When does an ear infection require antibiotics?

A picture of a woman holding her ear in pain


Ear infections are common in children, and many parents are convinced they need antibiotics. But sometimes antibiotics aren’t the answer. Learn more about ear infections from Rachel Johnson, MD.

Many parents know what it’s like when a child is experiencing an ear infection. It’s painful for them and causes lots of sleepless nights for everyone. Here’s why it’s best to treat ear infections as soon as possible.

What causes ear infections?

Rachel Johnson, MD, Nebraska Medicine internal medicine, pediatrics, explains that ear infections start when fluid containing bacteria or viruses is trapped in the ear. The bacteria can cause infection and inflammation in the ear, which leads to pain. The area then becomes a breeding ground for bacteria.

“Our sinuses are connected to our ears and mouth, like a big tube system,” Dr. Johnson says. “When there’s inflammation in the sinuses, that area gets smaller, mucus is produced, and the fluid backs up into the ear canal. With fluid and mucus, infection happens.”

Ear infections can cause fever and severe ear pain as well as dizziness, yellowish discharge, disrupted sleep, loss of balance, headaches, redness, and even hearing loss or change in more severe cases.

Why are some kids more prone to ear infections than others?

Chronic or recurrent ear infections can happen in children and infants. Though rare, adults can also get recurring ear infections.  But what causes this?

“In some people, the anatomy and angle of the eustachian tube are not as sloped, so it’s easier for mucus and fluid to get stuck,” explains Dr. Johnson. “Being exposed to smoke is another big risk factor. We see ear infections commonly in kids who are exposed to smoke in their homes or a caretaker environment.

Allergies can also play a role in ear infections, she says. Allergy symptoms can cause the sinuses and eustachian tubes to become inflamed and trap bacteria. But there are ways to help prevent ear infections.

“Kids who are breastfed have a lesser risk of ear infection. The antibodies present in breast milk can help decrease infections because of the natural immunities.”

Frequent hand washing and avoiding secondhand smoke are other ways to reduce the risk of developing ear infections. If babies are bottle-fed, holding them in an upright position during feeding can also help.

Why are some ear infection symptoms worse at night?

Ear infection symptoms can worsen at night because the pressure is greater. Lying down can back up the drainage in the middle ear, causing pressure and pain.

“This makes sense due to gravity and lying down,” Dr. Johnson explains. “All the fluids can sit and pool. Your ear is supposed to be a negative pressure environment, so when you get lots of pressure it causes pain.”

When does a patient need ear tubes, and what do they do?

Ear tubes are small plastic or metal tubes inserted into ears to reduce ear infections by allowing fluids to drain and refreshing the air in the ear. Children with recurrent ear infections (three or more in 6 months or four or more in a year) or affected hearing will sometimes need tubes to help get air into the middle ear. Ear infections, in general, aren’t as common in adults, but sometimes tubes are still necessary.

“There definitely are some adults that need tubes. I’ve had a few adult patients who need tubes because of recurrent ear infections into adulthood,” says Dr. Johnson. “It’s rare, but it does happen.”

When are antibiotics necessary for ear infections?

Not all ear infections need to be treated with antibiotics. In fact, about a quarter of ear infections are viral, so antibiotics won’t help, according to Dr. Johnson.

“If kids have an ear infection and are 2 and under, we treat those with antibiotics. Adults almost always need antibiotics because ear infections for adults are so rare. If children and adults have severe symptoms, a high fever, or both ears are infected, we would also recommend antibiotics,” she says.

Ear infections that don’t require antibiotics, especially in children older than 2, can resolve on their own. This usually means they’re viral, so parents can watch and wait to make sure the symptoms clear up.

Who can treat ear infections in children and adults?

Parents or adults can contact a primary care doctor or pediatrician when they notice potential ear infection symptoms or schedule an On-Demand Video Visit to be seen virtually.

“Ideally, it's best to look at the ear to document for sure that it’s an ear infection, but it’s also very reasonable to do a virtual visit,” says Dr. Johnson. “If the patient has ear pain and a high fever or other viral symptoms, we can do a virtual visit. When kids have lots of ear infections, and they need to get tubes, we need to know exactly how many documented infections there have been.”