The main features of systemic reactions to insect stings are:

• rapid onset generalized urticaria
• angio-oedema
• bronchospasm/laryngeal oedema
• hypotension with collapse and loss of consciousness. Hypotension can be a dominant feature and may occur alone.

Further information on insect bites and stings can be found here.

If there are associated systemic features refer to anaphylaxis guidance.

Anaphylaxis is an acute severe systemic reaction which is most often allergic (but can be non-allergic, previously called anaphylactoid). It is commonly associated with urticaria and angioedema and occurs within minutes (typically less than 1 hour) of a trigger (e.g., food/drug/sting). Anaphylaxis is characterised by one or more of:

i) Airway – tongue/throat swelling, difficulty talking/hoarse voice

ii) Breathing – shortness of breath, wheeze, persistent cough

iii) Circulation – persistent dizziness or collapse, loss of consciousness

iv) Neurological – sense of impending doom, visual changes

Anaphylaxis should be treated immediately according to Resuscitation Council guidelines and the patient referred to hospital for acute measurement of mast cell tryptase and further management.

Investigations are not usually required (as generally the diagnosis of an insect bite or sting can be made from the history and examination.

No investigations are required prior to referral.

Further allergy testing or SpIgE blood testing is unnecessary in primary care (specialists may consider these investigations if the patient is a possible candidate for venom immunotherapy).

• Sting avoidance.
• Follow link for information on how to manage ‘Large Local Reactions After Insect Stings’.
• Attached are two patient information leaflets on managing future stings:
  • GP information – anaphylaxis action plan WITH adrenaline pdf
  • GP information – anaphylaxis action plan WITHOUT adrenaline pdf

• See anaphylaxis guidance here.

The information essential for clinical triage is outlined on the referral form.

For efficiency and to minimise returned referrals, use of the referral form is recommended.

Referrals not on the referral form will be accepted as long as all the essential information is included in a referral letter.

Referral Criteria

• Refer all adults (16 years and over) with:
  • systemic reaction to insect stings (usually within 2 hours of the insect sting)

• Consider referring adults (16 years and over) with:
  • large local reactions who are at high risk of sting exposure (e.g. beekeepers, pest controllers, patients with raised baseline MCT)

Referral Instructions

e-Referral Service Selection

Specialty: Allergy

Clinic Type: Allergy

Service: DRSS-Eastern-Allergy & Immunology-Devon ICB-15N

Referral Form

Adult allergy clinic referral form - no merge fields

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: December 2024