In a liver‑transplant recipient on tacrolimus or cyclosporine who develops a hordeolum, is warm compress the first‑line therapy and are bacitracin ophthalmic ointment or erythromycin ophthalmic ointment safe to use?

Bacitracin and Erythromycin Ophthalmic Ointments in Liver Transplant Recipients with Hordeolum

Warm compresses are first-line therapy for hordeolum, and both bacitracin and erythromycin ophthalmic ointments can be safely used in liver transplant recipients on tacrolimus or cyclosporine, as these topical agents have minimal systemic absorption and no clinically significant drug interactions with calcineurin inhibitors. 1

First-Line Conservative Management

Warm compresses applied to the closed eyelid, followed by eyelid massage and lid margin cleaning, represent the evidence-based first-line approach for hordeolum. 1

• The British Journal of Dermatology specifically recommends this conservative approach as initial therapy before considering any antimicrobial interventions. 1
• Lid hygiene measures using commercially available lid wipes or homemade bicarbonate solution should be employed to clean eyelid margins, unblock oil glands, and remove excess bacteria. 1
• This conservative approach can be trialed for up to 3 months but should be discontinued if eye symptoms worsen. 1

Safety of Topical Ophthalmic Antibiotics in Transplant Recipients

Both bacitracin and erythromycin ophthalmic ointments are safe options in liver transplant recipients because they lack systemic drug interactions with tacrolimus or cyclosporine.

• Topical ophthalmic preparations have negligible systemic absorption, making them pharmacologically distinct from systemic antibiotics that might interact with immunosuppressants. 2
• The major drug interactions with tacrolimus and cyclosporine involve systemically administered medications metabolized through cytochrome P450-3A4, not topical ophthalmic agents. 2, 3
• Erythromycin, when given systemically, can interact with calcineurin inhibitors; however, ophthalmic erythromycin ointment achieves only local tissue concentrations without meaningful systemic levels. 2

Important Clinical Caveats

Avoid indiscriminate use of topical antibiotics, as they can induce ocular surface toxicity and contribute to antibiotic resistance. 1

• Topical antibiotics should only be added if conservative management fails or if there are signs of spreading infection. 1
• Topical corticosteroid ointments are contraindicated for simple hordeolum, as they carry risks of increased intraocular pressure, cataract formation, and secondary infections. 1
• Antihistamine or mast cell stabilizer eye drops/ointments should be avoided, as hordeolum is an infectious/inflammatory process, not an allergic condition. 1

Evidence Quality Considerations

The evidence base for hordeolum treatment is notably limited—Cochrane reviews found no randomized controlled trials evaluating non-surgical interventions for acute internal hordeolum. 4, 5 Despite this lack of high-quality evidence, the conservative approach with warm compresses remains standard practice based on clinical experience and pathophysiologic rationale. 1

Monitoring in Transplant Recipients

While topical ophthalmic antibiotics pose no specific concerns regarding immunosuppressant levels, liver transplant recipients require ongoing monitoring of their tacrolimus or cyclosporine trough concentrations as part of routine post-transplant care. 2, 3 The addition of topical ophthalmic agents does not necessitate changes to this monitoring schedule.