Management options

Rapid-onset reactions to bites or stings are likely to be allergic or inflammatory in nature. Infection is unlikely to be evident until at least 48 hours after the bite or sting. Local inflammation, shown by redness, heat, swelling and pain, will usually subside. 

However, if the inflammation spreads over the next three days and/or a purulent discharge develops, then infection is likely.

One way to gauge spread is to draw around the affected area with an indelible marker and ask the patient to monitor and return if it worsens.

The decision not to supply an antibiotic until the Gateway Point is reached will need to be communicated clearly and carefully, including the fact that there is no need for antibiotics ‘just in case’. Suggested points to cover during consultations about suspected infected insect bites are shown below. Self-care advice should also be provided.

If the Gateway Point on the clinical pathway is reached, first-line treatment is flucloxacillin. Check for penicillin allergy and supply alternative (clarithromycin or erythromycin subject to inclusion/exclusion criteria) if necessary.

Self-care advice

Ensure patients get the best out of treatment by providing self-care advice:

• If the stinger is visible in the skin (from a honey bee), remove as soon as possible by scraping sideways with a finger nail or credit card
• If a tick is visible, remove as soon as possible using a tick remover or suitable tweezers by pulling up gently but firmly perpendicular to skin. Avoid squeezing or leaving mouth parts in the skin
• Oral analgesics – paracetamol or ibuprofen can be taken for pain
• Oral antihistamines (e.g. chlorphenamine [sedating]) or topical corticosteroids (e.g. hydrocortisone 1% cream or ointment) may help to reduce the itching and therefore the temptation to scratch and further damage the skin
• Topical treatments such as antihistamines and local anaesthetics should be avoided as they can cause allergic skin reactions.