Management options

Rapid-onset reactions to bites or stings are likely to be allergic or inflammatory reactions. 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 it spreads over the next three days and/or a purulent discharge develops, then infection is likely. One way to gauge spread is to draw round the affected area with 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 there is no need for antibiotics ‘just in case’. 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.