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 1 study [17] showed a significant number of patients returning to the emergency department 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 days) of oral antibiotics.
Prescribing oral narcotics for patients to use as needed upon discharge is appropriate.
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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Typical stingray puncture wound on a foot, approximately 60 minutes after injury. Photo by John L. Meade, MD.
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Stingray barb in forearm. Photo by John L. Meade, MD.
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Stingray barb broken off in ring finger. Photo by John L. Meade, MD.
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Spine removed from stingray injury. Image courtesy of Scott Plantz, MD.
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Stingray.
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Stingray.
