ABSTRACT
BACKGROUND: Ten percent of the population claims an allergy to penicillin, but 90% of these individuals are not allergic. Patients labeled as penicillin-allergic have higher medical costs, longer hospital stays, are more likely to be treated with broad-spectrum antibiotics, and develop drug-resistant bacterial infections. Most penicillin skin test reagents are not approved by the Food and drug Administration or readily available to evaluate patients labeled penicillin-allergic. OBJECTIVE: To determine the negative predictive value (NPV) of the Penicillin Skin Test Kit containing the major allergenic determinant (penicilloyl polylysine), a minor determinant mixture (penicillin G, penicilloate, penilloate), and amoxicillin, produced according to Food and Drug Administration standards. METHODS: This was a prospective, multicenter, open-label investigation of penicillin skin testing using the Penicillin Skin Test Kit. Skin test-negative subjects were challenged with 250 mg amoxicillin, whereas skin test-positive patients were not challenged. The primary end point was NPV of the Penicillin Skin Test Kit, defined as the percentage of subjects with negative skin test results who did not experience an IgE-dependent reaction within 72 hours of amoxicillin challenge. RESULTS: In total, 455 patients with a history of penicillin allergy underwent skin testing and 63 (13.8%) had 1 or more positive test results; 65% of the positive test results were to the minor determinant mixture and/or amoxicillin alone. In the per protocol group of 373 skin test-negative subjects, 8 developed potential IgE-dependent reactions following oral amoxicillin challenge, translating to an NPV of 97.9% (95% CI, 95.8-99.1; P < .0001). All but 1 of the reactions was mild or moderate, and most subjects who required treatment received only antihistamines. CONCLUSIONS: The Penicillin Skin Test Kit, containing all relevant penicillin allergenic determinants, demonstrated very high NPV. Removal of a penicillin allergy label in a large majority of currently mislabeled patients has substantial personal and public health implications.
Subject(s)
Anti-Bacterial Agents/adverse effects , Drug Hypersensitivity/diagnosis , Penicillins/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Predictive Value of Tests , Skin Tests , Young AdultABSTRACT
BACKGROUND: Food allergy and anaphylaxis appear to be increasing in the United States, especially in young children, and preparedness is paramount to successful emergency management in the community. Although the treatment of choice for anaphylaxis is epinephrine delivered by autoinjection, some devices are challenged by less user-friendly designs or pose the risk of injury, especially in young patients. Human factors engineering has played a larger role in the development of more recent epinephrine autoinjector technologies and will continue to play a role in the evolution and future design of epinephrine autoinjectors. OBJECTIVE: To discuss contemporary issues related to the identification and management of anaphylaxis, current and future epinephrine autoinjector design, and unmet needs for the treatment of special populations, namely, young children weighing less than 15 kg. METHODS: The literature was reviewed and select articles retrieved to support expert clinical opinions on the need for improved recognition of anaphylaxis, epinephrine autoinjector design, and unmet needs in special populations. RESULTS: Anaphylaxis may be underrecognized and poorly defined in infant- and toddler-aged children, current devices may not be adequate to safely treat these patients (ie, inappropriate needle length), and health care professionals may not be aware of these issues. CONCLUSION: As epinephrine autoinjector technology continues to evolve, device characteristics that promote safe, user-friendly experiences and give clinicians and their patients confidence to successfully treat anaphylaxis during an emergency, without injury, will be favored.
Subject(s)
Anaphylaxis/drug therapy , Bronchodilator Agents/therapeutic use , Epinephrine/therapeutic use , Injections/instrumentation , Adult , Anaphylaxis/diagnosis , Anaphylaxis/physiopathology , Child , Child, Preschool , Female , Humans , Infant , Injections, Intramuscular/instrumentation , Male , NeedlesSubject(s)
Anaphylaxis/chemically induced , Anti-Allergic Agents/adverse effects , Omalizumab/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Child , Female , Humans , Male , Middle Aged , Risk Factors , Young AdultABSTRACT
BACKGROUND: Case series of anaphylaxis can vary regarding causes, treatments, and follow-up of patients. Unfortunately, case series that are specific to the pediatric population are few. OBJECTIVE: To describe confirmed cases of pediatric anaphylaxis in patients presenting to a pediatric hospital emergency department (ED). METHODS: We identified all ED visits with the International Classification of Diseases, Ninth Revision (ICD-9) codes 995.XX (allergic reactions) and 989.5 (sting or venom reaction) for 1 calendar year (January 1, 2014, through December 31, 2014). Cases were reviewed by an allergist and an emergency medicine physician to identify true anaphylaxis cases using National Institute of Health/National Institute of Allergy and Infectious Diseases criteria. Any questionable or debatable cases were evaluated and adjudicated by a second allergist. RESULTS: We identified 927 unique ED visits. Of these visits, 40 were determined to definitively meet anaphylaxis criteria. Median age of the patients was 6.5 years. A total of 70% of patients were male, and 80% were African American. Causes included foods (65%), venom or insect sting (12.5%), and medications (5%), and 17.5% were idiopathic. All patients had multiorgan involvement, with 98% having skin involvement, 78% having lower respiratory tract symptoms, and 40% having gastrointestinal symptoms. There were no deaths. Only 33% of patients received epinephrine at some point in their care. Only 12 patients were referred to an allergist, and only 4 of these were actually seen by an allergist. CONCLUSION: At our center, foods are the most common trigger for pediatric anaphylaxis. Patients continue to be undertreated, and referral to an allergist from the ED is rare.
Subject(s)
Anaphylaxis/epidemiology , Anaphylaxis/etiology , Emergency Medical Services/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Pediatrics/statistics & numerical data , Adolescent , Allergens/immunology , Anaphylaxis/diagnosis , Child , Child, Preschool , Female , Follow-Up Studies , Humans , Infant , Infant, Newborn , Length of Stay , Male , Phenotype , Retrospective StudiesSubject(s)
Anaphylaxis/chemically induced , Anti-Allergic Agents/adverse effects , Anti-Asthmatic Agents/adverse effects , Omalizumab/adverse effects , Adult , Anti-Allergic Agents/therapeutic use , Anti-Asthmatic Agents/therapeutic use , Asthma/drug therapy , Case-Control Studies , Female , Humans , Male , Middle Aged , Omalizumab/therapeutic useABSTRACT
Chronic nonallergic rhinitis (NAR) is a syndrome rather than a specific disease. A lack of understanding of the pathogenesis of this condition has led to imprecise terminology with several alternate names for the condition, including vasomotor rhinitis, nonallergic rhinopathy, and idiopathic rhinitis. The therapy for NAR is best based on the underlying pathology, which typically exists in a form whereby an abnormality of the autonomic nervous system is dominant or a form in which inflammation seems to be the cause of symptoms. In general the most effective therapy is the combination of an intranasal antihistamine and an intranasal corticosteroid.
Subject(s)
Rhinitis/therapy , Administration, Intranasal , Adrenal Cortex Hormones/therapeutic use , Autonomic Nervous System/pathology , Humans , Hypersensitivity , Rhinitis/pathologySubject(s)
Anaphylaxis/chemically induced , Drug Hypersensitivity/diagnosis , Neuromuscular Blocking Agents/adverse effects , Perioperative Care/adverse effects , Adrenergic alpha-Agonists/therapeutic use , Adult , Anaphylaxis/drug therapy , Anaphylaxis/immunology , Anti-Inflammatory Agents/therapeutic use , Drug Hypersensitivity/drug therapy , Drug Hypersensitivity/immunology , Epinephrine/therapeutic use , Female , Humans , Hydrocortisone/therapeutic use , Male , Middle Aged , Neuromuscular Blocking Agents/immunology , Succinylcholine/adverse effectsSubject(s)
Dermatitis, Atopic/chemically induced , Milk/adverse effects , Pruritus/chemically induced , Adrenergic alpha-Agonists/therapeutic use , Animals , Dermatitis, Atopic/drug therapy , Dermatitis, Atopic/immunology , Epinephrine/therapeutic use , Humans , Infant , Male , Milk/immunology , Pruritus/drug therapy , Pruritus/immunologySubject(s)
Anaphylaxis/etiology , Cystoscopy/adverse effects , Urinary Bladder Neoplasms/pathology , Aged, 80 and over , Anaphylaxis/blood , Anaphylaxis/diagnosis , Anaphylaxis/drug therapy , Anaphylaxis/immunology , Anesthetics, Local/adverse effects , Anti-Allergic Agents/therapeutic use , Biomarkers/blood , Drug Hypersensitivity/blood , Drug Hypersensitivity/diagnosis , Drug Hypersensitivity/immunology , Humans , Hypromellose Derivatives/adverse effects , Immunoglobulin E/blood , Latex Hypersensitivity/blood , Latex Hypersensitivity/diagnosis , Latex Hypersensitivity/immunology , Lidocaine/adverse effects , Male , Predictive Value of Tests , Risk Factors , Serologic TestsSubject(s)
Cryopyrin-Associated Periodic Syndromes/diagnosis , Adult , Blood Sedimentation , C-Reactive Protein/analysis , Carrier Proteins/genetics , Cryopyrin-Associated Periodic Syndromes/blood , Cryopyrin-Associated Periodic Syndromes/genetics , Female , Humans , Mutation , NLR Family, Pyrin Domain-Containing 3 Protein , Young AdultSubject(s)
Arthroplasty, Replacement, Knee , Dermatitis, Allergic Contact/diagnosis , Dermatitis, Contact/diagnosis , Postoperative Complications/diagnosis , Skin Tests/methods , Aged , Allergens/adverse effects , Allergens/immunology , Bone Cements/adverse effects , Dermatitis, Allergic Contact/etiology , Dermatitis, Contact/etiology , Diagnosis, Differential , Expert Testimony , Humans , Male , Nickel/adverse effects , Nickel/immunology , Prostheses and Implants/adverse effectsABSTRACT
Idiopathic anaphylaxis is a perplexing problem that accounts for approximately 30% to 60% of cases of anaphylaxis in ambulatory adults and perhaps 10% of cases in children. Advances in our knowledge of idiopathic anaphylaxis have occurred over the past decade with the elucidation of mast cell activating disorders and the discovery of episodes of anaphylaxis caused by galactose-alpha-1,3-galactose. Most patients do well because fatalities can usually be prevented with proper therapy, and many individuals, for reasons not understood, undergo spontaneous remission.