Marine envenomations from corals, sea urchins, fish, or stingrays

INTRODUCTION — Marine injuries due to corals, sea urchins, fish spines, and stingrays will be reviewed here.

Jellyfish and Portuguese man-of-war stings and marine toxins, such as ciguatera, scombroid, and shellfish poisoning, are discussed separately:

●(See "Jellyfish stings".)

●(See "Overview of shellfish, pufferfish, and other marine toxin poisoning".)

●(See "Ciguatera fish poisoning".)

●(See "Scombroid (histamine) poisoning".)

EPIDEMIOLOGY AND CLINICAL MANIFESTATIONS — The mode of envenomations by coral, sea urchins, venomous fish, and stingrays vary by animal. These envenomations are painful. The degree of pain is largely determined by the amount of venom injected and the animal encountered.

The puncture wounds associated with marine envenomations often have retained foreign bodies and are frequently contaminated. Most wounds are superficial although stingrays can cause deep penetrating injuries.

Coral — Coral are cnidarians, like jellyfish, and members of the class Anthozoa [1]. Coral stings and lacerations are common among snorkelers, surfers, and scuba divers who touch, step, or fall onto coral [2].

Coral stings are usually only mildly toxic with local pain and erythema. The sting is caused by venomous capsules called nematocysts and can be treated similarly to jellyfish stings. In contrast, lacerations from coral (picture 1) are prone to secondary infection, including cellulitis, lymphangitis, fever, and ulceration of the wound within a few days of the injury [1,3].

Sea urchins — The sea urchin is an echinoderm, and the most significant member of this phylum in United States waters. Other members of this phylum include starfish and sea cucumbers, which have no venom apparatus (poisonous rather than venomous). Echinoderms have long, sharp spines made of calcium carbonate that easily penetrate flesh, rubber soled shoes, or wet suits, and may break off deep in the wound. Some species have venom-producing glands at the tips of the spines and thus, are venomous. Injuries typically occur after stepping or falling on an urchin, which results in multiple puncture wounds (picture 2) [4].

Clinical findings include redness, swelling, bleeding from multiple puncture wounds (picture 2), and intense pain, which may last up to 24 hours [2]. Discoloration may occur around the wounds and may indicate retained sea urchin spines. If the change in color resolves within 48 hours, it is unlikely that a spine remains lodged in the skin [5]. Imaging with plain radiographs or ultrasound may help identify the presence of embedded spines (image 1).

Venomous fish — Venomous fish have specific apparatus designed to inject poison. Stings occur in the marine and fresh water environment and also from fish kept in private aquariums. The venom apparatus is similar for fish worldwide. Spines cover integumentary sheaths which contain venom glands. When the spine penetrates the victim's skin, the surrounding integument covering the spine ruptures and venom is injected into the wound. The typical injury depends upon the fish and how it is encountered. For example, stonefish and weeverfish usually cause injuries when they are stepped on by swimmers or divers because they are bottom-dwellers, catfish cause injuries to the upper limbs when they are removed from fishing lines, and lionfish or scorpionfish typically envenomate the hands or fingers during routine care and feeding by their aquarium handlers.

The geographic distributions for the most common venomous fish include:

●Catfish – These bottom dwelling scavengers are found in fresh water rivers worldwide [6,7]. The marine catfish resides in the Indo-Pacific region.

●Stonefish – Stonefish are primarily found in the coastal waters of the Indo-Pacific region, including Australia, Indonesia, and India (picture 3) [7,8].

●Scorpion- and lionfish – These members of the Scorpaenidae family reside widely in tropical and temperate oceans (picture 4 and picture 5) [9,10]. They are frequently kept as pets in home aquariums.

●Weeverfish – Weeverfish inhabit the shallow waters of the Atlantic Ocean and Mediterranean Sea (picture 6) [11].

Local pain of varying severity and a puncture wound comprise the main clinical effects [6-11]. The pain may resolve over one hour in minor injuries, but with more severe stings (eg, marine catfish or stonefish (picture 3)) the pain may persist for over 24 hours and may radiate. Local effects include a simple puncture wound with erythema and edema in more severe cases. Uncommonly the spine can break off in the wound such as with catfish spine injuries when they are being removed from fishing lines. The spines may also have a series of "teeth" or barbs making removal difficult. Extensive tissue injury and necrosis is usually a result of infection.

Systemic effects have been reported in more severe cases, including nausea, vomiting, headache, sweating, hypotension and even syncope. However, despite many reports of systemic effects they are most likely to be secondary to severe pain. Fatalities have been attributed to many types of venomous fish, including stonefish and catfish. However, these cases are poorly reported and in many cases are more likely due to septicemia from secondary infection.

Stingrays — There are over 150 species of stingrays worldwide, accounting for thousands of injuries every year [1,12-14]. Stingrays possess whip-like tails with a furrowed, serrated spine containing secretory venom cells and sacs. When the animal is stimulated or frightened, it flings the barbed tail upward, embedding the spine in the victim which releases the venom. The resulting wound is a combination of a puncture and jagged laceration, usually of a limb (picture 7) [1,15].

In temperate and semitropical zones, injuries often occur during late summer and early fall when stingrays burrow within the sand in shallow surf. Unsuspecting bathers may step on a stingray while entering the water. Stings may be prevented by shuffling the feet along the bottom when walking in the surf and wading at shallow ocean depths. Injuries to the upper limbs are less common when stingrays are removed from fishing lines and thoraco-abdominal trauma may occur rarely to divers.

Stingray injuries will cause immediate and intense pain at the site of entry. Pain may then radiate up the limb and usually persists for hours. The wound site may appear erythematous and dusky, but there is often significant bleeding which will depend upon the site of injury (picture 7). Although numerous systemic effects are reported, they are uncommon and usually related to the systemic response to severe pain. A study of 393 patients with stingray injuries found that one-half had complete resolution of their pain within one week and almost all had resolution or improvement in their pain by one month [16].

The size and length of the stingray spine will dictate the extent of injury and larger spines are at an increased risk of trauma and secondary infection. Death or severe injury may also occur if the spine penetrates a major blood vessel, the heart, or another vital organ [14]. Thoracoabdominal injuries should be managed as per major penetrating trauma but have the additional risk of foreign body retention and infection. Those wounds that extend through the chest or abdominal wall will always need exploration in the operating room [14,17].

Lacerations of the popliteal artery and compartment syndrome have also been reported [18].

DIAGNOSIS — The diagnosis of marine envenomation is made based upon the following clinical findings:

●A history of an encounter with a coral, sea urchin, venomous fish, or stingray during typical activities (eg, fishing, snorkeling, surfing, scuba diving, cleaning an aquarium) (see 'Epidemiology and clinical manifestations' above)

●Sudden onset of pain

●Single or multiple puncture wounds (depending upon the animal), especially when foreign bodies (eg, bits of coral, sea urchin spines, fish or stingray spines and integument) are present

DIFFERENTIAL DIAGNOSIS — Envenomation by jellyfish stings, sea snakes, cone snails or the blue-ringed octopus (Hapalochlaena maculosa) and skin lesions associated with marine animals are the primary diagnostic considerations when marine envenomation is suspected. Clinical features differ from marine envenomation by corals, sea urchins, fish, and stingrays as follows:

Jellyfish and sea anemone stings — Patients with jellyfish or sea anemone stings do not have puncture wounds. After a jellyfish sting, linear red, urticarial lesions typically develop a few minutes later, although sometimes these lesions do not appear for several hours. "Tentacle prints" may be seen on examination of the skin, and less commonly vesiculation and ecchymosis (figure 1 and picture 8 and picture 9 and picture 10). Nematocysts can be obtained by skin scrapings or by applying sticky tape to the sting site when the diagnosis is unclear. (See "Jellyfish stings", section on 'Clinical manifestations' and "Jellyfish stings", section on 'Diagnosis'.)

Sea anemone stings present as circular and painful urticarial lesions which may have a central pallor. Treatment of these injuries and jellyfish stings are discussed in detail separately. (See "Jellyfish stings", section on 'Management'.)

Blue-ringed octopus (Hapalochlaena maculosa) — This animal is found in Papua New Guinea and Australia and its saliva contains tetrodotoxin which is a sodium channel blocker. The venomous bite typically occurs when it is picked up. The patient often thinks the bite is trivial at the time. However, symptoms begin within 10 to 20 minutes, and are marked by neurologic symptoms, such as paresthesias, muscular weakness, and respiratory arrest rather than pain. Treatment is supportive and includes close monitoring of respiratory status and timely endotracheal intubation with mechanical ventilation if respiratory failure occurs. (See "Potential health hazards in travelers to Australia, New Zealand, and the southwestern Pacific (Oceania)", section on 'Sea creatures'.)

Sea snake envenomation — Sea snakes reside in a variety of tropical regions including the warmer portions of the Indian and Pacific oceans from the East Coast of Africa to the West Coast of the United States and Central and South America. Typically they are found close to land in coral reefs or along islands although the pelagic sea snake may be found in open water [19].

The bite of a sea snake is often painless with limited local tissue injury. However, after a quiescent period which may last up to several hours, systematic effects become apparent. The predominant systemic features are due to myotoxicity. Clinical features include muscle pain and tenderness, trismus and sometimes weakness, with systemic rhabdomyolysis in severe cases, acute kidney injury and hyperkalemia [19-21]. The urine will often appear dark due to myoglobinuria. Sea snakes do not cause coagulopathy; neurotoxicity has been reported after sea snake bites in Australia but is not a regular feature of envenomation [22].

Sea snake envenomation may warrant treatment with antivenom (Sea Snake Antivenom, Seqirus, Parkville, Australia) depending on the severity. Consultation with a medical toxicologist is advised. Contact information for poison centers around the world is provided separately. (See 'Additional resources' below.)

Cone snail — Cone snails are primarily found in the warm regions of the Indian and Pacific Oceans. Envenomation occurs when the detachable radicular tooth is discharged via a harpoon-like apparatus and has primarily been described in divers and shell collectors [23,24]. The venom is a complex mix of proteins that have a wide range of effects on several different types of ion channels. Stings typically occur on the hand when the shell is held outside of water and are painful. Localized numbness spreads up the affected arm and can be accompanied by partial or complete total paralysis. Based upon one case report, paralysis may begin soon after the sting and may be prolonged. Total recovery has been described within three days of the sting [23]. Treatment is supportive and includes close monitoring of respiratory status and timely endotracheal intubation with mechanical ventilation if respiratory failure occurs.

Marine skin lesions — Several forms of dermatitis are associated with skin exposure to a variety of marine animals. These skin lesions are often accompanied by intense pruritus and occur in distinct patterns which differentiate them from marine envenomation. Commonly reported syndromes include:

Swimmer’s itch — Cercarial dermatitis, also known as swimmer's itch, is an itchy maculopapular rash that follows skin penetration by cercariae larvae of nonhuman schistosomes (often avian) which are found widely in natural bodies of fresh and salt water on all continents (picture 11). The distribution of the rash is limited to areas of the body immersed in water. Itchy red papules that may become vesicular develop hours to a day or so after exposure to water contaminated with schistosomes. As the bather's skin dries, the larvae burrow into the epithelium and then die. (See "Skin lesions in the returning traveler", section on 'Widespread pruritic papules or pustules'.)

Treatment consists of local measures to control itching including medium (trunk and limbs) or low potency (genitalia) corticosteroid preparations (table 1), topical lotions (eg, calamine lotion), or oatmeal or baking soda baths [25]. More severe eruptions may necessitate oral antihistamines (eg, diphenhydramine, hydroxyzine, or loratadine) or corticosteroids (eg, prednisone, prednisolone). The rash typically resolves within one week.

Preventative measures include [26]:

●Avoid bodies of water known to be contaminated with cercariae.

●Avoid prolonged exposure to lake shoreline water or water where snails have congregated (eg, marshy areas).

●Do not feed waterfowl, especially near bathing sites.

●Remove swimsuits, shower, and towel off soon after leaving the water.

Seabather’s eruption — Seabather's eruption is due to skin penetration by the tiny larvae of jellyfish, including Linuche unguiculata, Edwardsiella lineata, and probably other species, which are found in oceans (salt water). The larvae release nematocysts and inject toxin. The distribution of the lesions conforms to skin areas covered by a bathing suit, wet suit, or points of pressure (eg, wristbands of diving suits, flexural areas). Skin lesions are inflammatory papules, often becoming vesicular or pustular (picture 12). Many descriptions have been reported from the Atlantic coast of North America and from the Caribbean.

The treatment of seabather's eruption is discussed elsewhere.

Stinging sponge dermatitis — This syndrome occurs primarily in divers and people who collect live sponges, especially in Australia and New Zealand [27]. A brief initial asymptomatic period after touching the sponge is followed by stinging and itching that often increases in intensity over two to three days and can be quite severe. These sensations are accompanied by erythema at the site of skin contact which later may develop into papules, vesicles, or bullae.

Treatment consists of irrigation of the affected skin with copious normal saline or sea water. Pain can be treated with application of cold packs and oral nonsteroidal antiinflammatory medications (eg, ibuprofen) or, in severe cases, parenteral opioids. Removal of the tiny spicules by application of adhesive tape (eg, duct tape) has been suggested by some experts. Topical steroids may be helpful in severe cases. Full recovery generally takes several weeks. Administration of antihistamines and systemic corticosteroids are not known to be effective.

MANAGEMENT — Pain control as well as localization, removal of embedded foreign material or spines, and wound irrigation are important aspects of initial treatment for all marine envenomations.

Patients with severe physical effects (eg, shock, signs of myocardial infarction) after envenomation should receive rapid support of airway, breathing, and circulation. (See "Pediatric advanced life support (PALS)" and "Advanced cardiac life support (ACLS) in adults".)

Deep stingray wounds may require management as for severe penetrating trauma, including exploration in the operating room. (See "Initial evaluation and management of abdominal stab wounds in adults", section on 'Methods of evaluation' and "Initial evaluation and management of abdominal stab wounds in adults", section on 'Initial management' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Initial evaluation and management'.)

Pain control — We suggest that patients with pain following marine envenomations undergo hot water immersion of the involved area (water temperature 40 to 45°C) for up to 90 minutes. If a thermometer is not available, the clinician can use the hottest water temperature that is tolerated by the patient on an unaffected limb; adults should test the water temperature for young children. Hot water immersion should not be used for longer than 90 minutes and is contraindicated in patients who have had local or regional anesthesia for pain control. There is considerable risk of burns in patients with exposure for longer than 90 minutes and the risk increases with water temperature and duration of exposure.

Unlike jellyfish stings where there is good evidence for the effectiveness of hot water immersion, the evidence to support this therapy for penetrating marine injuries is primarily derived from case reports, small case series, and anecdotal experience. Universal pain relief is not necessarily achieved [7,10,11,28-30]. As an example, in a retrospective series of 97 patients with stingray envenomation, 67 percent had complete analgesia with hot water immersion alone [13].

Patients may also receive opioids (eg, intravenous morphine) for moderate to severe pain and nonsteroidal antiinflammatory drugs (eg, ibuprofen) or acetaminophen for mild pain. If pain persists, local or regional anaesthesia may also be required but should never be combined with hot water immersion. (See "Overview of peripheral nerve blocks".)

Patients with severe pain that is unresponsive to hot water immersion and pain medications after stonefish envenomation may be candidates for stonefish antivenom. However, clinical effectiveness is uncertain. (See 'Stonefish antivenom' below.)

Use of hot water immersion for jellyfish stings is discussed in detail separately.

Local wound care — The key aspects of wound care in patients with marine envenomations include:

●Thorough cleansing and copious irrigation with saline. (See "Minor wound evaluation and preparation for closure", section on 'Irrigation'.)

●Removal of visible foreign bodies (eg, bits of coral, sea urchin spines, fish or stingray spines and integument) and, when necessary, debridement of devitalized tissue. (See "Minor wound evaluation and preparation for closure", section on 'Debridement'.)

●Plain radiographs or ultrasound or both to identify retained foreign bodies.

●Tetanus prophylaxis, as needed (table 2).

●Wounds should be left open or, if extensive or in a cosmetically important areas, undergo delayed primary closure. (See "Minor wound evaluation and preparation for closure", section on 'Delayed primary closure'.)

Additional wound management specific to the type of marine envenomation include the following:

●Stingrays – Deep penetrating wounds into the thorax or abdomen after stingray encounters warrant additional methods of evaluation such as computed tomography (CT) or diagnostic laparoscopy for abdominal wounds and thoracic ultrasound, echocardiography, chest CT, esophagoscopy and esophagography, or bronchoscopy for thoracic wounds. (See "Initial evaluation and management of abdominal stab wounds in adults", section on 'Methods of evaluation' and "Initial evaluation and management of penetrating thoracic trauma in adults", section on 'Diagnostic testing in Stable/Stabilized Patient'.)

Larger stingray wounds to the limbs may also need surgical exploration, particularly if they are deep, involve major blood vessels or joint spaces, have retained foreign materials, or are delayed presentations.

●Sea urchins – Plain radiographs (AP and lateral soft tissue density films of the involved area) should be obtained, but may not identify all retained spines. For example, in one case series of five patients, retained sea urchin spines were not seen on plain radiography in any patient [31] while in a separate series, plain radiographs identified spines in 8 of 12 patients [32]. Bedside ultrasound may also be helpful for locating spine fragments during initial care [32]. Magnetic resonance imaging is an excellent means of visualizing retained sea urchin spines, but is costly and typically not rapidly available.

Any retained fragments that are not visible may resorb or are extruded with time; however, complications of retained fragments can include granuloma formation, arthritis, bursitis, or tenosynovitis [33]. Opinions differ regarding early removal of less accessible spines; some experts will remove with a dermal biopsy punch or an Erbium:YAG laser. It is reasonable to remove visible and easily removed spines during initial evaluation and then closely follow the patient for a week or more. If there are ongoing signs or symptoms of a retained foreign body, then surgical removal may be required.

●Venomous fish – Wounds are generally small and superficial. Rarely, those that involve joints will warrant surgical exploration and debridement.

Antibiotic therapy — We suggest that patients with superficial wounds caused by marine envenomations not routinely receive prophylactic oral or parenteral antibiotics in addition to local wound care. Superficial wounds from coral may benefit from application of topical antibiotics such as bacitracin or mupirocin. Although one observational study of 101 patients with stingray envenomations found a lower infection rate in patient receiving prophylactic oral antibiotics [13], another observational study found no infections among 100 patients with stingray envenomation who did not receive prophylactic antibiotics [34]. Wound infection is also rare following fish envenomations [6,7,10].

We suggest that patients with deep puncture wounds, especially those with retained foreign bodies, and with penetrating wounds caused by stingrays receive prophylactic antibiotics effective against Vibrio species and skin flora pending the results of wound cultures. Empiric antibiotic therapy for wounds with water exposure is discussed separately and typically consists of either a first generation cephalosporin (eg, cephalexin or cefazolin) or, in patients with risk for MRSA or penicillin allergy, clindamycin plus levofloxacin. Patients with seawater exposure should also receive doxycycline for coverage of Vibrio species. Tetracycline antibiotics may cause permanent tooth discoloration for children younger than 8 years of age if used repeatedly. However, doxycycline binds less readily to calcium than other tetracyclines and may be used for ≤21 days in children of all ages [35]. Fluoroquinolones are also acceptable for use in children in this instance because of the lack of other options that permit oral therapy. (See "Soft tissue infections following water exposure", section on 'Empiric therapy'.)

Wounds caused by marine envenomations require close follow-up because of the risk of serious infection [36]. Empiric oral or parenteral antibiotics, depending upon the severity of infection for prophylaxis are indicated if signs of infection develop [1]. Suggested antibiotic regimens are the same as previously described for prophylaxis of deep wounds. The most common marine pathogens are facultatively anaerobic Gram-negative rods and other bacteria that commonly produce soft tissue infections in association with exposure to water or water-related animals (eg, Vibrio vulnificus, other Vibrio spp., Erysipelothrix rhusiopathiae, and Mycobacterium marinum). Empiric and directed antibiotic therapy of these infections are discussed in more detail separately. (See "Soft tissue infections following water exposure", section on 'Empiric therapy' and "Soft tissue infections following water exposure", section on 'Directed therapy'.)

In addition, infections from marine injuries can still be caused by normal skin flora. Thus, antibiotic coverage should also include antibiotics with activity against Staphylococcal and Streptococcal species (eg, clindamycin, vancomycin, or, when the likelihood of methicillin resistant Staphylococcus aureus is low, cefazolin or cephalexin). (See "Acute cellulitis and erysipelas in adults: Treatment".)

The potential organisms associated with superficial or deep wounds sustained in fresh water are discussed separately. (See "Soft tissue infections following water exposure".)

Stonefish antivenom — Stonefish antivenom is a horse-derived Fab'₂ antivenom produced by Seqirus Ltd in Australia against Synanceia trachynis. We suggest that patients with stonefish envenomation, who do not receive adequate relief from hot water immersion and parenteral analgesia, receive stonefish antivenom. Anecdotal evidence suggests that antivenom may be effective in patients with systemic effects and those with severe pain that is unresponsive to hot water immersion and analgesia, but benefit is not universal [37]. The dose is 1 vial intravenously diluted with normal saline over at least 15 minutes.

Allergic reaction and anaphylaxis are known adverse effects of the antivenom. Thus, it should only be given in settings where close monitoring, immediate availability of epinephrine and antihistamines, and resuscitation capability are assured. Delayed reactions are also possible. For example, in one series of 26 patients who received stonefish antivenom, delayed allergic reaction (serum sickness) was described in 8 percent [38].

ADDITIONAL RESOURCES

Regional poison control centers — Regional poison control centers in the United States are available at all times for consultation on patients who are critically ill, require admission, or have clinical pictures that are unclear (1-800-222-1222). In addition, some hospitals have clinical and/or medical toxicologists available for bedside consultation and/or inpatient care. Whenever available, these are invaluable resources to help in the diagnosis and management of ingestions or overdoses. Contact information for poison centers around the world is provided separately. (See "Society guideline links: Regional poison control centers".)

Society guideline links — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Envenomation by snakes, arthropods (spiders and scorpions), and marine animals".)

SUMMARY AND RECOMMENDATIONS

●Mode of envenomation – Wounds caused by coral, sea urchins, spiny fish, or stingrays are common occurrences around the world during fishing, swimming, snorkeling, scuba diving, and aquarium maintenance. The mode of envenomation varies by animal and can include venomous stings and punctures with a spine. (See 'Epidemiology and clinical manifestations' above.)

●Clinical manifestations – Marine envenomations are characterized by pain, which can be severe, and puncture wounds to the affected area. The degree of pain is largely determined by the amount of venom injected and the animal encountered. Severe pain is common after stonefish and stingray envenomations. Most wounds are superficial although stingrays can cause deep penetrating injuries. (See 'Epidemiology and clinical manifestations' above.)

●Diagnosis – The diagnosis of a marine envenomation is supported by a history of an encounter with a coral, sea urchin, venomous fish, or stingray during water activities, sudden onset of pain, and single or multiple puncture wounds (depending upon the animal) especially when foreign bodies (eg, bits of coral, sea urchin spines, fish or stingray spines and integument) are present. (See 'Diagnosis' above.)

●Differential diagnosis – The differential diagnosis of marine envenomation includes envenomation by various toxic marine species and common marine skin lesions. (See 'Differential diagnosis' above.)

•Jellyfish stings are notable for characteristic skin findings which include linear, red, urticarial lesions, and tentacle prints without puncture wounds (figure 1 and picture 8 and picture 9 and picture 10). (See 'Jellyfish and sea anemone stings' above.)

•Blue-ringed octopus and cone snail bites are marked by neurologic symptoms rather than pain. (See 'Blue-ringed octopus (Hapalochlaena maculosa)' above and 'Cone snail' above.)

•Sea snake envenomation is more commonly accompanied by myotoxicity with rhabdomyolysis although neurotoxicity has been occasionally described. (See 'Sea snake envenomation' above.)

•Marine skin lesions are primarily pruritic and typically localized to immersed areas (swimmer's itch), skin regions covered by the bathing suit (seabather's eruption), or the hand (stinging sponge dermatitis). (See 'Marine skin lesions' above.)

●Pain management – In a patient with pain following a marine envenomation, we suggest immersing the involved area in hot water (40 to 45°C) for up to 90 minutes (Grade 2C). Patients may also receive opioids (eg, intravenous morphine) for moderate to severe pain and nonsteroidal antiinflammatory drugs (eg, ibuprofen) or acetaminophen for mild pain. If pain persists, local or regional anesthesia may also be required but should never be combined with hot water immersion. (See 'Pain control' above.)

●Stonefish envenomation – In a patient with stonefish envenomation who does not receive adequate pain relief from hot water immersion and parenteral analgesia, we suggest administering stonefish antivenom (Grade 2C). Allergic reaction and anaphylaxis are known adverse effects of the antivenom. Thus, it should only be given in settings where close monitoring, immediate availability of epinephrine and antihistamines, and resuscitation capability are assured. (See 'Stonefish antivenom' above.)

●Wound care – Patients with marine envenomations should also undergo meticulous local wound care including irrigation, removal of foreign bodies, and tetanus prophylaxis, as needed (table 2). Wounds should be left open or, if extensive or in a cosmetically important areas, undergo delayed primary closure. Deep penetrating wounds and deep limb injuries to the thorax or abdominal cavity following stingray envenomation require management as for severe penetrating trauma, including exploration in the operating room. (See 'Local wound care' above.)

●Prophylactic antibiotics for superficial wounds – In a patient with superficial marine envenomation, we suggest routine prophylactic oral or parenteral antibiotics not be administered (Grade 2C). (See 'Antibiotic therapy' above.)

●Prophylactic antibiotics for deep wounds – In a patient with deep puncture wounds, especially those with retained foreign bodies, and penetrating wounds caused by stingrays, we suggest administration of prophylactic antibiotics (Grade 2C). The initial antibiotic choice should be effective against Vibrio species and skin flora pending the results of wound cultures. (See 'Antibiotic therapy' above.)

●Antibiotic options – Antibiotics are indicated if signs of infection develop after marine envenomation and should consist of agents with activity against common marine bacteria and skin flora. Empiric and directed antibiotic therapy of such infections include the following options (see 'Antibiotic therapy' above and "Soft tissue infections following water exposure", section on 'Empiric therapy' and "Soft tissue infections following water exposure", section on 'Directed therapy'):

•Empiric antibiotic therapy for wounds with water exposure typically consists of either a first-generation cephalosporin (eg, cephalexin or cefazolin) or, in patients with risk for MRSA or penicillin allergy, clindamycin plus levofloxacin.

•Patients with seawater exposure should also receive doxycycline or fluoroquinolones for coverage of Vibrio species.

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Erin Endom, MD, who contributed to earlier versions of this topic review.