What is the difference in treatment for domestic bee stings versus Africanized bee stings?

Treatment Differences Between Domestic and Africanized Bee Stings

The primary difference in treatment between domestic and Africanized bee stings is not in the immediate management approach, but in the threshold for hospitalization and monitoring—Africanized bees attack in much larger numbers (often hundreds of stings versus single digits), requiring 24-hour observation for patients with ≥50 stings due to risk of delayed multi-organ toxicity, whereas most domestic bee stings cause only local reactions treated with supportive care. 1, 2

Key Clinical Distinction

Number of Stings and Attack Behavior

• Africanized bees are far more aggressive and attack in swarms, delivering hundreds of stings in a single encounter, whereas domestic honeybees typically sting once or only a few times 3, 2
• Death from massive envenomation requires at least 20 stings by large hornets or hundreds of stings from honeybees, making Africanized bee attacks particularly dangerous due to sheer venom volume 1
• The estimated lethal dose is approximately 20 stings/kg in most mammals, meaning massive Africanized bee attacks can cause toxic reactions even in non-allergic individuals 4

Venom Composition

• The venom itself is essentially identical between domestic and Africanized honeybees—both are Apis mellifera species with the same venom proteins 3
• The clinical difference stems entirely from the number of stings delivered, not from any difference in venom potency or composition 3, 4

Treatment Algorithm by Clinical Presentation

For Single or Few Stings (Typical of Domestic Bees)

Local Reactions:

• Remove the stinger immediately by scraping or plucking—speed matters more than method, as venom delivery continues for up to 60 seconds 1, 5
• Apply ice or cold packs to reduce pain and swelling 1, 6
• Administer oral antihistamines for itching 1, 6
• Apply topical corticosteroids for local inflammation 6
• Give oral acetaminophen or ibuprofen for pain relief 1, 6

Anaphylaxis (Can Occur from Single Sting):

• Immediately inject intramuscular epinephrine 0.3-0.5 mg in adults (0.01 mg/kg up to 0.3 mg in children) into the anterolateral thigh 1, 7, 8
• Activate emergency medical services without delay 7, 8
• Be prepared to repeat epinephrine every 5-15 minutes if symptoms persist 8
• Position patient supine with legs elevated if hypotension develops 8

For Massive Envenomation (≥50 Stings—Typical of Africanized Bees)

Immediate Management:

• Remove all visible stingers by scraping to prevent continued venom injection 3
• Initiate supportive care with special attention to airway patency, blood pressure, and renal function 3
• Administer 1-2 liters IV normal saline bolus for fluid resuscitation, as massive fluid shifts occur 8

Critical Monitoring Threshold:

• Patients with ≥50 stings require 24-hour hospitalization for observation, even if initially asymptomatic, due to risk of delayed toxic reaction 2
• Pediatric patients, elderly patients, and those with underlying medical conditions should be hospitalized even with fewer stings if there is concern for massive envenomation 2
• The first signs of multi-organ failure may not appear until 12-24 hours after envenomation 2

Toxic Reaction Manifestations:

• Monitor for hemolysis, thrombocytopenia, rhabdomyolysis, liver dysfunction, kidney failure, and disseminated intravascular coagulation 2
• Signs and symptoms include urticaria, nausea, vomiting, diarrhea, hypotension, confusion, seizures, and renal failure 3
• Laboratory monitoring should include CBC, coagulation studies, renal function, liver enzymes, and creatine kinase 2

Intensive Treatment:

• Initiate dialysis if acute kidney injury develops 2
• Administer blood products as needed for coagulopathy or severe thrombocytopenia 2
• Provide mechanical ventilation if respiratory failure occurs 2

Critical Pitfalls to Avoid

• Never assume an asymptomatic patient with massive Africanized bee stings (≥50) is safe for discharge—delayed multi-organ toxicity can be fatal and may not manifest for 12-24 hours 2
• Do not confuse toxic reactions (dose-dependent, from massive envenomation) with anaphylaxis (IgE-mediated, not dose-dependent)—both can be life-threatening but require different monitoring approaches 4, 9
• Anaphylactic reactions can occur from a single sting regardless of bee type, so always assess for systemic symptoms even with minimal stings 1, 4
• Any eye sting (to the globe itself, not just eyelid) requires immediate ophthalmologic evaluation due to risk of permanent vision loss 1, 7

Post-Exposure Management

• All patients with systemic anaphylactic reactions should receive an epinephrine autoinjector prescription and training before discharge 7, 8
• Refer patients with anaphylaxis to an allergist for venom-specific IgE testing and consideration of venom immunotherapy, which can reduce future reaction risk from 25-70% to nearly zero 8, 9
• Patients with massive envenomation who survive should receive follow-up monitoring of renal and hepatic function for several weeks 2