Safety of Direct Drug Provocation for the Evaluation of Penicillin Allergy in Low-Risk Adults.

BACKGROUND: About 10% of patients have a penicillin allergy label, but less than 5% of them are actually allergic. Unnecessary penicillin avoidance is associated with serious medical consequences. Given the growing number of these labels, it is imperative that our diagnostic strategy for penicillin allergy be as efficient as possible. The validity of traditionally used skin tests (STs) has been questioned, whereas drug provocation testing (DPT), the criterion standard, without previous ST appears very safe in most cases. OBJECTIVE: To evaluate the safety of direct DPT without consideration for ST results and the validity of ST in the diagnosis of penicillin allergy. METHODS: In this prospective cohort study without a control group, we recruited patients consulting an allergist for penicillin allergy. Patients underwent ST followed by DPT regardless of ST results. Patients with anaphylaxis to penicillin within the past 5 years or a severe delayed reaction were excluded, as were those with significant cardiorespiratory comorbidity. RESULTS: None of the 1002 recruited patients had a serious reaction to DPT. Ten (1.0%) had a mild immediate reaction, of whom only 1 (0.1%) was considered likely IgE-mediated. The positive and negative predictive values of ST for an immediate reaction were 3.6% and 99.1%, respectively. CONCLUSIONS: In a low-risk adult population reporting penicillin allergy, ST has very poor positive predictive value. Direct DPT without ST is safe and appears to be an ideal diagnostic strategy to remove penicillin allergy labels that could be implemented in first-line practice.

Availability of the epinephrine autoinjector at school in children with peanut allergy.

BACKGROUND: Peanut allergy accounts for most severe food-related allergic reactions, and accidental exposures are frequent. Delayed administration of epinephrine and the allergic individual's failure to personally carry epinephrine contribute to fatal outcomes. OBJECTIVES: To describe epinephrine autoinjector availability at school and to determine factors that might affect autoinjector availability in children allergic to peanut. METHODS: Two hundred seventy-one children with peanut allergy living in Quebec were queried about their autoinjector. Logistic regression models were used to select factors associated with device availability. RESULTS: Four of 271 children diagnosed as having peanut allergy were not prescribed autoinjectors. Forty-eight percent of the children did not carry the autoinjector with them at school. In 78.0% of those, the autoinjector was located in the nurse's or another school office, which was staffed by a full-time nurse only in 18.5%. Of all the respondents, those administered epinephrine for a previous reaction (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.7), older children (OR, 1.1; 95% CI, 1.0-1.2), and those living only with their mother (OR, 3.4; 95% CI, 1.0-11.0) were more likely to carry the autoinjector with them at school. Of children 7 years or older, those who experienced a severe reaction were more likely to carry their autoinjector (OR, 3.3; 95% CI, 1.4-8.1). CONCLUSIONS: Almost 50% of children allergic to peanut might experience a delay in anaphylaxis treatment due to limited access to their device. More education is required regarding the importance of a readily available autoinjector.

Accidental ingestions in children with peanut allergy.

BACKGROUND: Accidental exposure to peanut has been reported to occur frequently. Total avoidance of peanut is difficult because of its widespread use, manufacturing and labeling errors, utensil contamination, and label misinterpretation. OBJECTIVE: Given the apparent increased awareness of peanut allergy by both consumers and food manufacturers, we aimed to determine the current frequency of accidental exposures occurring in peanut allergic children in Quebec and to identify factors associated with exposure. METHODS: The parents of children with peanut allergy diagnosed at the Montreal Children's Hospital completed questionnaires about accidental exposure to peanut occurring over the period of the preceding year. Logistic regression was used to identify associated factors. RESULTS: Of 252 children, 62% were boys, with a mean age of 8.1 years (SD, 2.9). The mean age at diagnosis was 2.0 years (SD, 2.1). Thirty-five accidental exposures occurred in 29 children over a period of 244 patient-years, yielding an annual incidence rate of 14.3% (95% CI, 10.0% to 19.9%). Fifteen reactions were mild, 16 moderate, and 4 severe. Of 20 reactions that were moderate to severe, only 4 received epinephrine. Eighty percent of children attended schools prohibiting peanut, and only 1 accidental exposure occurred at school. No associated factors were identified. CONCLUSION: Accidental exposure to peanut occurs at a lower frequency than previously reported, but most reactions are managed inappropriately. CLINICAL IMPLICATIONS: Enhanced awareness, access to safer environments, and good food manufacturing practices may have contributed to a lower incidence of inadvertent peanut exposure, but a further reduction and better education on allergy management are desirable.