What are the best antibiotics for treating a stye (hordeolum)?

Best Antibiotics for Stye (Hordeolum)

For styes (hordeola), warm compresses and topical antibiotics such as erythromycin or bacitracin ointment are the first-line treatment, with oral antibiotics like dicloxacillin, cephalexin, or clindamycin reserved for severe cases or those with surrounding cellulitis.

Initial Management

First-line Treatment

• Warm compresses: Apply for 10-15 minutes, 3-4 times daily to promote drainage
• Eyelid hygiene: Gentle cleansing of eyelid margins
• Topical antibiotics: Apply directly to the affected area
  • Erythromycin ointment
  • Bacitracin ointment
  • Mupirocin 2% ointment (for limited lesions) 1

When to Consider Oral Antibiotics

Oral antibiotics should be considered when:

• Stye is severe or extensive
• Rapid progression with surrounding cellulitis
• Signs of systemic illness
• Patient is immunocompromised
• Extremes of age
• Stye is in difficult-to-drain area
• No response to initial treatment 1

Oral Antibiotic Options

First-line Oral Antibiotics

1. Dicloxacillin: 500 mg four times daily (adults) 2
2. Cephalexin: 500 mg four times daily (adults) or 25-50 mg/kg/day in 4 divided doses (children) 2
3. Clindamycin: 300-450 mg three times daily (adults) or 10-20 mg/kg/day in 3 divided doses (children) 2, 1

For MRSA Concerns

If MRSA is suspected (previous MRSA infections, failed initial therapy, or high local prevalence):

• Trimethoprim-sulfamethoxazole: 1-2 double-strength tablets twice daily 2, 1
• Doxycycline: 100 mg twice daily (not for children <8 years) 2
• Clindamycin: 300-450 mg three times daily 2, 1

Special Populations

Children

• First choice: Topical antibiotics (mupirocin 2% ointment) 1
• If oral antibiotics needed:
  • Cephalexin: 25-50 mg/kg/day in 4 divided doses 2
  • Clindamycin: 10-20 mg/kg/day in 3 divided doses (if local resistance rates are low) 2, 1
  • Avoid tetracyclines in children <8 years of age 2

Severe Cases Requiring Hospitalization

For complicated cases with significant cellulitis or systemic symptoms:

• Vancomycin: 30 mg/kg/day in 2 divided doses IV 2
• Linezolid: 600 mg every 12 hours IV or PO 2
• Clindamycin: 600 mg every 8 hours IV 2

Duration of Therapy

• Topical antibiotics: 5-7 days
• Oral antibiotics: 7-10 days, individualized based on clinical response 2, 1

Important Considerations

When to Perform Incision and Drainage

• Primary treatment for abscesses that are pointing or fluctuant 1
• Should be performed by experienced clinicians
• Consider referral to ophthalmologist for persistent styes (>2 months) 1

Prevention of Recurrence

• Maintain good eyelid hygiene
• Remove eye makeup completely
• Treat underlying conditions (blepharitis, seborrheic dermatitis)
• Consider replacement of contact lenses and case after resolution 1

Clinical Pearls

• Despite the common use of topical antibiotics, there is limited high-quality evidence specifically for styes 3
• The reservoir of bacteria in sebaceous glands may not be affected by topical antibiotics alone 4
• Incision and drainage remains the definitive treatment for many styes, with antibiotics being adjunctive therapy 1
• Referral to an ophthalmologist is recommended for persistent styes or those that develop into chalazia 1

Remember that while antibiotics are important in the management of styes, warm compresses and proper eyelid hygiene are fundamental components of treatment that should not be overlooked.