Oral Antibiotics for Stye (Hordeolum)
Most styes do not require oral antibiotics and should be managed with warm compresses and observation, as they typically resolve spontaneously within one week. 1, 2, 3
When Oral Antibiotics Are Indicated
Oral antibiotics should be reserved for specific circumstances 4:
- Severe or extensive disease involving multiple sites
- Rapid progression with associated cellulitis
- Signs of systemic illness (fever, malaise)
- Immunosuppression or significant comorbidities
- Failure to respond to warm compresses and drainage
- Recurrent hordeola that persist despite conservative management 5
First-Line Oral Antibiotic Choices
When antibiotics are warranted, target the most common pathogen (Staphylococcus aureus) 4:
For Methicillin-Susceptible Staphylococcus aureus (MSSA):
- Dicloxacillin 500 mg four times daily for 7-10 days 4
- Cephalexin 500 mg four times daily for 7-10 days (alternative for penicillin-allergic patients without immediate hypersensitivity) 4
For Suspected or Confirmed MRSA:
- Doxycycline 100 mg twice daily for 7-10 days 4
- Trimethoprim-sulfamethoxazole (TMP-SMX) 1-2 double-strength tablets twice daily for 7-10 days 4
- Clindamycin 300-450 mg three times daily for 7-10 days (if local resistance rates are <10%) 4
Clinical Decision Algorithm
Step 1: Assess severity and risk factors
- Simple stye without systemic symptoms → warm compresses only 1, 2
- Complicated stye (see indications above) → proceed to Step 2
Step 2: Consider local MRSA prevalence
- Low MRSA prevalence (<10%): Start with dicloxacillin or cephalexin 4
- High MRSA prevalence or risk factors for MRSA: Start with doxycycline or TMP-SMX 4
Step 3: Duration
- 7-10 days of therapy based on clinical response 4
Important Caveats
- Children <8 years: Avoid doxycycline; use cephalexin or clindamycin instead 4
- Pregnant women: Avoid doxycycline and tetracyclines; use cephalexin or clindamycin 4
- Chronic blepharitis association: Consider underlying Demodex infestation if recurrent despite appropriate antibiotic therapy 5
- Culture guidance: Obtain cultures if there is treatment failure, recurrence, or concern for resistant organisms 4
Evidence Quality Note
The evidence base for antibiotic treatment of hordeolum is limited, with no high-quality randomized controlled trials comparing different antibiotic regimens 1, 2, 3. Current recommendations are extrapolated from skin and soft tissue infection guidelines targeting Staphylococcus aureus 4.