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Stingray Envenomation Medication

  • Author: John L Meade, MD; Chief Editor: Scott H Plantz, MD, FAAEM  more...
 
Updated: Feb 05, 2016
 

Medication Summary

Infection is not common but, if it occurs, is likely to result in high morbidity because of injury location and the possible infecting agents in the water environment. Staphylococci and streptococci remain the most common infecting agents and must not be ignored. However, pathogens of specific concern to such envenomations are Vibrio species in saltwater and Aeromonas species in freshwater. Optimal coverage should include staphylococci, streptococci, and pathogens expected in the involved water (freshwater or saltwater). Such antibiotics include quinolones (eg, ciprofloxacin, levofloxacin), doxycycline, trimethoprim/sulfamethoxazole (Bactrim, Septra), cefuroxime or other late-generation cephalosporins, an aminoglycoside, or chloramphenicol.

As one study[6] showed a significant number of patients returning to the ED with wound infections when prophylactic antibiotics were not administered at initial presentation, many physicians choose to treat the wounds associated with stingray envenomations prophylactically with a short course (~5 d) of oral antibiotics.

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Antibiotics

Class Summary

Antibiotics are used in the treatment of uncomplicated infections and wound prophylaxis. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Levofloxacin (Levaquin)

 

Levofloxacin is first-line treatment for infections caused by Vibrio species found in saltwater. It is indicated for Staphylococcus aureus and infections caused by multidrug resistant gram-negative organisms.

Cefixime (Suprax)

 

By binding to one or more of the penicillin binding proteins, cefixime arrests bacterial cell wall synthesis and inhibits bacterial growth. It is an advanced-generation cephalosporin.Its advantages include a once-per-day dosing schedule and broad spectrum. A disadvantage is relatively high cost.

Cephalexin (Keflex)

 

Cephalexin is a first-generation cephalosporin, which is usually effective against Staphylococcus and Streptococcus species. It is inexpensive and readily available, but it has no real efficacy against Vibrio species.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

 

Doxycycline inhibits protein synthesis and, thus, bacterial growth, by binding to 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. It covers Vibrio species well, although coverage is not as good for Staphylococcus and Streptococcus species. Generic versions are inexpensive.

Trimethoprim and sulfamethoxazole (TMP-SMZ, Bactrim, Septra)

 

This combination inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. It is an inexpensive combination agent that covers Vibrio and some Staphylococcus and Streptococcus species.

As with doxycycline, many individuals can develop photosensitive skin rashes while on the medication. (This is important if the patient is on vacation or lives at the beach and is likely to get significant sun exposure while on the medication.)

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Contributor Information and Disclosures
Author

John L Meade, MD CEO, Statdoc Consulting, Inc

John L Meade, MD is a member of the following medical societies: American College of Emergency Physicians, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Department of Emergency Medicine, University of Louisville School of Medicine

Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Richard S Krause, MD Senior Clinical Faculty/Clinical Assistant Professor, Department of Emergency Medicine, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. de Haro L, Pommier P. Envenomation: a real risk of keeping exotic house pets. Vet Hum Toxicol. 2003 Aug. 45(4):214-6. [Medline].

  2. Campbell J, Grenon M, You CK. Pseudoaneurysm of the superficial femoral artery resulting from stingray envenomation. Ann Vasc Surg. 2003 Mar. 17(2):217-20. [Medline].

  3. O'Malley GF, O'Malley RN, Pham O, Randolph F. Retained Stingray Barb and the Importance of Imaging. Wilderness Environ Med. 2015 Sep. 26 (3):375-9. [Medline].

  4. Fenner PJ, Williamson JA, Skinner RA. Fatal and non-fatal stingray envenomation. Med J Aust. 1989 Dec 4-18. 151(11-12):621-5. [Medline].

  5. Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. 2004 Feb 15. 69(4):885-90. [Medline].

  6. Clark RF, Girard RH, Rao D, Ly BT, Davis DP. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. J Emerg Med. 2007 Jul. 33(1):33-7. [Medline].

  7. Ellenhorn MJ. Envenomations: bites and stings. Ellenhorn's Medical Toxicology. Lippincott Williams & Wilkins; 1997. 1737-98.

  8. Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 1996. 868-73.

  9. Otten EJ. Venomous animal injuries. Rosen P, et al, eds. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998. 924-40.

 
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Typical stingray puncture wound on a foot, approximately 60 minutes after injury. Photo by John L. Meade, MD.
Stingray barb in forearm. Photo by John L. Meade, MD.
Stingray barb broken off in ring finger. Photo by John L. Meade, MD.
Spine removed from stingray injury. Image courtesy of Scott Plantz, MD.
Stingray.
Stingray.
 
 
 
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