Should Ear Infections Be Treated with Antibiotics?
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Should Ear Infections Be Treated with Antibiotics?

by Chris Kresser

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ear infection
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Ear infections are treated with antibiotics more than almost any other illness in children. However, we now know that most ear infections usually resolve safely on their own, and antibiotic treatment provides little to no additional benefit. On top of this, antibiotic use comes with serious long-term consequences. Read on to see what the research says about the safest way to treat ear infections.

Ear infections are one of the most common ailments in early infancy and childhood. Most children have at least one ear infection by age three. These ear infections are often treated with antibiotics. In fact, ear infection is one of the most common reasons for antibiotic prescriptions in children. (1) But is this treatment effective and safe?

Antibiotics Provide Limited Benefit for Ear Infection

Ear infections are not always caused by bacteria. Research estimates that ear infections have bacterial origin in 51 to 78 percent of cases. (1) This means that 22 to 49 percent of cases are due to other causes, such as viruses or even food sensitivities. (2) When an ear infection is caused by a virus or food sensitivity, antibiotics will not help.

Whether caused by bacteria or not, ear infections usually resolve on their own without treatment. In fact, a recent systematic review found that 60 percent of children had recovered from their ear infection within 24 hours of treatment, even if they did not receive antibiotics. (3)

Research suggests that over time, without treatment, 80 percent of ear infections clear on their own. (4)

A recent review analyzed a large collection of trials about antibiotics and ear infections. (3) Two main types of studies were looked at: those that compared antibiotic treatment to placebo treatment and those that compared immediate antibiotic treatment to an expectant watchfulness, or “watch and wait,” approach. In the watch-and-wait treatment, antibiotics were only given if symptoms and pain persisted or got worse after three to seven days.

In comparing antibiotic treatment to placebo, antibiotic prescription did slightly reduce pain at various follow-up times up to two weeks following the start of treatment. Instances of ruptured eardrums and infection of the originally unaffected ear were also decreased mildly in the antibiotic group compared to placebo. However, 20 percent fewer children had recurrent ear infections in the placebo group. (3) Perhaps a less damaged gut flora better protected the placebo-group children from subsequent infections.

In almost all cases, antibiotic treatment was not significantly more effective than a watch-and-wait approach. Antibiotics did not provide any additional benefit for reducing pain, hearing loss three months after treatment, or rate of ear infection recurrence. The only situation in which antibiotic treatment was more effective than watching and waiting was in children two years or younger with bilateral ear infection and discharge. Thus, in this specific case antibiotic treatment may be warranted. (3)

Overall, this review suggests that a watch-and-wait approach may be safest in most cases. Those in the placebo group who had severe infections eventually requiring antibiotics would have been identified within a few days and properly treated. And most children in the antibiotic group would have ended up NOT being given antibiotics, thereby preserving gut microbiomes whenever possible.

Despite all this data, 95 percent of ear infections were treated with antibiotics in the United States in 2001. (5) By almost any definition, this is a gross misuse. New guidelines by the American Academy of Pediatrics (AAP) reject immediately prescribing antibiotics for ear infections in favor of a watch-and-wait approach in most cases. (6) However, because this reversal occurred recently, and because of pressure from parents for immediate treatment, many doctors still jump to prescribing antibiotics.

Does your child need antibiotics for an ear infection?

Antibiotics Come with Serious Long-Term Risks—Especially for Children

The limited benefit of antibiotics for ear infection must be weighed against the risks. Among children treated with antibiotics, one in 14 had symptoms such as diarrhea, vomiting, and rash. (3) However, the effect of antibiotic use on long-term health is even more serious.

Antibiotics are not a precise treatment; they kill both harmful and beneficial bacteria all over the body. This is especially true for broad-spectrum antibiotics, which destroy a wider range of bacterial species.

This widespread bacterial death can have detrimental effects. It is hard to overstate the importance of the beneficial bacteria that live in the human body and make up a healthy microbiome. A rapidly growing body of evidence shows that resident bacteria affect diverse systems in the body and are essential components of long-term health.

We already know gut bacteria play a role in:

  • Immune regulation
  • Metabolism
  • Nutrient status
  • Detoxification
  • Inflammation
  • And more

Unfortunately, there is evidence that a person’s microbiome may never fully recover from antibiotic use. Lasting reduction in beneficial bacteria may increase our susceptibility to deadly pathogens like C. difficile and may play a role in the dramatic rise of conditions like obesity, type 1 diabetes, inflammatory bowel disease, allergies, and asthma. (7, 8, 9)

Children are especially susceptible to these potential dangers. As one example, a single course of amoxicillin or a macrolide antibiotic—most commonly used to treat pediatric ear infections—may eradicate H. pylori in 20 to 50 percent of cases. Unfortunately, the loss of this protective bacteria in children is associated with greater likelihood of developing asthma, hay fever, or skin allergies. (7)

On top of all these risks, overuse of antibiotics for ear infection may unnecessarily contribute to antibiotic resistance in the community. (3)

Antibiotics absolutely have a place in medicine and should be prescribed in certain cases, but over-prescription has been detrimental to patient health and has contributed to widespread antibiotic resistance.

Tubes for Recurrent Ear Infections Have Limited Effectiveness and High Risk

For children with chronic ear infections, inserting grommets, or ear tubes, into both ears is common practice. The tubes are meant to help fluid drain from the ears before an infection occurs. But the community is split on how effective they are at preventing future ear infections, especially beyond six months after insertion. (10, 11, 12) Furthermore, even though ear tubes did decrease overall time with ear infections compared to watchful waiting in one study, it increased instances of infection in the opposite ear, ear discharge, and eardrum scarring. These are some pretty severe and uncomfortable side effects. (13)

If you have a child who is experiencing ear infection after ear infection, a bigger underlying health issue is probably present and should be addressed. I would advise trying some of the health-boosting recommendations below before resorting to ear tubes because the research on their effectiveness is mixed, side effects are possible, and any surgery requiring general anesthesia carries its own separate risks. However, some children who already have severe, chronic ear infections may benefit from having tubes inserted while they also work on any underlying health issues.

A Safer Approach to Treating Ear Infections

Of course, the safest approach is to avoid ear infections altogether. You can help your child reduce the likelihood and severity of ear infection by taking steps to address health issues that may make them susceptible:

  • For infants, choose breastfeeding over formula whenever possible. Introducing formula in the first six months of life is associated with more ear infections in early childhood (14)
  • Eat a nutrient-dense, whole-foods diet
  • Identify food sensitivities and remove problematic foods from the diet. Dairy is the most common culprit in recurrent ear infection (2)
  • Ensure adequate vitamin D levels (15, 16)
  • Strengthen the immune system

For more strategies to promote overall health and help prevent illness, check out my free eBook 9 Steps to Perfect Health.

However, if your child does get an ear infection, research dictates that a watch-and-wait approach is best in most cases. Keep an eye on illness progression and schedule a follow-up in a day or two. Most ear infections will clear on their own in a few days without much added discomfort.

In the meantime, you might try these low-risk remedies to help ease symptoms and shorten duration:

  • Use xylitol nasal spray to break up biofilm to make it easier for the immune system to remove any pathogens (17, 18)
  • Use garlic and mullein oil ear drops, warmed gently, to provide antimicrobial and soothing effects. This remedy is safe as long as the ear drums are not ruptured and has been shown to alleviate ear infection pain as well as an anesthetic drop (19)
  • Offer probiotics and prebiotics in the form of fermented foods, fermentable fiber, or supplements to support gut and immune health
  • Give supplemental nutrients that help support the immune system
  • Consider additional botanical support to strengthen the immune system and provide symptom relief

You may also consider treating with herbal antimicrobials, especially if the infection is viral. See my previous article, 7 Tips for Preventing (and Shortening) Colds & Flus, for tips on how to use botanicals and other nutrients to fight viruses and support the immune function. These do affect the microbiome, but not as dramatically as broad-spectrum antibiotics, and the risk of antibiotic resistance is much lower.

Despite the risks, antibiotics may be necessary in some cases. If your doctor determines that antibiotics are the safest choice for your child, all hope is not lost. There are steps you can take to limit the negative impact of antibiotics.

Now I’d like to hear from you. Did you know antibiotics are usually unnecessary to recover from ear infection? What forms of prevention and treatment have you found most useful? Let us know in the comments below.

62 Comments

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  1. i written poor english but please you understand my problem. I have a left ear infection and fluid comes out, I use ciprofoxcin, novidate, augmentin, and also use tieman injection, but fluid not stop,
    please tell me what can i do next, I disappointed my Doctors.

  2. My 9 month old was just diagnosed with a respiratory infection with an ear infection in her right ear only. She has had fever for 5 days. I was prescribed amoxicillin for the ear infection. I have given 2 doses and she has vomited both times. I am going to suspend giving her any additional doses (mommy instinct combined with information i have read ), however, I did notice her fever disappear after the first dose. Coincidence?

    • You should not stop a dose of anitbiotics. No, it’s not coincidence the symptoms improved. Add one and one. Check the side effects of the drug and always discuss with your dr before you decide to stop. I’m a bit shocked

  3. I wanted to ask about the use of Lavender essential oil for this condition. I have heard of it’s use to ease the infection in dilution with a vegetable oil. Do you have any experience with this or any information whether this is a good and safe practice?

  4. Holy cow! I was a frequent ear ache sufferer since I as a child. AS an adult I have had such bad ones that I have ruptured both eardrums twice. Then I gave up dairy and hallelujah no more ear aches or sinus infections. Funny though now if I do eat cheese I can’t hear well out of my left ear. NOT too much to ask to give up cheese to get my hearing back;-) thanks for an awesome article Doc.

    • We have used garlic oil drops in the ears successfully for years. The best way is to catch it early onset – a few drops in the ear covered with cotton seems to ward off/fight infection and avoid the dangers of the antibiotics in our experiences.

  5. My daughter had a mild ear infection only one timeat age 5. We caught it very early, and I was a good mother for getting her to the doctor right away, right?! The doctor immediately prescribed amoxicillan, and not long after the antibiotics, we discovered that she had lost 80% of her hearing in her right ear. I later found out that antibiotics also have the ability to cause hearing loss. If I had only known then what I know now because of this kind of information, I would have gone the natural route like we have done ever since, and maybe we could have avoided one of the many adverse effects of antibiotic usage.

  6. I’m curious about topical abx drops and if they are equally harmful? How about as adults?
    I ask personally as I had lots of ear infections as a kid, and took abx over a dozen times….lost of strep throats as well. As an adult, 2-4 years on GAPS/Predominantly Paleo diet, and now I’m getting ear infections again in my 40’s. I had 2 last year, and just got a cold, (planes are disease vectors) which I’m afraid may be turning into an ear infection. Is there a way I can inoculate my ear microbiome? It’s just my right ear.

  7. Hi Chris,
    This is sure a timely article! Thank you!
    One of my client’s children has been DX’d with ‘Situs Inversus’ [organs reversed]. The rare condition also means deficient or dysfunctional cilia, in passages that should have them, causing slowed or no movement of fluids along air passages, Eustachian tubes, etc. It’s a challenge to find information, get needed equipment covered, etc.
    The child is about to have bilateral ear tubes installed now, at about age 5. He’s small but vigorous for age; muscularly strong.
    He uses a respiratory vibratory unit to help move fluids, at least once a day. He’s had some difficulties gaining weight; some speech impediments; behavioral issues.
    He’s yet to be tested for hearing impairment, but should.
    Allergy tested for foods, found less allergy-prone than siblings and parents; was breastfed for close to two years.
    Parents offer good selections of mostly organic foods into their children, as well as some supplements and probiotics. The parents prefer alternative medicine, but have needed to resort to regular medicine at times.
    ABX use has been rare.
    Because of how this child’s body works [sluggish fluid movement], I advised them of the usual things you advise in this article.
    However, due to special circumstances, their child might be one who really needs them, in addition to the other suggestions.

    QUESTIONS:
    1. Could you please share any other information or sources you might know of, about ear infections/fluid buildup, in this context?
    [Fluid buildup behind the eardrums, deficient cilia concurrent with that]?
    2. Also, this is one of the first articles I’ve read that mentions H.Pylori as something good!?
    I’d only ever heard of H.Pylori as something that pathologically proliferates, triggering various forms of GERD, morning sickness/hyperemesis gravidarum, and stomach ulcers!
    Would you please point me to articles that could elaborate on this new information on H.Pylori ?

    Thank you!

  8. I had a painful ear infection that was not treated with antibiotics. My eardrum burst and I start to bleed out of my ear. After that Kaiser finally gave me antibiotics, two courses of Z pack azithromycin. Ever since that time I’ve had terrible tinnitus in both ears. I hear it now, a decade later, that annoying high pitched hiss, so loud. Some antibiotics apparently damage the hair cells in your inner ear that let you hear.

  9. Whenever my daughter has an ear infection, it follows from her swimming lesson. Usually its the dirty water.

    What I do is try natural ways, so if its still around after 24 hours, I’ll drop in colloidal silver, and let it stay for 10-15min before emptying it out. This usually resolves in 24 hours majority of the time.

    In some instances that pain is still there or it gets worse, I take her to the doctor. If that means taking antibiotic, yeah I’vel let her take it but only as a last resort.
    In some instances that pain is still there or it gets worse, I take her to the doctor. If that means taking antibiotic, yeah I’ll let her take it but only as a last resort.

  10. Over the years if my kids ever had ear infections I used colloidal silver – 1tbs three times a day for two days, very effective.

  11. Wonderful article! More parents need to be aware of the potential dangers to their children’s future health from antibiotic use. I am a Chiropractor and have successfully treated ear infections in children for the past 28 years.

    The mechanism for how this treatment works is easily explained, and I will happily do so for anyone interested.

    Thank you to Chris for starting the great dialogue.

  12. Thank you for talking about it this. I am a paediatric osteopath, ( using cranial as part of treatment), and looking at a child’s base line health , and treating them holistically works in 99.9% of cases. I believe in the NICE guidelines, a watchful/ waiting was recommended, with analgesics where necessary. Not antibiotics.
    This is especially relevant with ‘superbugs’ that no longer seem to respond to AB.
    Parents need support and information to enable them to follow their instincts, and to nurse their children back to health

  13. I am very glad to see this ‘out there’. I had repeated episodes of severe earache as a child and was regularly prescribed antibiotics by an otherwise exemplary GP who was proud to say that no patient of his had ever suffered an otitis media. This was in the seventies – different times.

    I am now allergic to penicillin, erythromycin and all of the associated mainstream antibiotics, so that I can no longer take them safely and have to be very careful about any risk of bacterial infection. I have hypothyroidism (not modulated by standard levothyroxine treatment), adrenal problems (DHEA deficiency on blood test; cortisol low in saliva but not confirmed by blood tests), systemic inflammation, digestive issues and a weakened immune system. I take high-quality probiotics every day.

    As a small child I just wanted the agonising earache to cease. It must be very hard for parents to see a child sobbing with pain and resist their doctor’s recommendation of a course of antibiotics. But I would say that the long term consequences are not worth risking.

    • I see it everyday among my friends with children..they feed them with all the possible junk available, and at the first symptom they go to the doctor right away, and they come back with antibiotics and cortisone like if it was like eating an apple.
      And they are back in the same issue every month…
      This system is unbelievable to me…it’s simply crazy how people are not able to understand and go on in this way indefinetly

  14. From time to time I suffer from ear infections. Strange as it may seem I treat it like a pimple and use an appropriate pimple cream like Benzac AC on the infected part of the inner ear. The cream is soothing and gentle and will dry and disinfect the area like a pimple. I only use it when i feel that the infection causes a certain part of the inner ear to be sore or red when touched. It works i do it when i need to. Something to think about treating a visible ear infection like an infected pimple by using a soothing commercial pimple cream.

  15. My 10 year old was having regular ear infections monthly at 6 years old for about 9 months, we started using hydrogen peroxide as soon as we heard the first sniffle. He has only had to see the doctor 1x since treating in this manner

  16. My son was an antibiotics for 3 years straight until he was 3 y/o for constant ear infections. Back then, my only source of information I had were his doctors (whom I trusted). By the time he was 3, he had terrible behavioral issues and yeast literally in his ears. When the doctors wanted to try meds for the yeast in his ear, I finally got smart and found help elsewhere. After a year on a very low (10 g. Total) sugar and yeast free diet all issues were resolved. Actually improvements were made right away but b/c of The severity of the yeast we stuck to the diet. Now I am a holistic nutrition professional. One of my biggest regrets is not having the information and knowledge that I have now, back then.

    • no kidding, i feel same – i feel so guilty for feeding my kids doctors drugs and store bought jarred baby foods and boxed cereals – i wish i knew back then

  17. I’d also like to add another point. As an RN and a specialist primary care practitioner in the UK ear pain can often have numerous causes. In older individuals (not babes) TMJD, “computer neck’, compacted ear wax, MSK, poor posture, along with Tight scalenes and SCM issues can mimic sinus headaches, ear fullness and pain. Try finding some trigger point in your muscles. Incidentally medics are often poor at diagnosing these issues. Referral of pain it’s associated structures can serious symptoms. Did you know that TMJD can cause hearing loss and serve ear pain?

  18. I suggest homeopathic remedies which I used with my three girls. They are now in their mid, late-twenties and have hardly ever used antibiotics, only one has been hospitalized due to a gastrointestinal bacterial infection due to contaminated food!!!

    • When my son was young he developed an ear infection. Our homeopath prescribed an appropriate remedy that cleared up the infection. He also told me to keep him off wheat and most dairy products. He’s an adult now and hasn’t had an ear infection since.

  19. When my son was around two years old he kept getting ear infections. He got so many that the doctor was going to suggest putting tubes in his ears. Instead i took him to a chiropractor. He had about 5 adjustments and never got another ear infection after that.

  20. Ten years ago I had simultaneous ear infections in both ears, after reading that they usually went away on their own I added finely minced raw garlic to my diet to help things along safely. After 3 heads of raw garlic, and two of roasted garlic the infections went away in both ears and on day 6 I was pain free. Growing up I had many ear infections, and both as a child and now as an adult I have many allergies. Now the only time I have antibiotics are when I have a life threatening infection, and recovering from those antibiotics is brutal, unless you really need them just say no to antibiotics.

  21. I use coconut oil for ear infections and it works like a charm. A couple years ago I had painful ear infections in each ear. I put a little coconut oil in my ear, laid on my side to allow it to melt and sink in and by the next morning the severe pain was gone. I had some minor ear pain in the following days but I reapplied a couple times a day and within a few days the pain was gone completely.

  22. I can speak to this personally and professionally.
    To clarify-PE tubes are not inserted to prevent ear infections. They’re used to open the Eustachian tubes and allow for the fluid to flow out of the ear. They prevent fluid back up which could result in rupture to the ear drum.
    When you speak of abx overuse, do you mean oral or otic? Research suggests that there is really no need for systemic abx for localized ear infection. Otic is most beneficial, when ear cultures are positive.

    • A PE tube does not open the eustachian tube. It takes the place of a non-functioning eustachian tube. Immediately before a tube is inserted all the current fluid is suctioned out and then the tube is placed. If future fluid presents itself while the tube is in place, it then flows through the tube into the ear canal rather than building up in the middle ear, if the person’s eustachian tube is still non-functioning. Otic eardrops are typically used for outer ear infections. PE tubes do nothing to correct the underlying problem of poor Eustachian tube function, they merely help alleviate symptoms of pain and/or hearing loss.

  23. As a naturopath working in kids health I completely agree! Eliminating dairy is recurrent ear infections and boosting the immune system with fermented foods, probiotics, nutrients and herbs always works a treat 🙂

  24. A few drops of food grade hydrogen peroxide with colloidal or mono-atomic silver; it will likely also prevent or kill a cold.

  25. Hi, Would love any feedback. I have used Xylitol nasal spray twice a day for nearly 16 years ( I worked in a zoo with the public), but recently heard on a natural health conference that it is not good for the brain/body. I stopped using it a couple months ago, and now I have a cold. I have a TBI, and am careful of anything being hard on my brain. Thanks for any opinion or information.

  26. I suffered from ear infections most of my life. I can remember very painful earaches and “sweet oil” poured into my ears when I was in elementary school. Later screenings revealed hearing loss and in middle school I had tubes in both ears. This didn’t seem to help much and I continued to have ear infections as an adult even rupturing a couple of times. I now believe that my Eustachian tubes did not drain well and I was chronically inflamed.

    Since following an ancestral diet, I believe my ear health changed dramatically. The only ear infection I’ve had since trying a paleo/primal approach to eating was an outer-ear infection after accidentally going under water in a lake.

    I believe my hearing has improved as well. I credit this to the anti-inflammatory benefits of avoiding grains and PUFAs.

    So as an accidental benefit of going paleo, I think my hearing has improved and ear infections have been avoided.

    • I agree, as a child I suffered ear infections constantly especially after swimming, as I got older I got terrible sinus problems and skin rashes etc. Since going gluten free, no more infections whatsoever, immune system working better as gut health improved. My daughter is the same, she got grommets at 10 months which seemed to help her a lot, no more ear infections after that, and eating a gf diet.

  27. My 4 year old son had tubes at the age of 1. He has since had a few infections and I have always taken the “wait and see”. He has really not had many problems until October of last year. He is followed by a pediatric ENT and has had fluid on both ears since October. He visibly is having trouble with his hearing and he goes back to the ENT in a few weeks for possible recommendation of another set of tubes. He has had one infection, not treated with meds, since October. The main problem is the hearing loss. What can you do for fluid that won’t go away?

  28. I knew that antibiotics for ear infections isn’t the best first option. Have been using garlic mullien drops with warm moist compress for years (when occasion has warranted) with great results. 🙂

  29. I had a horribly painful ear infection a couple years ago. I tried all kinds of homeopathic and naturopathic remedies. Had to miss a lot of work, couldn’t chew, couldn’t sleep on that side… Finally got some antibiotic EAR DROPS from my doctor and that cleared it up very quickly. I’m sorry I messed around with all that other stuff because it was excruciating.

    • That sounds like otitis externa (OE), and not otitis media (OM) to which Chris is referring. That usually causes swelling and inflammation of the ear canal that can spread to the area around the ear, and is usually caused by bacteria and fungi. It is treated differently, and most commonly only with ear drops.

  30. Chris,
    Great article. Another possible treatment is a topical antibiotic — antibiotic ear drops.

    I had many bad ear infections as a child and my ears remained a weak spot into adulthood — I would get an infection pretty much every time I swam in lakes in the summer, so eventually avoided it as much as possible — my infections were bad, proceeding to screaming levels of pain as a kid. As an adult would get help right before that point 🙂

    Over 10 years ago, a doc suggested the drops, and they worked! I have had to use them a few more times, and the infections have cleared up quickly, often with just 1,2 sometimes 3 applications.

    Only N=1, but it’s been amazing to have relief from bad ear infections without having full-body antibiotic effects.

  31. I am going to mention some things that adults and older children can try for ear infections. If you look at buyer reviews on Amazon you can see that many people have benefited from Otovent and other devices to “pop” the ears; basically they provide air pressure to open up the Eustachian tubes so that the ears can drain. In my case I found that I needed to loosen up the “glue” in my ear with drug store remedies before Otovent would pop my ears. As soon as my ears popped, I could hear much better.
    My Eustachian tubes were blocked even when I had ear tubes. I wrote more about my ear experiences on my WordPress blog that titled Glue Ear Success.

  32. Chris, a question.
    If one has SIBO,any prebiotic is questionable Correct?
    How does one get prebiotic to the colon and not the small intestine?

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