Fatal anaphylaxis in the United States, 1999-2010: temporal patterns and demographic associations

Explore Adverse Drug Reactions (ADRs) reporting by clinical and community pharmacists in Duhok, Kurdistan region- Iraq: hampered and perspective

Background: Pharmacovigilance systems are crucial for monitoring, ensuring the safe use of medications, and reducing the frequency of adverse drug reactions (ADRs). They also raise awareness of the importance of reporting ADRs to healthcare systems.

Aim: Explore the hampered and perspective held by Duhok pharmacists, particularly those employed in hospitals and private pharmacy sectors, about pharmacovigilance and ADR reporting.

Methods: A cross-sectional study was carried out from 20 February to 20 March 2019 using a self-administered questionnaire that had been previously created and modified. The data were examined using SPSS version 20, a statistical application for social software.

Results: The majority of respondents, pharmacists, stated that it is their responsibility to report adverse drug reactions (ADRs), and that drug safety monitoring is crucial (91%). More than 85% of pharmacists agreed that ADRs that result in life-threatening situations and those that result in congenital abnormalities should be reported immediately. The majority of them, however, were unaware of the Iraqi pharmacovigilance system, had never reported any adverse drug reactions, were unable to get reporting forms, and lacked the clinical knowledge required to recognize ADRs.

Conclusion: Underreporting was the main issue identified by the study because the majority of respondents were unable to define the term “pharmacovigilance” correctly, but they were aware of ADRs and displayed a positive attitude toward ADR reporting despite the fact that the majority of them had never reported any ADRs. To raise pharmacists’ knowledge and awareness of the ADR reporting procedure, however, required steps should be made to establish interventional programs.

Anaphylaxis in elderly people

PURPOSE OF REVIEW

Anaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management.

RECENT FINDINGS

Data from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data.

SUMMARY

The most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.

Causes and Diagnostic Usefulness of Tryptase Measurements for Anaphylaxis in a Korean Tertiary Care General Hospital

PURPOSE

The causes of anaphylaxis in a general hospital may differ from those occurring in a community setting. Underlying diseases in admitted patients and vague presenting symptoms can make the diagnosis of anaphylaxis difficult. Serum tryptase measurements may provide valuable evidence for diagnosing anaphylaxis in admitted patients.

MATERIALS AND METHODS

This study was designed as a retrospective study of 53 patients with an anaphylaxis episode at a Korean tertiary care general hospital. Tryptase levels were measured at baseline and different time points from the onset of anaphylaxis.

RESULTS

Drugs (42 cases; 79.2%) and foods (10 cases; 18.9%) were the most common causes of anaphylaxis. In drug-induced anaphylaxis, antibiotics (24.5%), anticancer medications, which included monoclonal antibodies (22.6%), and contrast agents (11.3%) were the most frequent causes. The muscle relaxant eperisone (5.7%), neuromuscular blocking agent rocuronium (5.7%), and its antagonist sugammadex (3.8%) were other frequent triggering agents. Wheat-dependent exercise-induced anaphylaxis was the most common entity in food-induced anaphylaxis. Tryptase concentrations were higher in patients with higher grades of anaphylaxis, as well as in accidental anaphylaxis, compared to meticulously provoked anaphylaxis. Overall diagnostic sensitivity was higher for tryptase algorithm criteria (≥[1.2×baseline+2] µg/L: 71.4%) than for abnormal tryptase level criteria (≥11.4 µg/L: 52.8%).

CONCLUSION

The triggers of anaphylaxis in a Korean tertiary care hospital were diverse, including beta-lactam antibiotics, anticancer medications, contrast medias, eperisone, nonsteroidal anti-inflammatory drugs, rocuronium, sugammadex, and wheat. Tryptase measurements provided valuable evidence for diagnosis, and the sensitivity of algorithm criteria was superior to that of the abnormal value criteria.

Skin care interventions in infants for preventing eczema and food allergy

BACKGROUND

Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective for preventing eczema or food allergy.

OBJECTIVES

Primary objective To assess the effects of skin care interventions such as emollients for primary prevention of eczema and food allergy in infants. Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.

SEARCH METHODS

We performed an updated search of the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase in September 2021. We searched two trials registers in July 2021. We checked the reference lists of included studies and relevant systematic reviews, and scanned conference proceedings to identify further references to relevant randomised controlled trials (RCTs).  SELECTION CRITERIA: We included RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (≤ 12 months) without pre-existing eczema, food allergy, or other skin condition. Eligible comparisons were standard care in the locality or no treatment. Types of skin care interventions could include moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.

DATA COLLECTION AND ANALYSIS

This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured at the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.

MAIN RESULTS

We identified 33 RCTs comprising 25,827 participants. Of these, 17 studies randomising 5823 participants reported information on one or more outcomes specified in this review.  We included 11 studies, randomising 5217 participants, in one or more meta-analyses (range 2 to 9 studies per individual meta-analysis), with 10 of these studies providing IPD; the remaining 6 studies were included in the narrative results only.   Most studies were conducted at children's hospitals. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although the definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to three years. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported information on our prespecified outcomes, 13 assessed emollients. We assessed most of the evidence in the review as low certainty and had some concerns about risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. We assessed the evidence for the primary food allergy outcome as high risk of bias due to the inclusion of only one trial, where findings varied based on different assumptions about missing data. Skin care interventions during infancy probably do not change the risk of eczema by one to three years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; risk difference 5 more cases per 1000 infants, 95% CI 28 less to 47 more; moderate-certainty evidence; 3075 participants, 7 trials) or time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). Skin care interventions during infancy may increase the risk of IgE-mediated food allergy by one to three years of age (RR 2.53, 95% CI 0.99 to 6.49; low-certainty evidence; 976 participants, 1 trial) but may not change risk of allergic sensitisation to a food allergen by age one to three years (RR 1.05, 95% CI 0.64 to 1.71; low-certainty evidence; 1794 participants, 3 trials). Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial); however, this was only seen for cow's milk, and may be unreliable due to over-reporting of milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.33, 95% CI 1.01 to 1.75; risk difference 17 more cases per 1000 infants, 95% CI one more to 38 more; moderate-certainty evidence; 2728 participants, 6 trials) and may increase the risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) and stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although CIs for slippages and stinging/allergic reactions were wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses showed that the effects of interventions were not influenced by age, duration of intervention, hereditary risk, filaggrin (FLG) mutation, chromosome 11 intergenic variant rs2212434, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and eczema or food allergy development.

AUTHORS' CONCLUSIONS

Based on low- to moderate-certainty evidence, skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema; may increase risk of food allergy; and probably increase risk of skin infection. Further study is needed to understand whether different approaches to infant skin care might prevent eczema or food allergy.

Overview of registries for anaphylaxis: a scoping review

OBJECTIVE

This review aimed to describe the scope and operational features of anaphylaxis registries, and to assess their contribution to improving knowledge of anaphylaxis and care of patients who experience anaphylaxis by measuring their research output.

INTRODUCTION

Structured data collection and reporting systems, such as registries, are needed to better understand the burden of anaphylaxis and to protect the growing number of patients with severe allergy. There is a need to characterize current anaphylaxis registries to identify their value in anaphylaxis surveillance, management, and research. Information synthesized in this review will provide knowledge on benefits and gaps in current registries, which may inform the implementation and global standardization of future anaphylaxis reporting systems.

INCLUSION CRITERIA

This scoping review considered literature describing registries worldwide that enroll patients who have experienced anaphylaxis. Published and gray literature sources were included if they described the scope and operational features of anaphylaxis registries.

METHODS

This review followed the JBI methodology for scoping reviews. Embase, MEDLINE, Scopus, and CINAHL were searched for relevant articles. Identified keywords and index terms were adapted for searches of gray literature sources, using Google advanced search functions. Only full-text studies in English were considered for inclusion. Two independent reviewers conducted title and abstract screening and those that did not meet the inclusion criteria were excluded. The full text of potentially relevant articles were retrieved; full-text screening and data extraction were also conducted by two independent reviewers. Any discrepancies were resolved through discussion or with a third reviewer. Tables and a narrative summary were used to describe and compare the scope and features (eg, inclusion criteria, patient demographics, clinical symptoms) of the identified anaphylaxis registries, and to outline their output to assess their contribution to research and clinical practice for anaphylaxis.

RESULTS

A total of 77 full-text publications and eight gray literature sources were used to extract data. The literature search identified 19 anaphylaxis registries, with sites in 28 countries including Europe, the United Kingdom, Canada, the United States, Korea, and Australia. The main purposes of the identified registries were to collect clinical data for research; provide clinical support tools to improve patient care; and operate as allergen surveillance systems to protect the wider community with allergies. Differences in inclusion and health care settings exist, with 11 collecting data on anaphylaxis of any cause, two on food reactions alone, three on fatal anaphylaxis, one on perioperative anaphylaxis, and two on allergic reactions (including anaphylaxis). Five registries enroll cases in allergy centers, five in hospital settings, one in schools, and others target a combination of general practitioners, specialists in emergency departments, and other relevant hospital departments and allergy outpatient clinics. Only three registries operate under a mandatory framework. A total of 57 publications were considered research outputs from registries. All registries except two have published studies from collected data, with the greatest number of articles published from 2019 to the present. Publications mostly addressed questions regarding demographic profile, causes and cofactors, severity, fatal reactions, and gaps in management.

CONCLUSIONS

This review demonstrated that anaphylaxis registries differ in their scope and operation, having been established for different purposes. Importantly, registries have contributed significantly to research, which has highlighted gaps in anaphylaxis management, provoking allergens, and informed targets for prevention for severe and fatal events. Beyond this, registries relay information about anaphylaxis to clinicians and regulatory bodies to improve patient care and protect the community. The ability to link registry data with other health datasets, standardization of data across registries, and incorporation of clinical care indicators to promote quality health care across the health system represent important targets for future systems.

Availability of stock epinephrine in schools is needed to address health disparities in anaphylaxis

Significant health disparities exist in the diagnosis, prevalence, and management of anaphylaxis. This case acted as a community-level sentinel event for advocacy efforts to place stock epinephrine into schools throughout the greater New Orleans area.

Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis

This rapid review summarizes the most up to date evidence about the risk factors for severe food-induced allergic reactions. We searched three bibliographic databases for studies published between January 2010 and August 2021. We included 88 studies and synthesized the evidence narratively, undertaking meta-analysis where appropriate. Significant uncertainties remain with respect to the prediction of severe reactions, both anaphylaxis and/or severe anaphylaxis refractory to treatment. Prior anaphylaxis, an asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors. Some molecular allergology markers may be helpful. Hospital presentations for anaphylaxis are highest in young children, yet this age group appears at lower risk of severe outcomes. Risk of severe outcomes is greatest in adolescence and young adulthood, but the contribution of risk taking behaviour in contributing to severe outcomes is unclear. Evidence for an impact of cofactors on severity is lacking, although food-dependent exercise-induced anaphylaxis may be an exception. Some medications such as beta-blockers or ACE inhibitors may increase severity, but appear less important than age as a factor in life-threatening reactions. The relationship between dose of exposure and severity is unclear. Delays in symptom recognition and anaphylaxis treatment have been associated with more severe outcomes. An absence of prior anaphylaxis does not exclude its future risk.

Cardiac arrest caused by anaphylaxis refractory to prompt management: A case series and review of the literature

BACKGROUND

Anaphylaxis is a potentially life-threatening condition that occurs in the emergency department (ED). Although anaphylaxis is rapidly recognized and treated in the hospital compared with that in the community, in some cases, it does not respond to proper management.

OBJECTIVE

The aim of this study is to describe our experience of cases of refractory anaphylaxis leading to cardiac arrest in hospital, to review their characteristics compared with those seen in the community, and to discuss the best management practices for anaphylaxis-induced cardiac arrest with a literature review.

METHODS

We reviewed the medical records of patients referred to the ED with possible in-hospital anaphylaxis between January 2017 and May 2021. According to the anaphylaxis protocol, epinephrine, corticosteroid, and antihistamine were administered immediately on-site at our institution before the study period. Refractory anaphylaxis was defined as the development of anaphylaxis-induced cardiac arrest even after following the anaphylaxis protocol.

RESULTS

A total of 246 cases were evaluated for possible anaphylaxis, with 236 cases meeting the criteria for a diagnosis of anaphylaxis. Among them, 178 patients showed the signs and symptoms of shock, and cardiac arrest occurred in 6 patients (2.5%). Of the six patients, three had a return of spontaneous circulation before admission to the ED, while two died due to refractory cardiac arrest despite resuscitation in the ED. Following post-cardiac arrest care, including temperature management, one patient who received extracorporeal cardiopulmonary resuscitation survived neurologically intact.

CONCLUSION

We present our case series to highlight the risk of developing refractory anaphylaxis with subsequent in-hospital cardiac arrest. Patients may progress to cardiac arrest within minutes despite prompt recognition and management. If patients present with potentially fatal symptoms, a more aggressive approach, including intravenous adrenaline infusion, should be taken.

Negative impact of penicillin allergy labels on antibiotic use in hospitalized patients in Chinese Mainland

Background

Penicillin allergy labels have gained increasing global attention. However, to date, there are no data on the influence of penicillin allergy labels on patients in Chinese mainland.

Methods

This retrospective study reviewed the electronic health record (EHR) of hospitalized patients between June 1, 2018 and May 31, 2019. Patients with a penicillin allergy record were included in the allergy group. Every allergy patient was matched with 4 control patients by using propensity score-based matching to make sure the following were balanced: age, sex, date of admission, and the main diagnosis. We estimated the prevalence of penicillin allergy labels and compared the antibiotic prescription patterns and other clinical outcomes between the 2 groups.

Results

A total of 5691 patients and 22 585 patients were included in the allergy group and control group, respectively. The prevalence of penicillin allergy labels among the hospitalized patients in this study was 4.00%. Compared to the control group, significantly fewer patients in the allergy group were prescribed penicillins and most cephalosporins, while a larger proportion of allergy patients received clindamycin (10.02% vs 5.41%, p < 0.001) and some higher-class antibiotics, such as monobactams (1.81% vs 0.54%, p < 0.001), carbapenems (5.80% vs 4.98%, p = 0.014), macrolides (0.60% vs 0.25%, p < 0.001), and quinolones (17.62% vs 12.40%, p < 0.001). Allergy patients also had longer hospital stays and a greater need to consult infection specialists.

Conclusion

The prevalence of penicillin allergy labels was 4.00% in Chinese hospitalized patients. Penicillin allergy labels could cause irrational antibiotic prescribing, prolonged hospital stays, and greater consultation needs.

Socioeconomic Determinants of Food Allergy Burden-A clinical introduction

OBJECTIVE

This review characterizes what is currently known about how prevalence, severity, distribution, and management of food allergy (FA) differs across socioeconomic strata and provides guidance for practicing clinicians about how to improve equity in research participation, healthcare delivery, and patient outcomes through a deeper understanding of the socioeconomic determinants of FA.

DATA SOURCES

Epidemiological and biomedical literature published prior to April 2022.

RESULTS

Socioeconomic status (SES) is a complex concept that not only encompasses economic resources (e.g., income, wealth) but also a person's social, economic and political power and standing, each of which can impact health. However, in many studies of individuals and families with FA, assessment of SES has been limited and often a respondent's membership within a racial and ethnic group is utilized as a proxy for low SES. As a whole, findings from US-population-based studies indicate a consistent trend: those who self-identify as non-Hispanic Black, and to a lesser extent other subpopulations who identify as being of non-White race and ethnicity, experience a greater burden of food-allergic sensitization and disease including higher rates of emergency health care utilization and food-induced anaphylactic fatality as compared to those identifying as White.

CONCLUSION

Reports of FA management and outcomes highlight inequities among specific low SES populations in the US. Clinicians can and should act to reduce inequities by engaging more diverse populations in clinical research, equitably implementing FA risk screening and prevention, thoughtfully utilizing emerging technologies to ameliorate disparities based on SES in healthcare delivery and outcomes, and advocating for social change.

Anaphylaxis among elderly emergency department patients in a large health system in New York

BACKGROUND

Anaphylaxis in the elderly is poorly understood.

OBJECTIVE

To elucidate demographic, clinical, and management characteristics of older adults presenting to emergency departments (EDs) with National Institute of Allergy and Infectious Diseases (NIAID) criteria-confirmed anaphylaxis vs milder, non-anaphylactic acute allergic reactions (AARs).

METHODS

A retrospective analysis of ED patients more than or equal to 65 years was conducted, using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or ICD-9-based algorithms incorporating the NIAID diagnostic criteria. Descriptive statistics were generated, and the abovementioned characteristics were compared between cohorts.

RESULTS

Of 164 eligible visits, 71 (43.3%), 90 (54.9%), and 3 (1.8%) cases were identified by ICD-9 codes, the algorithms, or both, respectively. Only half fulfilled NIAID diagnostic criteria. Compared with the non-anaphylactic AAR group, criteria-confirmed anaphylaxis group had lower drug allergy rates (43.9% vs 61.0%, P = .03) but higher food allergy rates (26.8% vs 12.2%, P = .02). For the criteria-confirmed anaphylaxis group, presenting signs and symptoms in descending frequency were mucocutaneous, respiratory, cardiovascular, and gastrointestinal. Criteria-confirmed anaphylaxis group had higher rates of prior anaphylaxis (13.4% vs 2.4%, P = .009), pre-ED (12.2% vs 0.0%, P = .001) or ED (72.0% vs 4.9%, P < .001) epinephrine administration, and allergy referral (17.1% vs 2.4%, P = .002). Tryptase levels were rarely ordered, occurring once in the criteria-confirmed anaphylaxis group and never in the non-anaphylactic AAR group. Despite low mortality (n = 1), 64.6% of the criteria-confirmed anaphylaxis cohort required hospitalization, with 23.2% admitted to intensive care unit.

CONCLUSION

Diagnosis of elderly ED patients with anaphylaxis remains suboptimal. Identifying NIAID criteria-confirmed cases remain challenging, using the existing methods. Management of these patients poorly adheres to current guidelines.

Early Use of ECMO for Refractory Kounis Syndrome Concealed by General Anesthesia—A Case Report

A 46-year-old woman demonstrated refractory Kounis syndrome (KS) after induction of anesthesia. Despite conventional management of anaphylaxis and advanced cardiac life support, her cardiovascular function continued to deteriorate until she had a cardiac arrest, and after extracorporeal membrane oxygenation (ECMO) therapy, electrical cardiac activity reappeared. A large number of patients with KS—“allergic angina syndrome”—has been known to recover well with vasodilators; however, this patient showed antibiotics-induced refractory KS during general anesthesia. Severe bronchospasms with desaturation appeared as initial anaphylactic features; however, these did not respond to conventional treatment for anaphylaxis. Patient’s hemodynamic signs eventually worsened, leading to cardiac arrest despite ephedrine administration and chest compressions. During cardiopulmonary cerebral resuscitation, the central line was secured, and epinephrine, atropine, as well as sodium bicarbonate were administered repeatedly; nevertheless, cardiac arrest was sustained. After initiation of veno-arterial ECMO, atrial fibrillation was observed, which was later converted to sinus tachycardia by electrical cardioversions and amiodarone. Coronary angiography was performed before the patient was admitted to the intensive care unit; there were no indications of an impending cardiac arrest. The patient was discharged uneventfully owing to early use of ECMO despite the emergence of KS symptoms that were initially masked by anesthesia but later worsened abruptly.

Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement

Drug hypersensitivity reactions (DHRs) to intravenous drugs can be severe and might leave patients and doctors in a difficult position where an essential treatment or intervention has to be suspended. Even if virtually any intravenous medication can potentially trigger a life-threatening DHR, chemotherapeutics, biologics, and antibiotics are amongst the intravenous drugs most frequently involved in these reactions. Admittedly, suspending such treatments may negatively impact the survival outcomes or the quality of life of affected patients. Delabeling pathways and rapid drug desensitization (RDD) can help reactive patients stay on first-choice therapies instead of turning to less efficacious, less cost-effective, or more toxic alternatives. However, these are high-complexity and high-risk techniques, which usually need expert teams and allergy-specific techniques (skin testing, in vitro testing, drug provocation testing) to ensure safety, an accurate diagnosis, and personalized management. Unfortunately, there are significant inequalities within and among countries in access to allergy departments with the necessary expertise and resources to offer these techniques and tackle these DHRs optimally. The main objective of this consensus document is to create a great benefit for patients worldwide by aiding allergists to expand the scope of their practice and support them with evidence, data, and experience from leading groups from around the globe. This statement of the Drug Hypersensitivity Committee of the World Allergy Organization (WAO) aims to be a comprehensive practical guide on the technical aspects of implementing acute-onset intravenous hypersensitivity delabeling and RDD for a wide range of drugs. Thus, the manuscript does not only focus on clinical pathways. Instead, it also provides guidance on topics usually left unaddressed, namely, internal validation, continuous quality improvement, creating a healthy multidisciplinary environment, and redesigning care (including a specific supplemental section on a real-life example of how to design a dedicated space that can combine basic and complex diagnostic and therapeutic techniques in allergy).

Drug-Related Hypersensitivity Reactions Leading to Emergency Department: Original Data and Systematic Review

The aim of the present study is to describe pharmacological characteristics of drug-related allergies and anaphylaxis leading to the emergency department (ED). An 8-year post hoc analysis on the MEREAFaPS Study database was performed (2012−2019). Subjects who experienced drug-related hypersensitivity leading to an ED visit were selected. Logistic regression analyses were used to estimate the reporting odds ratios (RORs) of drug-related allergies and anaphylaxis adjusting for sex, age classes, and ethnicity. In addition, a systematic review of observational studies evaluating drug-related hypersensitivity reactions leading to ED visits in outpatients was performed. Out of 94,073 ED visits, 14.4% cases were drug-related allergies and 0.6% were anaphylaxis. Females accounted for 56%. Multivariate logistic regression showed a higher risk of drug-related allergy among males and all age classes < 65 years, while a higher risk of anaphylaxis was observed for females (ROR 1.20 [1.01−1.42]) and adults (ROR 2.63 [2.21−3.14]). The systematic review included 37 studies. ED visits related to allergy and anaphylaxis ranged from 0.004% to 88%, and drug-related allergies and anaphylaxis ranged from 0.007% to 88%. Both in our analysis and in primary studies, antibacterials, analgesics, and radiocontrast agents were identified as the most common triggers of hypersensitivity.

Burden of allergic disease among ethnic minority groups in high-income countries

The COVID‐19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene–environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high‐income countries. In conjunction with standards of care, it is prudent that a multi‐pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.

Acute Urticaria and Anaphylaxis: Differences and Similarities in Clinical Management

Acute urticaria is a common condition that presents with wheals and/or angioedema. However, these symptoms are also frequent in anaphylaxis, a life-threatening reaction that should be immediately diagnosed and treated. In both, mast cells play a central role in the physiopathology. Causes and triggers of acute urticaria and anaphylaxis are similar in general, but some peculiarities can be observed. The diagnostic approach may differ, accordingly to the condition, suspicious causes, age groups and regions. Adrenaline is the first-line treatment for anaphylaxis, but not for acute urticaria, where H1-antihistamines are the first choice. In this paper, we review the main aspects, similarities and differences regarding definitions, mechanisms, causes, diagnosis and treatment of acute urticaria and anaphylaxis.

Hypersensitivity reactions to chemotherapy: an EAACI Position Paper

Chemotherapeutic drugs have been widely used in the treatment of cancer disease for about 70 years. The development of new treatments has not hindered their use, and oncologists still prescribe them routinely, alone or in combination with other antineoplastic agents. However, all chemotherapeutic agents can induce hypersensitivity reactions (HSRs), with different incidences depending on the culprit drug. These reactions are the third leading cause of fatal drug-induced anaphylaxis in the United States. In Europe, deaths related to chemotherapy have also been reported. In particular, most reactions are caused by platinum compounds, taxanes, epipodophyllotoxins and asparaginase. Despite their prevalence and relevance, the ideal pathways for diagnosis, treatment and prevention of these reactions are still unclear, and practice remains considerably heterogeneous with vast differences from center to center. Thus, the European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology organized a task force to provide data and recommendations regarding the allergological work-up in this field of drug hypersensitivity reactions. This position paper aims to provide consensus on the investigation of HSRs to chemotherapeutic drugs and give practical recommendations for clinicians that treat these patients, such as oncologists, allergologists and internists. Key sections cover risk factors, pathogenesis, symptoms, the role of skin tests, in vitro tests, indications and contraindications of drug provocation tests and desensitization of neoplastic patients with allergic reactions to chemotherapeutic drugs. Statements, recommendations and unmet needs were discussed and proposed at the end of each section.

Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

Self-Efficacy Among Caregivers of Children With Food Allergy: A Cohort Study

Objective

The prevalence of pediatric food allergy (FA) is increasing and, due to early disease onset, requires significant caregiver management that is associated with psychosocial burden. Caregiver perception of how they cope and handle FA-related events (self-efficacy) has been linked to psychosocial outcomes in racially/geographically homogenous samples. This study explores FA-related caregiver self-efficacy and associations with FA-related caregiver quality of life (QoL) in a diverse cohort.

Methods

Caregivers of children, diagnosed with IgE-mediated FA who identified as non-Hispanic Black or White, were recruited from U.S. academic allergy clinics. Caregivers completed demographic and medical questionnaires, the Food Allergy Self-Efficacy Scale for Parents (FASE-P), Food Allergy Independent Measure—Parent Form (FAIM), and the Food Allergy Quality of Life—Parental Burden (FAQL-PB). Bivariate and multivariate associations estimated relationships between study variables.

Results

Caregivers of 365 children (Mage = 5.8 years, 62.2% male, 31.1% Black) were enrolled. Caregivers reported high FA self-efficacy (M = 82.06/100), moderate perceptions of risk/FA severity (FAIM: M = 3.9/7), and some limitations on the FAQL-PB (M = 3.9/7). Self-efficacy was related to lower perceptions of risk/FA severity across all demographic groups (r = −.42, p &lt; .001). Caregivers who reported higher self-efficacy reported better QoL, particularly Black caregivers (r = .67).

Conclusions

In this sample of caregivers of children with FA, greater self-efficacy was related to improved QoL regardless of sociodemographic factors. Caregivers’ perception of risk was lower for those with greater self-efficacy. Future research into the impact of FA management on QoL among diverse caregivers is needed.

Fatal Food Anaphylaxis: Distinguishing Fact From Fiction

Although there is a general perception that the prevalence of food allergy is increasing, data supporting this are limited. Food is the least common cause of fatal anaphylaxis, and fortunately, it is a very rare event; however, it is also unpredictable. There is widespread consensus that severe reactions cannot be predicted in a clinically meaningful way. Certain food triggers are more frequently associated with fatal anaphylaxis than others. In observational studies, peanut and tree nuts account for at least 30% to 50% of fatalities, with seafood and cow's milk also associated with fatal reactions. Fatal food-induced anaphylaxis is most likely to occur during adolescence and young adulthood, although the reasons for this are unclear. International guidelines agree that intramuscular (IM) epinephrine is the treatment of choice for managing food-triggered anaphylaxis and has a good safety profile when given by the IM route. However, fatalities still occur despite the timely administration of epinephrine. Food-allergic individuals must navigate a world that requires daily vigilance for allergens and preparedness for allergic reactions. Although the actual risk of fatal reactions is minimal, it is not zero, and severe reactions are unpredictable. Clinicians need to help patients better understand the very low but real risk of fatal reaction and enable them to lead as normal a life as possible through appropriate education, safety netting, and risk reduction.

Drug-induced anaphylaxis in the emergency department: A prospective observational study

Objective

Anaphylaxis is an acute, life-threatening, systemic hypersensitivity reaction. It is usually triggered by drugs, foods, and insect stings. The primary objective of our study is to determine the factors affecting drug-induced anaphylaxis to contribute to early diagnosis and treatment in these patients.

Methods

Patients over 18 years old who were diagnosed drug-induced anaphylaxis in the Goztepe Hospital within a period of 1 year were evaluated prospectively. Patients demographical data, etiological factors, clinical findings, and treatment information were recorded.

Results

Forty-four patients were enrolled in the study of which 25 (56.8%) were female. The median age of women and men was 54 (min: 22, max 82) and 44 (min 18, max 82), respectively. Twenty-three (52%) of them had a history of anaphylaxis. The most common causes of drug-induced anaphylaxis were antibiotics (36%) and nonsteroidal anti-inflammatory drugs (18%), respectively. Adrenaline was applied to 17 (38%) of the patients in the treatment.

Conclusion

Antibiotics were the most common drugs causing drug-induced anaphylaxis and adrenaline was underused which is the first-line treatment in the anaphylaxis. Some clinicians refrain from administering adrenaline. The reasons underlying this approach should be investigated.

Omalizumab for successful chemotherapy desensitisation: What we know so far

BACKGROUND

Hypersensitivity reactions induced by chemotherapeutic drugs may influence the course of the oncologic disease by preventing doctors from prescribing first-line therapy. In order to prevent another hypersensitivity reaction to the culprit chemotherapeutic agent, the physician can decide between two possibilities: premedication or desensitisation protocols. Rapid drug desensitisation showed successful results for most patients, but some of them may develop symptoms. Although omalizumab is not licensed as premedication or adjuvant therapy in chemotherapy desensitisation protocols, there have been published some case reports and small sample size studies that indicated promising results.

METHODS

We reviewed all the published literature regarding the use of omalizumab during chemotherapy desensitisation protocols.

RESULTS AND CONCLUSIONS

We found a great heterogeneity between the doses and the interval between omalizumab injections and chemotherapy - rapid drug desensitisation, but most of the studies showed promising results. As a corollary, we propose a dose regimen of omalizumab administered before the first desensitisation protocol. Then, omalizumab should be administered one day before every chemotherapy regimen. Omalizumab might be used as an adjuvant therapy and might be a solution for a hopeless situation.

Anaphylaxis: Epidemiology and Differential Diagnosis

Anaphylaxis-related emergency department (ED) visits and hospitalizations are increasing. Triggers for anaphylaxis include food, medications, and stinging insects. Idiopathic anaphylaxis accounts for 30% to 60% of cases of anaphylaxis in adults and up to 10% of cases in children with novel allergens such as galactose-α-1,3 galactose reclassifying these cases. Recent practice guidelines have recommended against the routine use of systemic corticosteroids and antihistamines for the prevention of biphasic reactions and recommend an extended observation, up to 6 hours, for those with risk factors for biphasic anaphylaxis and those with lack of access to epinephrine and to emergency medical services.

Anaphylaxis to Stinging Insect Venom

Hymenoptera stinging insects are common culprits for allergic reactions. Anaphylaxis to insect stings can be life threatening and is associated with a significant risk of recurrence. Insect allergy requires referral to an allergist/immunologist for education and for diagnostic evaluation that will direct further management and treatment. Venom immunotherapy is safe and effective; it prevents sting anaphylaxis in up to 98% of patients. Potential risk factors for side effects during testing and treatment should be assessed for every patient to mitigate risk and to guide treatment recommendations and the duration of immunotherapy.

Anaphylaxis to Drugs, Biological Agents, and Vaccines

Anaphylaxis is a multi-system syndrome resulting from the release of mediators from mast cells and basophils. Drugs are common causes. Anaphylaxis to certain drugs, vaccines, and biological agents present clinical challenges, and merit referral to a board-certified allergist/immunologist for further evaluation and management.

Drug Hypersensitivity Reactions

Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.

Anaphylaxis in Children and Adolescents

Anaphylaxis is an acute, potentially life-threatening systemic hypersensitivity reaction. Classically, anaphylaxis is an immunoglobulin (Ig) E-mediated reaction; however, IgG or immune complex complement-related immunologic reactions that lead to degranulation of mast cells can also cause anaphylaxis. Food allergy is the most common cause of anaphylaxis, followed by drugs. Patients with anaphylaxis commonly present with symptoms involving skin or mucous membranes, followed by respiratory and gastrointestinal symptoms. Epinephrine is the drug of choice for treating anaphylaxis. Patients and caregivers should be educated on the use of epinephrine autoinjectors with periodic review of symptoms and emergency action plan for anaphylaxis.

An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures

Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.

Risk factors of beta-lactam anaphylaxis in Korea: A 6-year multicenter retrospective adult case-control study

Background

Beta-lactams (BLs) are commonly used antibiotics and leading causative agents of drug-induced anaphylaxis. Few studies on the culprit drugs and risk factors of BL-induced anaphylaxis are available. Our goal was to evaluate the culprit drugs and compare the risk factors in patients with BL-induced anaphylaxis to matched tolerant controls in a hospital setting.

Methods

We retrospectively enrolled all patients who developed anaphylaxis from intravenous BL during hospitalization from 9 Korean hospitals. We compared clinical parameters between patients with BL-induced anaphylaxis and 4-fold BL-tolerant controls matched by age, sex, BL use, and the purpose of BL administration.

Results

Seventy-four cases of BL-induced anaphylaxis and 296 BL-tolerant controls were enrolled. Cephalosporin accounted for 77% of total BL-induced anaphylaxis, and the top derivatives were ceftriaxone (23.0%), cefazedone (10.8%), and cefbuperazone (9.5%). Among penicillin derivatives, piperacillin (16.2%) was the most common, followed by ampicillin (2.7%). History of drug allergy (odds ratio [OR], 19.91; 95% confidence interval [CI] 5.33–74.44), previous exposure to the causative BL (OR, 7.71; 95% CI, 1.62–36.76), and concurrent administration of angiotensin-converting enzyme inhibitors (ACEIs) (OR, 5.97; 95% CI, 1.28–27.91) were independent risk factors associated with BL-induced anaphylaxis. Food allergy (OR, 13.93; 95% CI 1.31–148.9) and previous exposure to BL (OR, 6.59; 95% CI, 1.30–33.31) were identified as risk factors for cephalosporin-induced anaphylaxis.

Conclusions

To prevent BL-induced anaphylaxis, attention should be paid to histories of drug or food allergy, previous exposure to BLs, and ACEI use. The risk factors and clinical outcomes might vary according to the BL classes.

ICD-10 anaphylaxis algorithm and the estimate of vaccine-attributable anaphylaxis incidence in Medicare

BACKGROUND

Anaphylaxis is a rare, serious allergic reaction. Its identification in large healthcare databases can help better characterize this risk.

OBJECTIVE

To create an ICD-10 anaphylaxis algorithm, estimate its positive predictive values (PPVs) in a post-vaccination risk window, and estimate vaccination-attributable anaphylaxis rates in the Medicare Fee For Service (FFS) population.

METHODS

An anaphylaxis algorithm with core and extended portions was constructed analyzing ICD-10 anaphylaxis claims data in Medicare FFS from 2015 to 2017. Cases of post-vaccination anaphylaxis among Medicare FFS beneficiaries were then identified from October 1, 2015 to February 28, 2019 utilizing vaccine relevant anaphylaxis ICD-10 codes. Information from medical records was used to determine true anaphylaxis cases based on the Brighton Collaboration's anaphylaxis case definition. PPVs were estimated for incident anaphylaxis and the subset of vaccine-attributable anaphylaxis within a 2-day post-vaccination risk window. Vaccine-attributable anaphylaxis rates in Medicare FFS were also estimated.

RESULTS

The study recorded 66,572,128 vaccinations among 21,685,119 unique Medicare FFS beneficiaries. The algorithm identified a total of 190 suspected anaphylaxis cases within the 2-day post-vaccination window; of these 117 (62%) satisfied the core algorithm, and 73 (38%) additional cases satisfied the extended algorithm. The core algorithm's PPV was 66% (95% CI [56%, 76%]) for identifying incident anaphylaxis and 44% (95% CI [34%, 56%]) for vaccine-attributable anaphylaxis. The vaccine-attributable anaphylaxis incidence rate after any vaccination was 0.88 per million doses (95% CI [0.67, 1.16]).

CONCLUSION

The ICD-10 claims algorithm for anaphylaxis allows the assessment of anaphylaxis risk in real-world data. The algorithm revealed vaccine-attributable anaphylaxis is rare among vaccinated Medicare FFS beneficiaries.

Nut Allergenicity: Effect of Food Processing

Nuts are considered healthy foods due to their high content of nutritional compounds with functional properties. However, the list of the most allergenic foods includes tree nuts, and their presence must be indicated on food labels. Most nut allergens are seed storage proteins, pathogenesis-related (PR) proteins, profilins and lipid transfer proteins (LTP). Nut allergenic proteins are characterized by their resistance to denaturation and proteolysis. Food processing has been proposed as the method of choice to alter the allergenicity of foods to ensure their safety and improve their organoleptic properties. The effect of processing on allergenicity is variable by abolishing existing epitopes or generating neoallergens. The alterations depend on the intrinsic characteristics of the protein and the type and duration of treatment. Many studies have evaluated the molecular changes induced by processes such as thermal, pressure or enzymatic treatments. As some processing treatments have been shown to decrease the allergenicity of certain foods, food processing may play an important role in developing hypoallergenic foods and using them for food tolerance induction. This work provides an updated overview of the applications and influence of several processing techniques (thermal, pressure and enzymatic digestion) on nut allergenicity for nuts, namely, hazelnuts, cashews, pistachios, almonds and walnuts.

Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule

BACKGROUND

The challenge of delabeling amoxicillin allergy is an important issue for patients and clinicians, especially when anaphylaxis is reported. A recent study has proposed a clinical decision rule, PEN-FAST, to identify low-risk penicillin allergies.

OBJECTIVE

To validate the PEN-FAST clinical decision rule in a population with high risk of suspected immediate amoxicillin allergy and to identify clinical predictive factors of amoxicillin immediate hypersensitivity.

METHODS

We retrospectively analyzed medical records of patients with a suspected immediate amoxicillin allergy who carried out an allergologic evaluation by a specialist in the Allergy Unit of Strasbourg University Hospital from 2015 to 2020.

RESULTS

A total of 142 adult patients (88 women [62.0%]; median age, 52 [interquartile range, 40.3-62.0] years) were analyzed. Most of them reported anaphylaxis (68.8%). Internal validation of PEN-FAST score revealed a good discrimination with area under the curve of 0.86 (95% confidence interval, 0.79-0.92). A cutoff of less than 3 points for PEN-FAST was used to classify 29 from 142 patients at low risk of allergy, of whom only 2 (6.9%) received positive results of allergy testing. The negative predictive value for successful delabeling was 0.93 (95% confidence interval, 0.77-0.99). Predictive clinical features for immediate amoxicillin hypersensitivity were time since reaction (P < .001), time elapsed between drug intake and first symptom (P < .001), severity grade reaction (P < .001), and treatment or hospitalization required (P < .001).

CONCLUSION

PEN-FAST has been validated to identify low-risk penicillin allergies in our European cohort of patients mainly reporting anaphylaxis. This is the first reported external validation of a penicillin allergy clinical decision rule internationally.

African American Children Are More Likely to Be Allergic to Shellfish and Finfish: Findings from FORWARD, a Multisite Cohort Study

BACKGROUND

Despite major differences in health profiles and rates of health care utilization between African American and White children with food allergy (FA), the detailed phenotypic variables that can potentially impact these outcomes have not been thoroughly studied.

OBJECTIVE

We aimed to characterize phenotypic differences such as allergies to different foods and allergic comorbidities between African American and White children with FA enrolled in the Food Allergy Outcomes Related to White and African American Racial Differences study.

METHODS

Our active, prospective, multicenter cohort study is currently enrolling African American and White children aged 0 to 12 years diagnosed with FA and followed by allergy/immunology clinics at 4 urban tertiary centers in the United States. To evaluate associations between race and phenotypic variables, we used multivariable logistic regression, adjusting for important demographic and confounding factors, as well as potential household clustering.

RESULTS

As of May 2020, there were 239 African Americans and 425 Whites with complete intake information enrolled in the study. In comparison with Whites, we found that African Americans had significantly higher adjusted odds of allergy to finfish (odds ratio [OR]: 2.54, P < .01) and shellfish (OR: 3.10, P < .001). African Americans also had higher adjusted odds of asthma than Whites (asthma prevalence of 60.5% in African Americans and 27.2% in Whites; OR: 2.70, P < .001). In addition, shellfish allergy was associated with asthma, after controlling for race.

CONCLUSION

Among a diverse cohort of children with physician-diagnosed FA, we observed that African American children had higher odds of allergy to shellfish and finfish, and higher rates of asthma. Interestingly, having asthma was independently associated with allergy to shellfish, after controlling for race.

Association between anaphylaxis and anti-influenza drug use: An analysis of the Japanese Adverse Drug Event Report database

We aimed to investigate the association between anaphylaxis and anti-influenza drug use using the Japanese Adverse Drug Event Report (JADER) database, a national spontaneous reporting database in Japan. We surveyed registered cases from the JADER database between April 2004 and November 2019. The target drugs were five anti-influenza drugs, namely oseltamivir, zanamivir, peramivir, laninamivir, and baloxavir. Adverse events associated with anaphylaxis, "anaphylactic reaction," "anaphylactic shock," "anaphylactoid reaction," and "anaphylactoid shock," were evaluated. The association between anaphylaxis and anti-influenza drug use was assessed by calculating the reporting odds ratio (ROR) and information component (IC) as a measure of disproportionality. Signals were considered positive if the lower limit of the 95% confidence interval (CI) of ROR was > 1, and that of IC was > 0. The number of anaphylaxis cases associated with anti-influenza drug use was 199 (0.9%). Signals were detected for inhaled laninamivir (ROR: 4.24 [95% CI: 3.06-5.88], IC: 1.83 [1.35-2.30]), intravenous peramivir (ROR: 2.97 [2.11-4.17], IC: 1.40 [0.90-1.89]), and oral baloxavir (ROR: 3.05 [2.22-4.18], IC: 1.44 [0.98-1.90]). Conversely, signals were not detected for oral oseltamivir or inhaled zanamivir. Although zanamivir and laninamivir were used as dry powder inhalers containing lactose as an additive, they differed in terms of signal detection. Our analysis indicated that the signal of anaphylaxis may varies based on the main component or dosage form of each anti-influenza drug. Appropriate use of these drugs is essential to prevent anaphylaxis and improve health status.

The Revenge of Unintended Consequences of Anaphylaxis-Risk Overdiagnosis: How Far We Have Come and How Far We Have to Go

Overdiagnosis of anaphylaxis risk is an underappreciated aspect of anaphylaxis prevention. Whereas the benefits of anaphylaxis-risk prevention are well known, potential harms resulting from preemptive approaches to mitigate anaphylaxis-risk are not insignificant. Still, great progress has been made in recent years to avoid the unintended consequences of anaphylaxis-risk overdiagnosis. Reflection on recent advances in the use of diagnostic testing, as well as the application of diagnostic labels, provides an important perspective to understand how far the specialty of allergy and immunology has come in improving the lives of patients and families. Examples of recent paradigm shifts in anaphylaxis-risk management include approaches to peanut allergy prevention without screening, deferral of corticosteroids to prevent biphasic anaphylaxis reactions, reevaluation of reflex use of emergency medical services for resolved community anaphylaxis, and an approach to penicillin allergy delabeling with direct oral challenge. Routine medical practices to decrease anaphylaxis risk can have lifelong impacts for patients-beyond just preventing anaphylaxis. As our understanding of these trade-offs evolves, it becomes necessary to weigh both the benefits and the harms of past management approaches. Because medicine remains a science of uncertainty and an art of probability, a critical approach to risk mitigation remains necessary to find the often-elusive balance in anaphylaxis prevention.

Management of penicillin allergy in primary care: a qualitative study with patients and primary care physicians

Background

Six percent of patients are allergic to penicillin according to their medical records. While this designation protects a small number of truly allergic patients from serious reactions, those who are incorrectly labelled may be denied access to recommended first line treatment for many infections. Removal of incorrect penicillin allergy may have positive health consequences for the individual and the general population.

We aimed to explore primary care physicians’ (PCPs) and patients’ views and understanding of penicillin allergy with a focus on clinical management of infections in the face of a penicillin allergy record.

Methods

We conducted an interview study with 31 patients with a penicillin allergy record, and 19 PCPs in the North of England. Data were analysed thematically.

Results

Patients made sense of their allergy status by considering the timing and severity of symptoms. Diagnosis of penicillin allergy was reported to be ‘imperfect’ with PCPs relying on patient reports and incomplete medical records. PCPs and patients often suspected that an allergy record was incorrect, but PCPs were reluctant to change records. PCPs had limited knowledge of allergy services. PCPs often prescribed alternative antibiotics which were easy to identify. Both patients and PCPs differed in the extent to which they were aware of the negative consequences of incorrect penicillin allergy records, their relevance and importance to their lives, and management of penicillin allergy.

Conclusions

PCPs and patients appear insufficiently aware of potential harms associated with incorrect penicillin allergy records. Some of the problems experienced by PCPs could be reduced by ensuring the details of newly diagnosed reactions to antibiotics are clearly documented. In order for PCPs to overturn more incorrect penicillin records through appropriate use of allergy services, more information and training about these services will be needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01465-1.

EAACI statement on the diagnosis, management and prevention of severe allergic reactions to COVID-19 vaccines

The first approved COVID‐19 vaccines include Pfizer/BioNTech BNT162B2, Moderna mRNA‐1273 and AstraZeneca recombinant adenoviral ChAdOx1‐S. Soon after approval, severe allergic reactions to the mRNA‐based vaccines that resolved after treatment were reported. Regulatory agencies from the European Union, Unites States and the United Kingdom agree that vaccinations are contraindicated only when there is an allergy to one of the vaccine components or if there was a severe allergic reaction to the first dose. This position paper of the European Academy of Allergy and Clinical Immunology (EAACI) agrees with these recommendations and clarifies that there is no contraindication to administer these vaccines to allergic patients who do not have a history of an allergic reaction to any of the vaccine components. Importantly, as is the case for any medication, anaphylaxis may occur after vaccination in the absence of a history of allergic disease. Therefore, we provide a simplified algorithm of prevention, diagnosis and treatment of severe allergic reactions and a list of recommended medications and equipment for vaccine centres. We also describe potentially allergenic/immunogenic components of the approved vaccines and propose a workup to identify the responsible allergen. Close collaboration between academia, regulatory agencies and vaccine producers will facilitate approaches for patients at risks, such as incremental dosing of the second injection or desensitization. Finally, we identify unmet research needs and propose a concerted international roadmap towards precision diagnosis and management to minimize the risk of allergic reactions to COVID‐19 vaccines and to facilitate their broader and safer use.

Algorithm to guide re-exposure to penicillin in allergic pregnant women with syphilis: Efficacy and safety

Background

Gestational syphilis is underdiagnosed and undertreated, leading to stillbirth, prematurity, low birthweight, neonatal death, and congenital syphilis. Most patients who label as allergic to penicillin are misdiagnosed.

Objective

To assess the efficacy and safety of an algorithm to guide re-exposure to penicillin in pregnant women with syphilis and reporting allergy to the antibiotic.

Methods

We performed a prospective study assessing pregnant women with syphilis and labeled as allergic to penicillin. Based on clinical history, patients were divided in two groups: high-risk and low-risk to penicillin allergy. Low-risk patients with negative skin testing and negative serum specific IgE to penicillin underwent drug provocation test. The remaining patients underwent desensitization.

Results

Ninety-one patients were enrolled. Allergy to penicillin was confirmed in 7.69% of pregnant women with syphilis and clinical history of allergy to penicillin; in all cases the diagnosis was made through intradermal testing, which predicted 100% of the breakthrough reactions observed during rapid drug desensitization (p < 0.001). Risk stratification based on the initial clinical reaction and skin testing to guide penicillin re-introduction through drug challenge or desensitization was safe (97.8%) and effective (97.8%).

Conclusion

We developed and showed the efficacy and safety of an algorithm to guide re-exposure to penicillin in pregnant women with syphilis and labeled as allergic to this drug. Intradermal test is an excellent biomarker in the diagnosis of immediate hypersensitivity reaction to penicillin and to predict breakthrough reaction during rapid drug desensitization. Further studies may confirm the greater safety of the intravenous protocol compared to the oral protocol.

Praktischer Umgang mit allergischen Reaktionen auf COVID-19-Impfstoffe

Hintergrund: Zur vorbeugenden Behandlung von COVID-19 (Coronaviruserkrankung 2019) wurden in einer beispiellosen weltweiten Forschungsanstrengung Sicherheit und Wirksamkeit neuer Impfstoffplattformen studiert, die noch nie zuvor am Menschen eingesetzt wurden. Weniger als ein Jahr nach der Entdeckung der SARS-CoV-2-Virussequenz (SARS-CoV-2, "severe acute respiratory syndrome coronavirus type 2") wurden diese in zahlreichen Ländern für den Einsatz zugelassen und es wurde mit Massenimpfungen begonnen. Die bislang in der Europäischen Union (EU) zugelassenen mRNA-Impfstoffe (mRNA, "messenger"-RNA) gegen SARS-CoV-2 BNT162b2 und mRNA-1273 basieren auf einer ähnlichen lipidbasierten Nanopartikelträgertechnologie; die Lipidkomponenten unterscheiden sich jedoch. Schwere allergische Reaktionen und Anaphylaxien nach COVID-19-Impfungen sind sehr seltene unerwünschte Nebenwirkungen, die aber aufgrund potenziell letaler Ausgänge viel Aufmerksamkeit erhalten und ein hohes Maß an Verunsicherung ausgelöst haben.

Methoden: Das aktuelle Wissen zu anaphylaktischen Reaktionen auf Impfstoffe und speziell zu den derzeit neuen mRNA-COVID-19-Impfstoffen wurde zusammengestellt mittels einer Literaturanalyse durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinienregistern, der Cochrane Library und dem Internet unter besonderer Berücksichtigung offizieller Webseiten der World Health Oranization (WHO), der Centers for Disease Control and Prevention (CDC), der European Medicines Agency (EMA), des Robert-Koch-Instituts (RKI) und des Paul-Ehrlich-Instituts (PEI).

Ergebnisse: Basierend auf der internationalen Literatur und bisheriger Erfahrungen zu schweren allergischen Reaktionen im Kontext der COVID-19-Impfungen werden von einem Expertengremium Empfehlungen für Prophylaxe, Diagnostik und Therapie dieser allergischen Reaktionen gegeben.

Schlussfolgerung: Vor einer COVID-19-Impfung mit den derzeit zugelassenen Impfstoffen sind Allergietests für die allermeisten Allergiker nicht notwendig. Bei allergischer/anaphylaktischer Reaktion auf den verabreichten COVID-19-Impfstoff wird eine allergologische Abklärung empfohlen, wie auch für eine kleine potenzielle Risikopopulation vor der ersten Impfung. Die Evaluierung und Zulassung von Testverfahren sollten hierfür erfolgen.

Zitierweise: Klimek L, Bergmann K-C, Brehler R, Pfützner W, Zuberbier T, Hartmann K, Jakob T, Novak N, Ring J, Merk H; Hamelmann E, Ankermann T, Schmidt S, Untersmayr E, Hötzenecker W, Jensen-Jarolim E, Brockow K, Mahler V, Worm M. Practical Handling of Allergic Reactions to COVID-19 vaccines. A Position Paper from German and Austrian Allergy Societies AeDA, DGAKI, GPA and ÖGAI. Allergo J Int 2021;30:79-95

https: //doi.org/10.1007/s40629-021-00165-7