What is the recommended management of a bee sting, including immediate care, medication, tetanus prophylaxis, and precautions for patients with known bee‑venom allergy?

Bee Sting Treatment and Precautions

Immediate Stinger Removal

Remove the stinger within 10-20 seconds by scraping or flicking it away with a fingernail—speed of removal matters far more than technique. 1 The honeybee's barbed stinger continues injecting venom for up to 60 seconds if left embedded, and envenomation increases directly with time the stinger remains in the skin. 2 Never grasp or pinch the venom sac, as this forces additional venom into tissue. 1, 3

Algorithmic Treatment Based on Reaction Type

Simple Local Reactions (Pain, Swelling, Itching at Sting Site Only)

• Apply cold compresses or ice packs immediately to reduce local pain and swelling. 2, 1
• Give oral antihistamines (e.g., diphenhydramine, cetirizine) to reduce itching and discomfort. 2, 1
• Provide oral analgesics (acetaminophen or ibuprofen) for pain relief. 2, 1
• No antibiotics are needed—the swelling is allergic inflammation, not infection. 4

Large Local Reactions (>10 cm Induration, Lasting >24 Hours)

• Continue cold compresses and oral antihistamines throughout the reaction, which typically peaks at 24-48 hours and resolves over 5-10 days. 4
• Initiate a short course of oral corticosteroids within the first 24-48 hours to limit progression of extensive swelling. 1, 4
• Prescribe antibiotics only if clear signs of secondary bacterial infection develop: progressive redness, increasing pain, purulent discharge, fever, or warmth and tenderness. 4
• Refer to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, as patients with large local reactions have approximately 5% risk of anaphylaxis with future stings. 5

Systemic Reactions/Anaphylaxis (Urticaria Beyond Sting Site, Angioedema, Respiratory Distress, Hypotension, Vomiting, Lightheadedness)

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—this is the ONLY first-line treatment for anaphylaxis. 2, 1, 3 Antihistamines and corticosteroids are not substitutes, and delayed epinephrine administration is associated with fatal outcomes. 4, 3

• Call emergency services immediately after administering epinephrine. 3
• Position the patient supine with legs elevated if hypotension develops to prevent empty-ventricle syndrome. 3
• Repeat epinephrine every 5 minutes if symptoms persist or worsen. 3
• Administer supplemental oxygen to all patients with prolonged reactions or requiring multiple epinephrine doses. 3
• Give 1-2 liters IV normal saline bolus for persistent hypotension. 3
• Administer inhaled albuterol (2.5 mg nebulized) for bronchospasm persisting despite epinephrine. 3
• Give H1 antihistamines (diphenhydramine 25-50 mg IV/IM) and H2 blockers (ranitidine 50 mg IV or famotidine 20 mg IV) as adjuncts only. 3
• Give corticosteroids (methylprednisolone 125 mg IV or prednisone 0.5 mg/kg PO) to potentially prevent biphasic reactions, though they have no immediate effect. 3

Special Circumstances Requiring Heightened Vigilance

• Eye stings require immediate ophthalmology evaluation, as they can cause permanent vision loss. 2, 3
• Multiple stings (>20 from large hornets or >100 from honeybees) can cause toxic reactions from massive envenomation even in non-allergic individuals, potentially causing multi-organ dysfunction including renal failure, seizures, and hypotension. 2, 3, 6
• Patients on beta-blockers may be refractory to epinephrine and require higher doses or alternative vasopressors like glucagon. 3

Post-Treatment Management for All Systemic Reactions

• Prescribe an epinephrine autoinjector before discharge and demonstrate proper use to the patient and caregivers. 1, 3
• Consider prescribing two autoinjectors, as some patients experiencing anaphylaxis require more than one injection. 4
• Refer all patients with systemic reactions to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy (VIT). 1, 4, 3
• VIT reduces the risk of subsequent systemic reactions from 60% in adults (20-32% in children) to less than 5%, making it highly effective for patients with positive venom-specific IgE and history of anaphylaxis. 4, 3, 5

Tetanus Prophylaxis

While the provided guidelines do not specifically address tetanus prophylaxis for bee stings, standard wound care principles apply: update tetanus immunization if the patient's last dose was more than 10 years ago or if immunization status is uncertain.

Critical Pitfalls to Avoid

• Never delay epinephrine when systemic symptoms appear—delayed administration has been linked to fatal outcomes. 4, 3
• Do not assume the reaction is over after initial improvement—biphasic reactions can occur hours later. 3
• Do not use subcutaneous epinephrine or inject in the arm—intramuscular injection in the anterolateral thigh achieves faster and higher plasma concentrations. 3
• Do not routinely prescribe antibiotics for large local reactions—the swelling is IgE-mediated allergic inflammation, not infection. 4
• There are no contraindications to epinephrine in anaphylaxis, even in patients with cardiovascular disease, as the benefits far outweigh risks. 3

Prevention Strategies for High-Risk Patients

• Avoid walking barefoot outdoors. 3
• Wear protective clothing when outdoors. 3
• Avoid bright colors, floral patterns, and scented products. 3
• Have nests professionally removed. 3
• Carry epinephrine autoinjector at all times. 4, 3