What oral antibiotic is recommended for treating a stye (hordeolum)?

Oral Antibiotic Treatment for Stye (Hordeolum)

For styes requiring oral antibiotics, use dicloxacillin 500 mg four times daily as first-line treatment, or trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily if MRSA is suspected or the patient is penicillin-allergic. 1

When Oral Antibiotics Are Actually Needed

Most styes do NOT require oral antibiotics—warm compresses and drainage are primary treatment. 2 However, oral antibiotics become necessary when:

• Severe or extensive disease with multiple sites of infection 2
• Rapid progression with associated cellulitis spreading beyond the eyelid 2
• Systemic signs of infection (fever >38°C, elevated white blood cell count) 2
• Immunocompromised patients 2
• Failure to respond to warm compresses and drainage alone 2
• Difficult drainage location on the face/periorbital area 2

First-Line Antibiotic Selection

For Methicillin-Susceptible Staph aureus (MSSA):

• Dicloxacillin 500 mg orally four times daily for 5-10 days 1, 2
• Alternative: Cephalexin 500 mg orally four times daily 1

For Penicillin Allergy (Anaphylactic/Immediate Hypersensitivity):

• Clindamycin 300-450 mg three times daily 1, 2

For Suspected MRSA (Community-Acquired):

• TMP-SMX 1-2 double-strength tablets (160-320/800-1600 mg) twice daily 1, 2
• Alternative: Doxycycline 100 mg twice daily 1, 2
• Alternative: Minocycline 200 mg loading dose, then 100 mg twice daily 2

Critical Pitfalls to Avoid

Do NOT use clindamycin empirically for MRSA without susceptibility testing due to increasing resistance rates—reserve it for culture-proven susceptible strains. 1

Avoid tetracyclines (doxycycline/minocycline) in children <8 years old due to tooth discoloration and bone growth effects. 1, 2

Avoid TMP-SMX in third trimester pregnancy and tetracyclines throughout pregnancy—use beta-lactams (dicloxacillin, cephalexin) instead. 1

Do NOT use rifampin as monotherapy or adjunctive therapy for skin infections. 2

Treatment Duration

5-10 days of therapy is recommended for uncomplicated styes requiring antibiotics. 2

When to Escalate to IV Antibiotics

Switch to intravenous therapy if: 1

• Systemic signs of infection persist despite oral therapy
• Rapid progression despite appropriate oral antibiotics
• Immunocompromised host with worsening infection
• Concern for deeper orbital/periorbital infection (orbital cellulitis, preseptal cellulitis)

IV options for MRSA: Vancomycin 30-60 mg/kg/day divided every 8-12 hours OR linezolid 600 mg IV every 12 hours. 1, 2

Local Resistance Patterns Matter

In areas with high MRSA prevalence (>10-15% of community Staph aureus isolates), empiric coverage for MRSA with TMP-SMX or doxycycline should be strongly considered even for initial presentation. 2, 3 Conversely, in areas with low MRSA rates, dicloxacillin remains the most appropriate first choice. 1