What is the treatment for bacterial blepharitis (bacterial eyelid infection)?

Treatment of Bacterial Blepharitis

Begin with daily eyelid hygiene using warm compresses and eyelid cleansing for 2-4 weeks, then add topical antibiotic ointment (bacitracin or erythromycin) to the eyelid margins if inadequate response occurs. 1

First-Line Treatment: Eyelid Hygiene

• Apply warm compresses for several minutes to soften crusts and warm meibomian secretions 1, 2
• Perform gentle eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaners 1
• Remove all scales and crusts carefully before applying any topical medications 3
• Consider hypochlorous acid 0.01% eye cleaners, which have strong antimicrobial effects for both anterior and posterior blepharitis 1, 2
• Add artificial tears to manage associated dry eye symptoms, using preservative-free formulations if needed more than 4 times daily 1, 2

Second-Line Treatment: Topical Antibiotics

If eyelid hygiene alone provides inadequate relief after 2-4 weeks, add topical antibiotic ointment to the eyelid margins. 1, 2

Preferred Topical Antibiotics:

• Bacitracin ointment: Apply directly to eyelid margins 1-3 times daily after removing all scales and crusts, spreading uniformly over the lid margins 2, 3
• Erythromycin ointment: Apply to eyelid margins one or more times daily or at bedtime for a few weeks 1, 2, 4
• Azithromycin 1% ophthalmic solution: For moderate to severe chronic blepharitis, apply twice daily for 2 days, then once daily for 12 days, combined with warm compresses 2

Important Antibiotic Considerations:

• Rotate different antibiotics intermittently to prevent development of resistant organisms 1, 2
• Topical antibiotics effectively decrease bacteria from the eyelid margin and provide symptomatic relief 2
• Avoid long-term continuous antibiotic use due to resistance concerns 1

Third-Line Treatment: Oral Antibiotics for Severe or Resistant Cases

For posterior blepharitis/meibomian gland dysfunction with persistent symptoms despite topical therapy, consider oral antibiotics. 2

Oral Antibiotic Options:

• Adults: Doxycycline, minocycline, or tetracycline 1, 2
• Children, pregnant women, or women of childbearing age: Erythromycin or azithromycin (tetracyclines are contraindicated) 1, 2
• Azithromycin pulse regimen: 500 mg daily for 3 days in three cycles with 7-day intervals between cycles, or 1 g per week for 3 weeks 1, 2

Critical Caveat for Azithromycin:

• The FDA warns that oral azithromycin may cause cardiac electrical abnormalities with potential for serious heart rhythm irregularities, particularly in patients with high baseline cardiovascular disease risk 1, 2
• Perform careful cardiovascular risk assessment before prescribing oral azithromycin 2

Adjunctive Treatments for Inflammation

• Short-course topical corticosteroids (1-2 weeks): Consider loteprednol etabonate or fluorometholone phosphate for significant eyelid or ocular surface inflammation, including marginal keratitis or phlyctenules 1, 2
• Use minimal effective dose and limit duration to minimize steroid-related complications including elevated intraocular pressure 1, 2
• Topical corticosteroid-antibiotic combinations may be effective but should be limited to 1-2 weeks 2

Treatment Algorithm Summary

1. Weeks 0-4: Warm compresses + eyelid cleansing + artificial tears 1, 2
2. If inadequate response: Add topical bacitracin or erythromycin ointment to eyelid margins 1, 2
3. If still inadequate or severe disease: Consider oral antibiotics (doxycycline for adults, erythromycin/azithromycin for children/pregnant women) 1, 2
4. For marked inflammation: Add short-course topical corticosteroid (1-2 weeks maximum) 1, 2

Critical Patient Education Points

• Blepharitis is typically chronic and cannot be permanently cured—symptoms often recur when treatment is discontinued, requiring ongoing management rather than expecting complete resolution 1, 2
• Daily eyelid hygiene is essential for long-term control and must be continued indefinitely 1
• Avoid compresses that are too hot to prevent skin burns 1
• Address moderate to severe blepharitis prior to intraocular surgical procedures to reduce risk of postoperative endophthalmitis 2