What is the appropriate acute management for a bee sting in a patient without a known allergy to insect venom?

Acute Management of Bee Stings in Patients Without Known Allergy

For uncomplicated bee stings in patients without known allergy, remove the stinger immediately by scraping or flicking (not grasping), apply cold compresses, and administer oral antihistamines for symptomatic relief; antibiotics are not indicated unless clear signs of secondary bacterial infection develop. 1

Immediate Stinger Removal

• Remove the stinger within 10–20 seconds by flicking or scraping it away with a fingernail, credit card edge, or similar flat object 1
• Never grasp or pull the stinger by the venom sac, as this injects additional venom into the tissue 1, 2
• The method of removal matters less than the speed—every second of delay allows more venom injection 1

Symptomatic Treatment for Simple Local Reactions

• Apply cold compresses or ice packs to the sting site to reduce local pain, swelling, and inflammation 1, 3
• Administer oral antihistamines (such as cetirizine or diphenhydramine) to alleviate itching, pain, and discomfort 1, 3
• Use oral analgesics (acetaminophen or ibuprofen) for pain management as needed 1, 3
• Elevate the affected limb if swelling is significant 1
• Simple local reactions typically resolve within 24 hours with these conservative measures 3

Management of Large Local Reactions

Large local reactions are characterized by extensive swelling (>10 cm diameter) that peaks at 24–48 hours and may persist 5–10 days 1, 3:

• Continue cold compresses and oral antihistamines throughout the reaction period 1, 3
• Consider a short course of oral corticosteroids (e.g., prednisone) initiated within the first 24–48 hours for severe cases with extensive swelling, though definitive controlled trial evidence is lacking 1, 3
• These reactions represent IgE-mediated allergic inflammation, not infection—the swelling is caused by allergic mediator release 1

Critical Pitfall: Inappropriate Antibiotic Use

• Do not prescribe antibiotics for local or large local reactions unless there are clear signs of secondary bacterial infection 1, 3
• Signs of true bacterial infection include progressive redness beyond 48 hours, increasing pain, purulent discharge, fever, or warmth and tenderness 1
• The vast majority of swelling after bee stings is allergic inflammation, not infection, and antibiotics are both unnecessary and contribute to antimicrobial resistance 1

Monitoring for Systemic Reactions

Immediately assess for any systemic symptoms and be prepared to administer epinephrine if they develop 1, 3:

• Cutaneous: urticaria or angioedema beyond the sting site 1, 3
• Respiratory: throat tightness, dyspnea, wheezing, stridor 1, 3
• Cardiovascular: hypotension, tachycardia, dizziness, syncope 1, 3
• Gastrointestinal: nausea, vomiting, diarrhea, abdominal cramping 1, 3
• Neurological: confusion, altered mental status 1

If any systemic symptoms appear:

• Administer intramuscular epinephrine immediately: 0.3–0.5 mg in adults (0.01 mg/kg, maximum 0.3 mg in children) into the anterolateral thigh 3, 4
• Antihistamines and corticosteroids are NOT substitutes for epinephrine in anaphylaxis—delayed epinephrine administration is associated with fatal outcomes 3, 4
• Call emergency medical services and transport to the emergency department for observation (minimum 4–6 hours for biphasic reactions) 4
• Repeat epinephrine dosing may be required every 5–15 minutes for persistent or recurrent symptoms 3

Post-Acute Considerations

For Patients Who Develop Systemic Reactions

• Prescribe an epinephrine autoinjector with structured training on proper technique and indications for use 3, 4
• Refer to an allergist-immunologist for venom-specific IgE testing (skin testing or in vitro IgE antibody testing) 3, 4
• Venom immunotherapy (VIT) is indicated for adults with any systemic reaction beyond isolated cutaneous manifestations and reduces the risk of future systemic reactions from 25–70% to <5% 5, 3
• Testing may be temporarily non-reactive within the first few weeks after a reaction and may require repeat testing at 4–6 weeks 5, 3

For Patients With Large Local Reactions Only

• VIT is generally not necessary for patients who experience only large local reactions 5
• However, consider allergist referral for patients with frequent unavoidable exposure (e.g., beekeepers, outdoor workers) or recurrent large local reactions with vascular compromise 1, 3
• Prescribing an epinephrine autoinjector is reasonable for this group, as up to 10% may later develop systemic reactions 3

Special Situations

• Fire ant stings characteristically produce a sterile pseudopustule within 24 hours, which is pathognomonic and not infected—leave the vesicle intact and keep clean to prevent secondary infection 1
• Stings to the eye require immediate ophthalmologic evaluation due to risk of permanent vision loss 3
• Multiple stings (>50) carry higher risk of toxic reactions with systemic symptoms (nausea, vomiting, hypotension, confusion, renal failure) even in non-allergic individuals and require supportive care with attention to airway, blood pressure, and renal function 2