What is the recommended antibiotic regimen for blepharitis?

From the Guidelines

For blepharitis, a topical antibiotic ointment such as erythromycin 0.5% or bacitracin applied to the lid margins twice daily for 7-10 days is recommended as first-line treatment, as supported by the most recent evidence from 2024 1. Alternatively, azithromycin 1% ophthalmic solution can be used once daily for 2-4 weeks. For more severe cases, oral antibiotics may be necessary, with doxycycline 100mg twice daily for 2 weeks, then once daily for 2-4 weeks being effective, especially for posterior blepharitis associated with rosacea, as noted in the 2019 study 1. Tetracycline 250mg four times daily or minocycline 100mg twice daily are also options. These antibiotics work not only by reducing bacterial load but also by decreasing inflammatory mediators and inhibiting bacterial lipase production, which reduces irritating free fatty acids on the lid margin. Some key points to consider in the treatment of blepharitis include:

• Treatment should be combined with daily lid hygiene using warm compresses and gentle lid scrubs to remove debris and crusts.
• Patients should be advised to avoid eye makeup during acute treatment and to replace eye cosmetics regularly to prevent reinfection.
• Artificial tears may provide symptomatic relief for associated dry eye symptoms, as discussed in the 2024 study 1.
• The use of oral azithromycin may lead to abnormalities in the electrical activity of the heart, with the potential to create serious irregularities in heart rhythm, as warned by the FDA in 2013, and highlighted in the 2024 study 1.
• Topical corticosteroids may be helpful for eyelid or ocular surface inflammation, but their use should be minimized due to potential adverse effects, such as increased intraocular pressure and cataract, as noted in the 2024 study 1.

From the Research

Antibiotic Regimen for Blepharitis

• The mainstay of treatment for blepharitis is an eyelid hygiene regimen, which needs to be continued long term 2.
• Topical antibiotics are used to reduce the bacterial load, and topical corticosteroid preparations may be helpful in patients with marked inflammation 2, 3.
• Systemic antibiotics may be appropriate in some patients 2.
• Fixed combinations of a topical antibiotic and a corticosteroid offer an effective and convenient treatment modality that addresses both infectious and inflammatory components of the disease 3.
• For Demodex blepharitis, treatment options include tea tree oil, metronidazole ointment, and oral ivermectin, but none of these options seem to be clearly effective 4.
• Recent randomized controlled clinical trials suggest that lotilaner ophthalmic solution, 0.25%, is a topical treatment with the potential to eradicate Demodex mites and eliminate collarettes and eyelid redness for an extended period 5.

Treatment Options

• Topical antibiotics:
  • Used to reduce bacterial load 2, 3
  • Examples: not specified in the studies
• Systemic antibiotics:
  • May be appropriate in some patients 2
  • Examples: not specified in the studies
• Topical corticosteroids:
  • May be helpful in patients with marked inflammation 2, 3
  • Examples: not specified in the studies
• Other treatment options:
  • Tea tree oil 4
  • Metronidazole ointment 4
  • Oral ivermectin 4
  • Lotilaner ophthalmic solution, 0.25% 5