What topical antibiotics do you give for hordeolum?

Topical Antibiotic Treatment for Hordeolum

For hordeolum (stye), topical antibiotic ointment such as bacitracin or erythromycin applied directly to the eyelid margin is recommended only if the lesion persists beyond 1-2 weeks or worsens despite initial conservative management with warm compresses and eyelid hygiene. 1, 2

First-Line Management (No Antibiotics Initially)

Most hordeola resolve spontaneously within 1-2 weeks with conservative measures alone, making antibiotics unnecessary as initial therapy 2:

• Apply warm compresses to the affected eyelid for 5-10 minutes, 3-4 times daily (or 4-6 times daily for more severe cases) to soften crusts, warm meibomian secretions, and promote spontaneous drainage 1, 2
• Perform eyelid cleansing once or twice daily using diluted baby shampoo or commercially available eyelid cleaner on a cotton ball, cotton swab, or clean fingertip to remove debris and inflammatory material 1
• Gentle vertical massage of the eyelid helps express secretions, particularly for posterior blepharitis or meibomian gland involvement 1

When to Add Topical Antibiotics (Second-Line)

Add topical antibiotics only after 1-2 weeks if the hordeolum persists or worsens despite conservative treatment 1, 2:

Specific Antibiotic Recommendations

• Bacitracin ointment or erythromycin ointment applied directly to the eyelid margins where the lashes emerge 1, 2
• Apply approximately 1 cm ribbon to the eyelid margin (not into the conjunctival sac) one or more times daily or at bedtime 3, 2
• Frequency: For mild cases, apply once daily at bedtime; for more severe cases, apply up to 4-6 times daily 3
• Duration: Continue for a few weeks, then reassess based on clinical response 1, 3
• Mupirocin 2% ointment is an alternative option for minor skin infections 1

Important Application Details

The target is the eyelid margin itself where bacterial colonization occurs in the meibomian glands or lash follicles—never apply into the conjunctival sac when treating hordeolum 2. This is a critical distinction from treating conjunctivitis.

When Systemic Antibiotics Are Needed

For recurrent or severe hordeola not responding to topical treatment, or if there are signs of spreading infection 2:

• Oral cephalexin or dicloxacillin for deeper infection 2
• In children under 8 years or pregnant women: Use oral erythromycin (30-40 mg/kg divided over 3 doses for 3 weeks, then twice daily for 4-6 weeks) instead of tetracyclines to avoid tooth staining 3, 2
• For suspected MRSA: Consider trimethoprim-sulfamethoxazole or tetracycline (doxycycline/minocycline), though treatment failure rates up to 21% have been reported with tetracyclines 1
• Re-evaluate in 24-48 hours after starting oral antibiotics to verify clinical response 1

Critical Pitfalls to Avoid

• Never use corticosteroid drops for an active hordeolum, as steroids worsen bacterial infections; they are only indicated for inflammatory complications after infection is controlled 2
• Avoid aggressive manipulation or squeezing of the hordeolum, as this can spread infection or cause mechanical irritation 2
• In patients with advanced glaucoma, avoid aggressive lid pressure during warm compress application, as this may increase intraocular pressure 1, 2
• Rotate different antibiotics if long-term or repeated treatment is needed to prevent development of resistant organisms 3, 2
• Patients with neurotrophic corneas require proper counseling to avoid injury to corneal epithelium during eyelid cleaning 1

Evidence Quality Considerations

Research evidence for topical antibiotics in hordeolum is limited. One randomized placebo-controlled trial found that combined antibiotic ophthalmic solution (neomycin sulfate, polymyxin B sulfate, and gramicidin) was not more effective than placebo after incision and curettage 4. However, azithromycin hydrate ophthalmic solution showed efficacy for internal hordeolum and meibomitis in a retrospective study, particularly when Cutibacterium acnes was detected 5. The guideline recommendations are based primarily on clinical experience and expert consensus rather than high-quality randomized trials 1, 2.

When to Refer

• If no improvement after incision and drainage plus appropriate antibiotic therapy 1
• Signs of orbital cellulitis or systemic illness require immediate ophthalmology referral 1
• Stye in difficult-to-treat location such as the inner eyelid 1