself may be red, swollen, or draining fluid.
Swimmer’s ear is treated with antibiotic ear drops, not oral antibiotics. A common prescription is ciprofloxacin combined with dexamethasone (a steroid that reduces swelling and itching). The typical regimen is four drops in the affected ear twice daily for seven days. The drops work directly at the site of infection, which means they’re more effective and cause fewer body-wide side effects than oral antibiotics would for this type of infection.
Keeping the ear dry during treatment speeds recovery. Oral antibiotics are only added if the infection has spread beyond the ear canal, which is uncommon in otherwise healthy people.