Allergy to beta-lactam antibiotics in children: Risk factors for a positive diagnostic work-up

BackgroundAllergy to beta-lactam (βL) antibiotics is highly reported in children, but rarely confirmed. Risk factors for a positive diagnostic work-up are scarce.The primary aim was to characterize the cases of children with confirmed βL allergy, investigating potential risk factors. Secondary aims were to assess the prevalence of allergy to βL in this population and to confirm the safety of less extensive diagnostic protocols for milder reactions.MethodsWe reviewed the clinical data from all children evaluated in our Department for suspected βL allergy, over a six-year period.ResultsTwo hundred and twenty children (53% females) with a mean age of 6.5 ± 4.2 years were evaluated. Cutaneous manifestations were the most frequently reported (96.9%), mainly maculopapular exanthema (MPE). The reactions were non-immediate in 59.5% of the cases.Only 23 children (10.5%) were diagnosed with allergy to βL. The likelihood of βL allergy was significantly higher in children with a family history of drug allergy (p < 0.001) and in those with a smaller time period between the reaction and the study (p = 0.046). The probability of not confirming βL allergy is greater in children reporting less severe reactions (p < 0.001) and MPE (p < 0.001).We found the less extensive diagnostic protocol in milder reactions safe, since only 4.2% of the children presented a positive provocation test (similar reaction as the index reaction).ConclusionThis study highlights family history of drug allergy as a risk factor for a positive diagnostic work-up. Larger series are required, particularly genetic studies to accurately determine future risk for βL allergy in children.     

Management of patients with a history of allergy to beta-lactam antibiotics

Patients with a history of penicillin allergy pose a treatment dilemma. Unnecessary avoidance of this relatively nontoxic class of drugs exposes the patient to potentially more toxic drugs, increases health care costs, and contributes to the development of antibiotic resistance. Yet for those who truly have allergy or other serious adverse reactions to beta-lactams, the use of alternate drugs is a must. This article reviews current management strategies to determine which patients are good candidates for reintroduction of beta-lactams and which patients should continue avoidance.     

食物依赖运动诱发严重过敏3例并文献复习

目的：提高对食物依赖运动诱发严重过敏（FDEIA）的诊疗水平。方法：回顾分析3例食物依赖运动诱发过敏反应患者的临床特征及诊疗情况,并复习相关文献。结果：2例患者在进食小麦面食后,1例患者在进食海虾后由运动诱发全身荨麻疹、呼吸困难及意识障碍,发病时间均在进食食物后30min～2h,经肾上腺素、糖皮质激素及抗组胺药物治疗后缓解。3例患者致敏食物皮肤点刺试验和血清特异性IgE均为阳性。2例患者在禁食致敏食物1年,随访期间未发生过敏反应。结论：FDEIA临床罕见,患者可反复发生过敏性休克而导致死亡,临床进食某些食物过敏原和进食后运动2个因素同时存在时才会诱发FDEIA,治疗方法以抗组胺药物、肾上腺素和糖皮质激素等对症治疗为主,禁食致敏食物及进食致敏食物后4h内避免剧烈运动有可能避免本病的发生。     

Anaphylaxis caused by lipid transfer proteins: an unpredictable clinical syndrome

Introduction

Lipid transfer proteins (LTPs) are panallergens found in many plant foods. They are a common cause of food-induced anaphylaxis (FIA) in adults living in the Mediterranean area. LTPs have also been proposed as a main cause of food-dependent exercise-induced anaphylaxis (FDEIA).

Pine nut allergy in Korean children: Clinical characteristics and diagnostic values of specific IgE against pine nuts

Background

Hypersensitivity reactions to pine nuts in children have been occasionally encountered recently, although reports on pine nut allergy cases are rare worldwide. The study aimed to feature clinical and laboratory findings pertaining to pine nut allergy in Korean children.

Prevention of Anaphylaxis: The Role of the Epinephrine Auto-Injector

Anaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.     

徐州不同人群尘螨过敏调查

目的　调查徐州市人群包括健康人群和临床上过敏患者对尘螨的反应性。　方法　用尘螨变应原皮肤点刺试验(SPT),并以组胺当量标准检测健康人群及临床门诊有关各科过敏患者的尘螨反应率和反应强度。　结果　健康人群在托幼儿和在校学生222人,弱阳性(+)34人(15.3%),各年龄段间无显著性差异,但女性18.6%(22/118),高于男性11.5(12/104,P<0.05),尤以女幼儿和小学女生的SPT反应率高于中学和大学生。检测临床儿科、耳鼻喉科、呼吸内科、皮肤科过敏患者515例,阳性424例(82.3%)。患者各年龄段及男女性别之间的阳性率差异无显著性(P>0.05)。尘螨SPT强阳性者 (≥ + + + )依次为儿科68.6%,耳鼻喉科63.5%,呼吸内科41.9%,皮肤科25.7%(P<0.01)。强阳性(+ + + )在不同年龄段变化不大 ,特强应答 (+ + + + )在10岁以下低年龄段最高,随着年龄增大而逐渐下降。　结论　徐州地区健康人群尘螨SPT阳性反应率为15.3%,呈弱阳性,过敏患者为82.3%,其中47.9%为强阳性和特强阳性     

Allergy to COVID-19 vaccines: A current update

Adverse allergic reactions due to the administration of the vaccines developed for the protection of coronavirus disease 2019 (COVID-19) have been reported since the initiation of the vaccination campaigns. Current analyses provided by the Center for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) in the United States have estimated the rates of anaphylactic reactions in 2.5 and 11.1 per million of mRNA-1273 and BNT162b2 vaccines administered, respectively. Although rather low, such rates could have importance due to the uncommon fact that a large majority of the world population will be subjected to vaccination with the aforementioned vaccines in the following months and vaccination will most likely be necessary every season as for influenza vaccines. Health regulators have advised that any subject with a previous history of allergy to drugs or any component of the vaccines should not be vaccinated, however, certain misunderstanding exists since allergy to specific excipients in drugs and vaccines are in occasions misdiagnosed due to an absence of suspicion to specific excipients as allergenic triggers or due to inaccurate labeling or nomenclature. In this review, we provide an updated revision of the most current data regarding the anaphylactic reactions described for BNT162b2 vaccine, mRNA-1273 vaccine, and AZD1222 vaccine. We extensively describe the different excipients in the vaccines with the potential to elicit systemic allergic reactions such as polyethylene glycol (PEG), polysorbates, tromethamine/trometamol, and others and the possible immunological mechanisms involved.     

Approach to patients with symptoms of food allergy

“Allergy” is a term often used by patients to describe symptoms that arise after eating. The term “adverse reaction to food” is preferred unless the event has an immunologic basis. True food allergy, primarily mediated by immunoglobulin (Ig)E antibodies to food proteins, is present in 3% to 4% of US adults. Symptoms range from mild mouth itching (“oral allergy syndrome”) to anaphylaxis. The diagnosis is established by history and appropriately performed skin testing or in vitro assays for specific IgE antibodies to the suspected food. Because food-allergic reactions can be fatal, it is important to identify and avoid the causative food. Food-allergic reactions are treated by prompt use of intramuscular epinephrine. Patients may be referred to an allergy/immunology specialist when the diagnosis is uncertain or if avoidance measures are not successful. Investigational therapies may ultimately be preventative or curative.     

Prevalence of parent-reported immediate hypersensitivity food allergy in Chilean school-aged children

BackgroundFood allergies (FAs) affect 2–4% of school-aged children in developed countries and strongly impact their quality of life. The prevalence of FA in Chile remains unknown.MethodsCross-sectional survey study of 488 parents of school-aged children from Santiago who were asked to complete a FA screening questionnaire. Parents who reported symptoms suggestive of FA were contacted to answer a second in-depth questionnaire to determine immediate hypersensitivity FA prevalence and clinical characteristics of school-aged Chilean children.ResultsA total of 455 parents answered the screening questionnaire: 13% reported recurrent symptoms to a particular food and 6% reported FA. Forty-three screening questionnaires (9%) were found to be suggestive of FA. Parents of 40 children answered the second questionnaire; 25 were considered by authors to have FA. FA rate was 5.5% (95% CI: 3.6–7.9). Foods reported to frequently cause FA included walnut, peanut, egg, chocolate, avocado, and banana. Children with FA had more asthma (20% vs. 7%, P < 0.02) and atopic dermatitis (32% vs. 13%, P < 0.01) by report. The parents of children with FA did not report anaphylaxis, but 48% had history compatible with anaphylaxis. Of 13 children who sought medical attention, 70% were diagnosed with FA; none were advised to acquire an epinephrine autoinjector.ConclusionUp to 5.5% of school-aged Chilean children may suffer from FA, most frequently to walnut and peanut. It is critical to raise awareness in Chile regarding FA and recognition of anaphylaxis, and promote epinephrine autoinjectors in affected children.     

Drug allergy in tertiary care in Turkey: Results of a national survey. The ADAPT study: Adult drug allergy perception in Turkey

BackgroundNo data are available on the incidence of drug hypersensitivity (DH) reactions in outpatient settings of tertiary allergy/immunology clinics. Our aims were to document the frequency of outpatient hospital admissions due to DH reactions to allergy/immunology clinics in adults and the management of these reactions in real life. We also investigated whether drug allergy affected social and medical behaviours of the patients.MethodsThis multi-centre study was performed for one year with the participation of 11 out of 16 tertiary allergy/clinical immunology clinics in Turkey. The study group consisted of the patients with DH reactions. Results of a questionnaire including drug reactions and management were recorded.ResultsAmong 54,863 patients, 1000 patients with DH were enrolled with a median of 2.1% of all admissions. In real life conditions, the majority of approaches were performed for finding safe alternatives (65.5%; 1102 out of 1683) with 11.7% positivity. Diagnostic procedures were positive in 27% (154/581) of the patients. The majority of the patients had higher VAS scores for anxiety. A total of 250 subjects (25%) reported that they delayed some medical procedures because of DH.ConclusionOur results documented the frequency of admissions due to DH reactions to allergy/clinical immunology clinics for the first time. Although physicians mostly preferred to perform drug tests in order to find safe alternatives, considering the fact that DH was confirmed in 27% of the patients, use of diagnostic tests should be encouraged, if no contraindication exists in order to avoid mislabelling patients as DH.     

Microbial resistance to newer generation beta-lactam antibiotics: clinical and laboratory implications

Certain nonfastidious, gram-negative bacilli possess the ability to rapidly develop resistance to many of the newer "enzyme stable" beta-lactam antibiotics. This finding poses many clinical problems including emergence of resistance during therapy with the drugs. Therapeutic alternatives for patients are severely limited when this problem occurs because multiple drug resistance may arise simultaneously. To date, two mechanisms have been found to be responsible for this resistance. The first, which produces multiple beta-lactam resistance, is the induction of chromosomal beta-lactamases that mediate resistance to nonsubstrate drugs by the creation of a nonhydrolytic barrier that blocks access to target proteins within the cell. The second mechanism, which produces beta-lactam/aminoglycoside resistance, involves a change in outer membrane permeability. Outbreaks of nosocomial infections with these multiple drug-resistant organisms and spread of the strains throughout the hospital are already being seen. Control of these problems can only be achieved through the judicious and restricted use of these new antibiotics.     

A fresh look at the definition of susceptibility of Streptococcus pneumoniae to beta-lactam antibiotics.

Definitions for susceptibility or resistance of Streptococcus pneumoniae to penicillin were not developed until penicillin-resistant pneumococci appeared in South Africa in the late 1970s. The definition that was accepted (which still remains in use) and later definitions of resistance to most other beta-lactam antibiotics were derived from laboratory and clinical data relating to the treatment of meningitis, not otitis media, sinusitis, or pneumonia. An understanding of the origin of these definitions helps to resolve the apparent paradox that infections of the respiratory tract due to seemingly beta-lactam-resistant pneumococci may still respond well to standard doses of these drugs. A recently sanctioned change in the definition of susceptibility to amoxicillin is helpful in eliminating the paradox for this drug, but it may create further confusion by implying that, on a microgram basis, amoxicillin is substantially more effective than penicillin or third-generation cephalosporins. This article examines definitions of susceptibility and resistance of pneumococci, highlighting areas that have led to confusion and proposing a new way of understanding them.     

Shellfish allergy and relation to iodinated contrast media: United Kingdom survey

AIM: To assess current practice of United Kingdom cardiologists with respect to patients with reported shellfish/iodine allergy, and in particular the use of iodinated contrast for elective coronary angiography.Moreover we have reviewed the current evidence-base and guidelines available in this area.METHODS: A questionnaire survey was send to 500senior United Kingdom cardiologists(almost 50% cardiologists registered with British Cardiovascular Society)using email and first 100 responses used to analyze practise. We involved cardiologists performing coronary angiograms routinely both at secondary and tertiary centres. Three specific questions relating to allergy were asked:(1) History of shellfish/iodine allergy in pre-angiography assessment;(2) Treatments offeredfor shellfish/iodine allergy individuals; and(3) Any specific treatment protocol for shellfish/iodine allergy cases. We aimed to establish routine practice in United Kingdom for patients undergoing elective coronary angiography. We also performed comprehensive PubMed search for the available evidence of relationship between shellfish/iodine allergy and contrast media.RESULTS: A total of 100 responses were received, representing 20% of all United Kingdom cardiologists. Ninety-three replies were received from consultant cardiologists, 4 from non-consultant grades and 3 from cardiology specialist nurses. Amongst the respondents, 66% routinely asked about a previous history of shellfish/iodine allergy. Fifty-six percent would pre-treat these patients with steroids and anti-histamines. The other 44% do nothing, or do nonspecific testing based on their personal experience as following:(1) Skin test with 1 mL of subcutaneous contrast before intravenous contrast;(2) Test dose 2 mL contrast before coronary injection;(3) Close observation for shellfish allergy patients; and(4) Minimal evidence that the steroid and anti-histamine regime is effective but it makes us feel better.CONCLUSION: There is no evidence that allergy to shellfish alters the risk of reaction to intravenous contrast more than any other allergy and asking about such allergies in pre-angiogram assessment will not provide any additional information except propagating the myth.     

High-dose infliximab for treatment of pediatric ulcerative colitis: a survey of clinical practice

AIM:To assess attitudes and trends regarding the use of high-dose infliximab among pediatric gastroenterologists for treatment of pediatric ulcerative colitis(UC).METHODS:A 19-item survey was distributed to subscribers of the pediatric gastroenterology(PEDSGI) listserv.Responses were submitted anonymously and results compiled in a secure website.RESULTS:A total of 113 subscribers(88% based in the United States) responded(101 pediatric gastroenterology attendings and 12 pediatric gastroenterology fellows).There were 46% in academic medical institutions and 39% in hospital-based practices.The majority(91%) were treating 10 patients with UC;13% were treating 100 patients with UC;91% had prescribed infliximab(IFX) 5 mg/kg for UC;72% had prescribed IFX 10 mg/kg for UC.Using a 5-point Likert scale,factors that influenced the decision not to increase IFX dosing in patients with UC included:"improvement on initial dose of IFX"(mean:3.88) and "decision to move to colectomy"(3.69).Lowest mean Likert scores were:"lack of guidelines or literature regarding increased IFX dosing"(1.96) and "insurance authorization or other insurance issues"(2.34)."Insurance authorization or other insurance issues" was identified by 39% as at least somewhat of a factor(Likert score ≥ 3) in their decision not to increase the IFX dose.IFX 10 mg/kg was more commonly used for the treatment of pediatric UC among responders based in the United States(75/100) compared to non-United States responders(6/13,P = 0.047).Induction of remission was reported by 78% of all responders and 81% reported maintenance of remission with IFX 10 mg/kg.One responder reported one death with IFX 10 mg/kg.CONCLUSION:IFX 10 mg/kg is more commonly used in the United States to treat pediatric UC.Efficacy and safety data are required to avoid insurance barriers for its use.     

Resistance patterns of nonfermentative gram-negative rods and aeromonads to beta-lactam antibiotics: A diagnostic aid

Consistent resistance to certain antimicrobial agents has in the past been of help in the diagnosis of nonfermentative gram-negative rods. In order to establish patterns of consistent resistance to 15 mostly newer betalactam antibiotics, 561 strains of such organisms plus Aeromonas and Plesiomonas were tested with the Kirby-Bauer method and also against the selective agent C-390 in three concentrations in Mueller-Hinton agar. No species-specific patterns emerged but the resistance data can be used to exclude certain species. C-390 was almost specifically selective for Pseudomonas aeruginosa.     

Managing food allergy and anaphylaxis: A new model for an integrated approach

There is an increasing public concern on food allergy and related anaphylactic reactions that occur mainly at the community level. The perception of the disease is huge among parents who believe that 1 out of 20 children suffers from severe food allergy. The discrepancy between this self-reported prevalence and the real one when a food challenge is performed, points out the gap in the implementation of guidelines for clinical practice. Health professionals as well show scarce adherence to the guidelines both at the Emergency Departments and at the primary care level. Anaphylactic reaction are not recognized, adrenaline is under-used and self-injectable devices are not prescribed. Although education and training are limited to local, spontaneous initiatives from patient's organization and few allergists, the data so far available demonstrate that improvement in knowledge and attitudes can be achieved further to a structured program. There is the need to establish good evidence -based practices for educational intervention that should be adopted in the context of public health policies for food allergy. This would imply a change in legislation in many countries to prevent prosecution for liability of lay people administering adrenaline when properly trained. In parallel an integrated clinical care pathway should be developed by multidisciplinary and multi-professional teams in the context of national Centres of Excellence -CoE. These CoE could drive the progression to digital health create, creating networks of CoE for best practices of care and for clinical trials