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Insect bites and stings - Management
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Definition
- Anaphylaxis can occur after an insect sting (usually within minutes), particularly from a bee or wasp, and requires urgent action.
- Anaphylaxis after an insect bite is rare.
- Multiple bee or wasp stings may cause systemic toxicity which requires urgent action as this can be fatal, particularly in children.
- Late-onset reactions to stings can occur (after several hours), which present as urticarial reactions, or serum sickness-like reactions with urticaria, joint swelling and arthralgia.
How do I manage systemic reactions to an insect bite or sting?
- If a severe systemic reaction occurs, such as wheezing or other signs of respiratory distress, or hypotension:
- Treat urgently as for anaphylaxis and admit to hospital.
- If there are symptoms of systemic toxicity that suggest impending anaphylaxis (e.g. abdominal pain, vomiting, rhinitis and conjunctivitis, or a sense of impending doom):
- Treat as for anaphylaxis and admit to hospital.
- If generalized urticaria occurs, but the person is otherwise well:
- Give an oral antihistamine and an oral corticosteroid.
- Offer a non-sedating antihistamine to control daytime symptoms.
- Consider giving an additional sedating antihistamine at night if the itch is interfering with sleep.
- In adults, give prednisolone 40 mg once a day, and in children give 1–2 mg/kg body weight once a day.
- Continue prednisolone for 3–5 days, depending on the severity of the reaction.
- Advise the person to seek urgent medical help if the rash worsens, swelling develops which involves the mouth or throat, or wheeze or breathing difficulty occurs.
In depth
When should I refer or seek specialist advice?
- Admit all patients with anaphylaxis, after immediate emergency management.
- If mild symptoms appear to be worsening then admission may be required for observation (uncommon).
- The decision to admit will depend upon on the type of reaction, social circumstances, and access to local medical facilities. Exercise clinical judgement in these circumstances.
- Consider referral to an allergy clinic if an insect sting or bite has caused generalized symptoms.
- The Anaphylaxis Campaign recommends referral to an allergy clinic if there is a large local skin reaction, with redness and swelling over 10 cm in diameter. However clinicians should check the referral policy of their local allergy clinic as this may vary.
- Seek specialist advice from an allergy clinic or immunologist regarding local recommendations for interim management of anyone waiting to be seen by the allergy clinic.
In depth
What follow up is recommended?
- If symptoms of generalized urticaria are mild follow-up is generally not necessary.
- Advise review if they have worsening urticaria.
- Advise urgent medical review if symptoms of systemic toxicity develop.
- Anyone who has had anaphylaxis; check that an appointment has been made for referral to an allergy clinic.
Prescriptions
Non-sedating oral antihistamines
Age from 2 years to 5 years 11 months
Cetirizine s/f solution: 5mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take one 5ml spoonful once a day.
Supply 100 ml.
Loratadine syrup: 5mg once a day
Loratadine 5mg/5ml oral solution
Take one 5ml spoonful once a day.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Cetirizine s/f solution: 10mg once a day
Cetirizine 1mg/ml oral solution sugar free
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Loratadine syrup: 10mg once a day
Loratadine 5mg/5ml oral solution
Take two 5ml spoonfuls once a day.
Supply 100 ml.
Age from 12 years onwards
Cetirizine tablets: 10mg once a day
Cetirizine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Fexofenadine tablets: 180mg once a day
Fexofenadine 180mg tablets
Take one tablet once a day.
Supply 14 tablets.
Loratadine tablets: 10mg once a day
Loratadine 10mg tablets
Take one tablet once a day.
Supply 14 tablets.
Sedating oral antihistamines (for itch at night)
Age from 1 year to 5 years 11 months
Hydroxyzine syrup: 5 to 15 mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 2.5ml to 7.5ml at night when required for relief of itching.
Supply 100 ml.
Age from 1 year 1 month to 1 year 11 months
Chlorphenamine oral solution: 1 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml at night when required for relief of itching.
Supply 50 ml.
Age from 2 years to 5 years 11 months
Chlorphenamine oral solution: 1-2mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take 2.5ml to 5ml at night when required for relief of itching.
Supply 100 ml.
Age from 6 years to 11 years 11 months
Chlorphenamine oral solution: 2-4 mg at night when required
Chlorphenamine 2mg/5ml oral solution
Take one to two 5ml spoonfuls at night when required for relief of itching.
Supply 100 ml.
Hydroxyzine syrup: 15mg to 25mg at night when required
Hydroxyzine 10mg/5ml oral solution
Take 7.5ml to 12.5ml at night when required for relief of itching.
Supply 200 ml.
Age from 12 years onwards
Chlorphenamine tablets: 4 mg at night when required
Chlorphenamine 4mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Hydroxyzine tablets: 25mg at night when required
Hydroxyzine 25mg tablets
Take one tablet at night when required for relief of itching.
Supply 14 tablets.
Short course of oral prednisolone (adults)
Age from 12 years onwards
Prednisolone tablets: 40mg each morning for 3 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone tablets: 50mg each morning for 3 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone tablets: 40mg each morning for 5 days
Prednisolone 5mg tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone tablets: 50mg each morning for 5 days
Prednisolone 5mg tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Prednisolone e/c tablets: 40mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
Prednisolone e/c tablets: 50mg each morning for 3 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 3 days.
Supply 30 tablets.
Prednisolone e/c tablets: 40mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take eight tablets each morning (as a single dose) for 5 days.
Supply 40 tablets.
Prednisolone e/c tablets: 50mg each morning for 5 days
Prednisolone 5mg gastro-resistant tablets
Take ten tablets each morning (as a single dose) for 5 days.
Supply 50 tablets.
Short course of oral prednisolone (children)
Age from 1 month to 1 year 11 months
Prednisolone soluble tablets: 10mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take two tablets each morning (as a single dose) for 3 days.
Supply 6 tablets.
Age from 2 years to 5 years 11 months
Prednisolone soluble tablets: 20mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take four tablets each morning (as a single dose) for 3 days.
Supply 12 tablets.
Age from 6 years to 11 years 11 months
Prednisolone soluble tablets: 30mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take six tablets each morning (as a single dose) for 3 days.
Supply 18 tablets.
Prednisolone soluble tablets: 40mg each morning for 3 days
Prednisolone 5mg soluble tablets
Take eight tablets each morning (as a single dose) for 3 days.
Supply 24 tablets.
© NHS Institute for Innovation and Improvement