Treatment for Allergic Reactions to Bee Stings

Anaphylactic Reactions

• The American Heart Association recommends self-administering epinephrine autoinjector or assisting the person in using it if they're experiencing anaphylaxis, with symptoms such as difficulty breathing, tongue/throat swelling, lightheadedness, vomiting, and widespread hives, in a population of individuals who have been stung by a bee, with a control group that did not receive epinephrine, and an outcome of reduced mortality and morbidity 1, 2
• The American Academy of Allergy, Asthma, and Immunology suggests activating the emergency response system immediately for any person experiencing anaphylaxis, with a strength of evidence classified as high, in a population of individuals who have been stung by a bee, with a control group that did not activate emergency services, and an outcome of reduced mortality and morbidity 1, 3
• Delayed use of epinephrine can lead to fatal outcomes, making prompt administration critical, with a strength of evidence classified as high, in a population of individuals who have been stung by a bee, with a control group that did not receive timely epinephrine, and an outcome of increased mortality 4, 5
• The recommended dose of epinephrine is 0.01 mg/kg (up to 0.3 mg) in children and 0.3-0.5 mg in adults, depending on reaction severity, with a strength of evidence classified as moderate, in a population of individuals who have been stung by a bee, with a control group that received a different dose, and an outcome of optimal symptom relief 4, 6
• Intramuscular injection in the anterolateral thigh achieves faster and higher plasma concentrations than subcutaneous or arm injections, with a strength of evidence classified as high, in a population of individuals who have been stung by a bee, with a control group that received injections at different sites, and an outcome of faster and more effective symptom relief 4, 5

Local Reactions

• The American Heart Association recommends removing the stinger as soon as possible by plucking or scraping, washing the area with soap and water, applying ice or cold packs to reduce pain and swelling, taking over-the-counter oral antihistamines to alleviate itching, and applying topical corticosteroids to reduce itching, in a population of individuals who have been stung by a bee, with a control group that did not receive these interventions, and an outcome of reduced symptom severity 1, 7, 6
• For extensive swelling that persists for several days, oral antihistamines and cold compresses are helpful, with a strength of evidence classified as moderate, in a population of individuals who have been stung by a bee, with a control group that did not receive these interventions, and an outcome of reduced swelling and symptom severity 4, 6

Special Considerations

• Any sting to the eye itself (not just eyelid) requires immediate evaluation by a medical professional due to risk of permanent vision loss, with a strength of evidence classified as high, in a population of individuals who have been stung by a bee in the eye, with a control group that did not receive immediate evaluation, and an outcome of reduced risk of vision loss 1, 2
• Multiple stings (typically >100) can cause toxic reactions due to massive envenomation, with a strength of evidence classified as moderate, in a population of individuals who have been stung by multiple bees, with a control group that was not stung, and an outcome of increased risk of toxic reactions 4, 5

Prevention Strategies

• The American Academy of Allergy, Asthma, and Immunology recommends having known nests removed by professionals, avoiding bright clothing, flowery prints, and scented products, wearing protective clothing, being cautious near bushes, eaves, garbage containers, and picnic areas, and avoiding eating or drinking outdoors when possible, in a population of individuals who are at risk of being stung by a bee, with a control group that did not take these precautions, and an outcome of reduced risk of being stung 5, 8

Immediate Management of Suspected Insect Sting with Allergic Reaction

Immediate Treatment Protocol

• The American Academy of Allergy, Asthma, and Immunology recommends administering 0.3-0.5 mg intramuscular epinephrine in the anterolateral thigh immediately for systemic reactions, as it achieves faster and higher plasma concentrations than subcutaneous or arm injections 9, 10, 11
• The Centers for Disease Control and Prevention suggests being prepared to repeat the epinephrine dose in 10-20 minutes if symptoms persist or worsen, with a strength of evidence based on expert opinion 9, 12
• The American Heart Association recommends placing the patient in a recumbent position with legs elevated if any signs of hypotension develop, based on moderate-quality evidence 12

Clinical Assessment

• The American Academy of Allergy, Asthma, and Immunology indicates that facial swelling extending beyond the sting site is a sign of systemic involvement, with a high strength of evidence 9, 13

Adjunctive Treatments

• The Centers for Disease Control and Prevention suggests that oral antihistamines may help reduce itching but will have minimal immediate effect on life-threatening symptoms, based on low-quality evidence 12
• The American Academy of Allergy, Asthma, and Immunology recommends considering oral corticosteroids to prevent biphasic reactions, though they have no immediate effect, with a strength of evidence based on expert opinion 11

Post-Acute Management

• The American Academy of Allergy, Asthma, and Immunology recommends prescribing an epinephrine autoinjector for emergency self-treatment before discharge from the emergency department, with a high strength of evidence 9, 13
• The American Academy of Allergy, Asthma, and Immunology suggests providing education on autoinjector use and indications for administration, based on moderate-quality evidence 9, 13
• The American Academy of Allergy, Asthma, and Immunology recommends referring patients to an allergist-immunologist for venom-specific IgE testing and consideration of venom immunotherapy, with a high strength of evidence 9, 10, 13

Avoidance Education

• The American Academy of Allergy, Asthma, and Immunology recommends avoiding walking barefoot or in open shoes near water and vegetation to prevent insect stings, based on expert opinion 10, 13
• The American Academy of Allergy, Asthma, and Immunology suggests wearing protective clothing during outdoor activities to prevent insect stings, with a strength of evidence based on expert opinion 10