A Penicillin Allergy Stewardship Team to Address Unconfirmed Pediatric Penicillin Allergies in Houston, TX.

BACKGROUND: Penicillin (PCN) allergy labels are common and limit use of first-line antibiotics for common pediatric bacterial infections. Improving access to PCN allergy evaluations is a priority for allergy & immunology (A&I) and infectious diseases (ID) programs. OBJECTIVE: The objective of this study was to increase the number of completed PCN allergy evaluations from six to twenty-four per month from Jan 2022-Dec 2023. METHODS: A collaborative PCN allergy stewardship team was established in the A&I and ID divisions at Texas Children's Hospital. Telemedicine evaluations and, when clinically indicated, in-person PCN allergy evaluations were conducted from Jan-Dec 2023. Plan-do-study-act cycles were conducted to increase awareness about the clinics. The primary outcome measure was the average number of monthly completed PCN allergy evaluations. RESULTS: The average number of completed PCN allergy evaluations increased from six to 19 per month. Children were seen rapidly in the ID telemedicine clinic (20 versus 62 days, p<0.001), and 428/627 (68%) children who required in-person challenge were scheduled for their in-person evaluation. Of the 211 children de-labeled, 71 (33.6%) were subsequently diagnosed with a bacterial infection requiring penicillin during the study period. CONCLUSION: A collaborative penicillin allergy stewardship team consisting of ID and A&I specialists increased the number of completed penicillin allergy evaluations three-fold. ID telemedicine services allowed prompt access to care, and most children were de-labeled and subsequently able to receive penicillin antibiotics for bacterial respiratory tract infections. Future work should explore ways to minimize barriers to penicillin allergy evaluations and further expand testing services in other primary care settings.

Current and Future Treatment of Food Allergies.

Food allergy prevalence is rapidly growing among school-age children in the United States, posing a significant health concern in school settings. This article aims to provide an overview of the current state of food allergy treatment options, emergency food allergy care plans, and using epinephrine autoinjectors. In addition, it explores potential future treatment options, including immunotherapy and novel therapeutic approaches. This article emphasizes the crucial role of school nurses in recognizing the treatment options currently available to students and their families, as well as fostering a safe environment for students with food allergies.

Maximum Dose Food Challenges Reveal Transient Sustained Unresponsiveness in Peanut Oral Immunotherapy (POIMD Study).

BACKGROUND: The maximum tolerated dose of peanut protein following peanut oral immunotherapy (POIT) is unknown because most research studies have not examined very high thresholds. OBJECTIVE: To define the maximum dose tolerated by patients on POIT and severity of allergic reactions after a 1-month period of treatment discontinuation. METHODS: In a phase 2 3-year POIT open-label study, we enrolled participants age 5 to 13 years with a 1-year build-up period followed by a 2-year daily maintenance dose of 3900 mg with assessment of the maximum tolerated dose using double-blind placebo-controlled food challenges (DBPCFCs) of 26,225 mg cumulative dose of peanut protein. The DBPCFC was performed at baseline, after 12-month build-up, at 2 year of maintenance, and after a 1-month period of treatment discontinuation. Biomarkers were assessed every 6 weeks for the first 6 months of therapy. A general linear mixed model was used for analysis. RESULTS: The mean maximum cumulative tolerated dose after 12 months increased by 12,063 mg (P < .001) (n = 12), slightly decreased during maintenance (n = 11), and significantly decreased by 7593 mg after avoidance for 1 month (P = .03) (n = 6). Biomarker analysis revealed decreases in cytokine expression within the first 6 weeks of initiation of POIT and decreased peanut-IgG4 and increased cytokine expression after 1 month of discontinuation. The DBPCFC reaction severity, examined through a symptom score with 1 point for each defined symptom, decreased after 12 months, but did not significantly change after 1 month of POIT discontinuation. CONCLUSIONS: The evaluation of POIT and sustained unresponsiveness by maximum tolerated dose by DBPCFCs in this small phase 2 trial showed that desensitization is diminished, with 100% loss of tolerated dose after 1 month of avoidance following 3 years of treatment.

Diagnosis and management of anaphylaxis.

Anaphylaxis is a serious allergic reaction that is rapid in onset and may be life threatening. An informal review of the literature was performed in a nonsystematic way for this article. Key published work was identified and included. The incidence and prevalence of anaphylaxis have increased over time. Anaphylaxis is unpredictable and can be the result of various allergic triggers, including food, insect venom, and medication. In children, the most frequent trigger is food. The diagnosis is based on clinical criteria. After confirmation of the relevant allergen trigger, prevention occurs through strict avoidance of the allergen and optimal management of existing comorbidities. Patients with anaphylaxis require immediate assessment and treatment. The management of a patient with anaphylaxis should start with the removal of exposure to the known or suspected trigger, followed by the assessment of the patient's circulation, airway patency, breathing, and mental status. The administration of epinephrine at a dose of 0.01 mg/kg (1:1000) intramuscularly is the first-line treatment for anaphylaxis, and there are no absolute contraindications to this treatment. The maximum single dose of epinephrine is 0.5 mg and may be repeated after 5-10 minutes if needed. After administration of epinephrine, patients with anaphylaxis should be placed supine with their lower limbs elevated. They should not be placed in the upright position. Studies of fatal and near-fatal allergic reactions identified potential risk factors for fatalities such as asthma, peanuts and/or tree nuts, and delayed epinephrine use, and provided important information that may help minimize the future risk. Patients and their families need to be well educated on how to manage potential anaphylactic reactions with training in the use of epinephrine autoinjectors and personalized emergency management plans. Health care professionals must be familiar with this clinical emergency and able to respond to anaphylaxis in a timely and appropriate manner.