What is the treatment for an Africanized bee sting?

Treatment for Africanized Bee Stings

For Africanized bee stings, immediately remove the stinger by scraping within 60 seconds, administer intramuscular epinephrine 0.3-0.5 mg in the anterolateral thigh for any signs of anaphylaxis, and activate emergency medical services, as this is the single most critical life-saving intervention. 1

Immediate Stinger Removal

• Remove the stinger within the first 60 seconds by scraping or flicking it away with a fingernail to prevent continued venom injection 1, 2
• The method of removal (scraping vs. plucking) does not matter—speed is what counts 3
• Wash the area with soap and water after stinger removal 3

Critical Distinction: Africanized vs. Domestic Honeybees

• Africanized honeybees are hybrids that are much more aggressive than domestic honeybees and often attack in swarms, resulting in multiple stings 4
• It is not the individual bee's venom composition or volume, but rather the cumulative dose of multiple stings that accounts for morbidity and mortality 5
• Patients with more than 50 stings are at higher risk of toxic reactions, even in non-allergic individuals 6
• Multiple stings (typically >100) can cause toxic reactions from massive envenomation, including rhabdomyolysis, hemolysis, acute renal failure, hypotension, confusion, seizures, and organ damage 6, 7, 8

Treatment Algorithm by Reaction Type

For Local Reactions (Few Stings, No Systemic Symptoms)

• Apply cold compresses or ice packs to reduce pain and swelling 3
• Administer oral antihistamines (diphenhydramine 25-50 mg) to reduce itching 3
• Apply topical corticosteroids directly to sting sites for local inflammation 3
• Give oral acetaminophen or ibuprofen for pain relief 3
• Do not prescribe antibiotics—the swelling is allergic inflammation, not infection 3

For Large Local Reactions

• Initiate a short course of oral corticosteroids (prednisone 0.5 mg/kg) within the first 24-48 hours to limit progression of swelling 3

For Anaphylaxis (Life-Threatening Emergency)

Immediate Actions:

• Administer intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh immediately 1, 9
• Call emergency medical services immediately after administering epinephrine 1
• Position the patient supine with legs elevated if hypotension develops 1
• Never delay epinephrine to give antihistamines or corticosteroids first—this can be fatal 1, 3

Signs of Anaphylaxis to Watch For:

• Urticaria, angioedema, bronchospasm, laryngeal edema, hypotension, syncope, tachycardia, convulsions, vomiting, diarrhea, or airway swelling 4, 9
• Laryngeal edema and circulatory failure are the most common causes of death from anaphylaxis 4

Repeat Dosing:

• Be prepared to repeat epinephrine every 5 minutes if symptoms persist or worsen 1
• For refractory hypotension despite multiple IM doses, transition to intravenous epinephrine infusion (1 mg in 250 mL D5W at 1-4 mcg/min, titrating up to 10 mcg/min) 1
• Administer 1-2 liters of IV normal saline bolus for persistent hypotension 1

Adjunctive Treatments (NOT Substitutes for Epinephrine):

• Administer supplemental oxygen to all patients with prolonged reactions 1
• Give inhaled albuterol (2.5 mg nebulized) for bronchospasm persisting despite epinephrine 1
• Administer H1 antihistamines (diphenhydramine 25-50 mg IV/IM) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts only 1
• Give corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions 1

For Massive Envenomation (>50-100 Stings)

• Treatment is entirely supportive with special attention to airway patency, blood pressure, and renal function 6
• Monitor for signs of toxic reactions including hypotension, confusion, seizures, rhabdomyolysis, hemolysis, and acute renal failure 6, 7, 8
• Consider hemodialysis for severe toxic reactions with renal failure 7, 8
• Manage shock, hypoxia, and other effects of organ damage 7

Critical Pitfalls to Avoid

• Do not use subcutaneous epinephrine or inject in the arm—intramuscular injection in the thigh is superior 1
• Avoid raising the patient to upright position during shock; maintain supine position with legs elevated 1
• Do not assume the reaction is over after initial improvement—biphasic reactions can occur hours later 1
• Patients on beta-blockers may be refractory to epinephrine and require higher doses or alternative vasopressors like glucagon 1
• There are no contraindications to epinephrine in anaphylaxis, even in patients with cardiovascular disease 1

Post-Treatment and Prevention

• Prescribe epinephrine autoinjector (EpiPen or equivalent) before discharge and demonstrate proper use 1, 2, 3
• Refer all patients with systemic reactions to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, which reduces risk of future anaphylaxis to less than 5% 4, 1
• Patients with history of systemic reactions who remain in endemic areas should be treated with venom immunotherapy, possibly administered more intensively and for longer periods 7
• Educate on avoidance measures: avoid walking barefoot outdoors, wear protective clothing, avoid bright colors and floral patterns, eliminate scented products, and have nests professionally removed 1
• Smoke or aerosolized DEET may thwart attacking bees, but avoidance is the best defense 6