Stingray Envenomation Medication
- Author: John L Meade, MD; Chief Editor: Scott H Plantz, MD, FAAEM more...
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[4] 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.
Antibiotics
Class Summary
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)
First line for infections caused by Vibrio species found in saltwater. 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, it arrests bacterial cell wall synthesis and inhibits bacterial growth. An advanced-generation cephalosporin. Advantages include once-per-day dosing schedule and broad spectrum. A disadvantage is relatively high cost.
Cephalexin (Keflex)
First-generation cephalosporin, which is usually effective against Staphylococcus and Streptococcus species. Inexpensive and readily available, but has no real efficacy against Vibrio species.
Doxycycline (Bio-Tab, Doryx, Vibramycin)
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. Covers Vibrio species well, although coverage not as good for Staphylococcus and Streptococcus species. Generic versions are inexpensive.
Trimethoprim and sulfamethoxazole (TMP-SMZ, Bactrim, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. 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.)
de Haro L, Pommier P. Envenomation: a real risk of keeping exotic house pets. Vet Hum Toxicol. Aug 2003;45(4):214-6. [Medline].
Fenner PJ, Williamson JA, Skinner RA. Fatal and non-fatal stingray envenomation. Med J Aust. Dec 4-18 1989;151(11-12):621-5. [Medline].
Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. Feb 15 2004;69(4):885-90. [Medline].
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. Jul 2007;33(1):33-7. [Medline].
Campbell J, Grenon M, You CK. Pseudoaneurysm of the superficial femoral artery resulting from stingray envenomation. Ann Vasc Surg. Mar 2003;17(2):217-20. [Medline].
Ellenhorn MJ. Envenomations: bites and stings. In: Ellenhorn's Medical Toxicology. Lippincott Williams & Wilkins; 1997:1737-98.
Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. In: Tintinalli JE, et al, eds. Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill; 1996:868-73.
Otten EJ. Venomous animal injuries. In: Rosen P, et al, eds. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:924-40.
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