Do Antibiotics Help Ear Infections?

Overview

The body’s immune system can clear out an ear infection on its own. In the majority of cases, an ear infection lasts for 2-3 days but the symptoms can persist for up to a week. Antibiotics are not always the appropriate treatment for every type of ear infection and the benefits and risks should always be weighed before using them.

The most common type of ear infection occurs in the middle ear and is called Otitis Media. Otitis media is most commonly caused by a viral infection which resolves completely on its own and antibiotics are not needed. Children are more likely to suffer from ear infections than adults and they recover from it within 2-3 days. The use of antibiotics in children should be done with caution as it can lead to unnecessary treatments and harmful side effects.

Health care providers generally recommend a watchful waiting approach in middle ear infections which means that they do not give any active treatment, such as antibiotics during this time as the ear infection is highly likely to go away on its own and does not require any treatment. So instead they recommend treating only the symptoms of the ear infection such as using painkillers for the pain or medications like ibuprofen or paracetamol for fever and in some cases antiseptic ear drops.

Antibiotics may be beneficial and are required in certain cases. For example, your healthcare provider might consider giving antibiotics when the ear infection is not going away on its own and has lasted for more than 5 days. Studies also recommend the use of antibiotics in infants less than 2 years of age who are suffering from an infection in both ears at the same time.

Antibiotics are also helpful in other types of ear infections like outer ear infections (swimmer’s ear), which are caused by bacteria and in certain kinds of patients whose immune systems are weak and who cannot recover from the infection without antibiotics.

Ear infections

The ear can be structurally divided into three parts; the outer ear, the middle ear and the inner ear. An infection can develop in any of these parts. These infections can be acute (lasting for a few days) or chronic (lasting for a longer period). They can also be localized in the form of boils or widespread infections.

Outer ear infection

The outer ear is composed of the ear auricle or the pinna, the ear canal and the eardrum. Any infection in these parts is called an outer ear infection or Otitis Externa. These infections usually affect adults between the ages of 45-75. With treatment, Otitis externa resolves within 7-10 days.¹

Symptoms of outer ear infection

Symptoms of an outer ear infection include:

• Severe pain in the ear
• Pain worsens on touching or pressing on the ear
• Itching and irritation inside and around the ear
• Redness outside and inside the ear
• Discharge from the ear canal
• Swelling of the ear canal
• Boils
• Difficulty in hearing

Causes of outer ear infection

Ninety percent of external ear infections are caused by bacteria. Fungal infections are rare and can lead to chronic infections in people with weak immune systems. 

Some factors that can make a person susceptible to otitis externa are:

• Structural causes such as abnormal narrowing of the ear canal or, heavy coverage of the canal with hair
• Temperature: humidity and high ambient temperature
• Trauma caused by manipulation/ excoriation (skin picking), q tips to remove ear wax, hearing aids, ear plugs, foreign body
• Systemic diseases such as diabetes mellitus
• Being immunosuppressed
• Skin diseases like eczema, psoriasis, and seborrhea
• Lack of or overproduction of earwax
• Water in the ear canal and swimming
• Use of irritants such as soaps and shampoos

Swimmer’s ear

The occurrence of external ear infections is increased up to fivefold in swimmers hence sometimes this condition is also called swimmer’s ear.

Treatment of outer ear infection:

Treatment of uncomplicated disease includes:

• Cleansing of the ear canal – should be done by an expert
• Topical antiseptics – help disinfect the ear canal
• Topical/local antibiotics – to treat bacterial infection
• Topical corticosteroids – to decrease the redness and swelling
• Adequate painkillers – to eliminate the pain
• Antifungal ear drops – to treat fungal infection

If there is a boil, drainage of pus is done by piercing it with a sterile needle.

Use of antibiotics for outer ear infection

Outer ear infections are generally caused by bacteria so antibiotic treatment is usually given.

Topical antibiotics

In cases of uncomplicated outer ear infection, where there is no rupture of the eardrum, a combination of antiseptic ear drops, corticosteroid ear drops and topical/ local antimicrobial treatment is given. This, along with cleaning of the ear canal and painkillers, helps resolve the infection within 7-10 days.
Common preparations used are:²

• Polymyxin B, neomycin, and hydrocortisone – 3 to 4 drops to the affected ear four times a day
• Ofloxacin ear drops – 5 drops applied to the affected ear twice daily
• Ciprofloxacin with hydrocortisone ear drops – 3 drops to the affected ear twice daily

Oral antibiotics

Oral antibiotics (capsules or tablets) are not beneficial in uncomplicated cases and their inappropriate use can lead to the development of drug resistance.

Cases, when oral antibiotics are indicated, are:

• Patients with uncontrolled diabetes and increased morbidity
• Patients with compromised immune systems such as those suffering from HIV/AIDS
• Suspected malignant otitis externa, a severe form of infection that affects and damages the bones of the ear canal and at the base of the skull
• Concomitant acute otitis media

Antibiotics would be prescribed according to the findings of bacterial culture and sensitivity testing.

Middle ear infection

The middle ear starts from behind the eardrum. It is also called the “tympanic cavity” and consists of three small ear bones. It has a connection to the back of the nose and throat via a narrow tube called the eustachian tube. Infection inside the middle ear cavity is called Otitis Media. It is the most common type of ear infection. Otitis media is mostly viral, arising as a result of the spread of viral influenza (flu) infection or a common cold, from the nose and throat. It usually affects young children.

Types of otitis media

Infection in the middle ear cavity occurs when a common cold or flu causes blockage/ narrowing of the eustachian tube. This results in fluid (mucus) building up inside the cavity, leading to increased pressure and pain. This mucus can also get infected as it can not get drained properly.  

Acute otitis media

When the fluid inside the middle ear cavity becomes inflamed and infected, it is called acute otitis media. The signs and symptoms of infection occur suddenly.

Otitis media with effusion

This occurs when there is a thick and sticky collection of fluid inside the middle ear cavity. This collection is not infected. It is also called glue ear.

Chronic otitis media

This is a type of recurrent middle ear infection where there is a rupture of the eardrum.

Symptoms of middle ear infection

• Pain in ear
• Fever
• cold/ flu symptoms – coughing, sneezing
• Fatigue
• Decreased hearing
• Discharge from ear

Symptoms of middle ear infection in young children and babies

• Pulling of ear
• Irritable
• Crying 
• Decreased feeding
• Losing balance
• Not reacting to the noise around them

Causes of middle ear infection

Young children are vulnerable to middle ear infections because:

• Their eustachian tubes are narrower and smaller compared to adults, and thus more easily obstructed
• Their adenoids are also larger than in adults

Other risk factors include:

• Certain conditions such as Down’s syndrome, Cleft palate
• Allergies
• Exposure to environmental smoking (passive smoking) and other airway irritants
• Formula milk
• Pacifier use
• Family history of recurrent middle ear infection
• Exposure to infection at group daycares

Treatment of middle ear infection

• Placing a warm or cold flannel over the ear
• Staying hydrated
• Rest 
• Painkillers like ibuprofen and paracetamol (aspirin should not be used in children below 16 years of age)
• Medication to treat fever – ibuprofen and paracetamol
• Antibiotics – antibiotic tablets/ capsules to treat infection 
• Intramuscular antibiotics – antibiotic injection in the muscle for persistent infection not improving with tablets  
• Tympanocentesis – small puncture made in the eardrum to drain fluid. It is done in recurrent AOM
• Grommets/ tympanostomy tube placement – a  small tube inserted into the eardrum to help drain fluid from the middle ear – done in glue ear

Antibiotics use In middle ear infection

Antibiotics are not routinely used in treating middle ear infections. There is no evidence that their use speeds up recovery. Instead, a watch-and-wait strategy is applied in children older than two years of age. A follow-up appointment is scheduled in 48-72 hours to see if the symptoms have improved. A delayed prescription of antibiotics can also be given, where the parents can obtain antibiotics after three days if the symptoms have not improved. 

Antibiotics are recommended in the following cases of middle ear infection:³

• In children less than 3 months
• Acute otitis media in one ear in children 6-23 months of age, having severe symptoms – antibiotics given for 10 days
• Acute otitis media of both ears in children less than 2 years of age – antibiotics given for 10 days
• Acute otitis media in children 2 years or older, not improving after 3 days of observation – antibiotics given for 5-7 days
• Children who have serious health conditions that make them more prone to complications, such as cystic fibrosis or congenital heart diseases
• Adults have serious health conditions that make them more prone to complications, such as cystic fibrosis or congenital heart diseases
• Adults that show no improvement after 4 days
• Pus coming out of the ear

Type of antibiotics used and common side effects

Amoxicillin is the choice of antibiotic in middle ear infections. Some common side effects in children are:

• Diarrhoea
• Rash
• Feeling sick

Those who are allergic to amoxicillin are given erythromycin or clarithromycin.

Inner ear infection

The inner ear, also called the labyrinth, has three organs, the cochlea, the vestibule and the semicircular canals. The cochlea is a coiled-shaped, snail-like organ which is responsible for hearing. The vestibule and the semicircular canals are responsible for balance.

An infection of the inner ear is called Labyrinthitis. It can occur in both adults and children and affects hearing and balance. 

Symptoms of inner ear infection

• Dizziness
• Vertigo – feeling that everything around you is spinning
• Disbalance – having difficulty staying upright or walking in a straight line
• Partial or complete hearing loss
• Tinnitus – humming or ringing sensation in the ear
• Headaches – mild
• Nausea – feeling sick
• Vomiting
• Fever – high temperature of 38C
• Ear pain
• Discharge from ear
• A feeling of fullness or pressure inside the ear
• Blurring of doubling of vision

Vestibular neuritis

Some people suffering from inner ear infections do not have hearing loss or ringing sensation inside the ear. When an inner ear infection only causes problems with balance, it is called vestibular neuritis.

Causes of inner ear infection

An inner ear infection is most commonly caused by viruses. Bacterial infections are rare and are caused by the spread of infection to the inner ear from other sites.  Viral labyrinthitis is more frequently seen in adults aged 30-60 years old. Young children under the age of 2 years are prone to develop bacterial labyrinthitis.

Causes of viral labyrinthitis

1. Common cold or flu – a viral infection of the chest, airways, mouth or nose can spread to the inner ear
2. Measles
3. Mumps
4. Glandular fever

Causes of bacterial labyrinthitis

1. Middle ear infection – bacterial infection from the middle ear can spread to the inner ear
2. Meningitis – infection of the coverings of the brain can spread to the inner ear
3. Head injury – head trauma can cause infections of the inner ear

Treatment of inner ear infection

Symptoms of inner ear infection can start suddenly and worsen as the day progresses. The severity of symptoms decreases in a few days and a person can regain complete balance in 2-6 weeks, although it can take longer in certain cases. 

Some self-help measures and medications can help alleviate the symptoms:

Self help measures

• Getting a good night's sleep — tiredness can worsen the symptoms
• Staying hydrated — drinking plenty of fluids helps if you feel sick
• Avoid noise and bright lights — these overwhelm the senses and worsen the symptoms
• Avoid alcohol
• Going for walks — going for walks can help regain confidence and balance. Have someone accompany you on walks to help keep you steady till you regain your balance.
• Avoid operating heavy machinery, driving and going to heights till symptoms resolve to avoid injury
• Lying in a quiet room – during an attack of dizziness, lie in a quiet and dark room

Medications

• Anti-motion-sickness tablets – reduce the symptoms of dizziness and feeling sick
• Corticosteroids – are given in some cases to reduce inflammation
• Antibiotics – to treat bacterial labyrinthitis
• Vestibular rehabilitation therapy – these are a series of exercises that can help recover balance in cases of chronic labyrinthitis

Anti-sickness medications should only be taken during the early days of infection to help reduce the severity of the symptoms. Using them for more than 3 days can slow down the recovery.

Antibiotics use in inner ear infection

Antibiotics are only used if the cause of the infection is suspected to be bacterial. Depending on the severity of the infection, oral (capsules or tablets) antibiotics or antibiotics through the veins may be given.

Treating an ear infection at home

Some practices that can be done at home to help relieve pain and clear out an ear infection are:

• Keeping the affected ear dry. Do not let any water or shampoo enter your ear by wearing shower caps while showering or taking a bath. Avoid swimming till the condition improves
• Using painkillers such as paracetamol or ibuprofen for pain. (Aspirin should not be used in children under 16 years of age)
• Remove any discharge from the ear by gently wiping it with cotton wool. Do not insert anything inside the ear such as cotton buds or fingers to remove earwax or discharge
• Using ear drops correctly and as prescribed
• Removing anything from the ear that might cause irritation or reaction, such as hearing aids, ear plugs, or earrings
• Placing a warm flannel or cloth over the ear. This helps boils heal faster

How long does an ear infection take to clear up?

• Outer ear infection clears up within 7-10 days with treatment. Middle ear infection can clear up in 2-3 days but symptoms can persist for up to a week. A middle ear infection which doesn't clear up in 3-5 days, needs to be seen urgently by the GP
• Inner ear infection clears up in a few days but symptoms can persist for up to 2-6 weeks or even longer

Prevention

Prevention of outer ear infection

• Wearing earplugs or a swimming cap when going swimming
• Avoid getting water or shampoo inside the ear, while taking a shower or bath
• Avoid inserting cotton buds and fingers inside the ear

Prevention of middle ear infection:

• Avoid using a pacifier after 6 months of age
• Breastfeeding instead of formula milk
• Make sure your child is up to date with their influenza vaccination
• Make sure your child is not exposed to a smoking environment (passive smoking)

Summary

Not every ear infection requires treatment with antibiotics. Most clear up on their own with simple home remedies and painkillers. In cases of swimmer’s ear, antibiotic ear drops are used. In acute otitis media, your doctor might recommend watchful waiting, where symptoms are observed for 2-3 days and wait for them to get better on their own. This method gives the body’s immune system time to fight and recover from the infection. If the infection does not get better after 3 days, antibiotics can be given.

Antibiotics are also given when there is an illness where the immune system is weak such as in cystic fibrosis or there is pus coming out of the ear. Infants less than 2 years of age, having infections in both ears are also given antibiotics.  It is important that when antibiotics are prescribed, they are taken as per the given instructions. If proper instructions are not followed or the antibiotic course is not completed it can result in recurrent infections and the development of resistance of bacteria to antibiotics.