Compliance with an allergen immunotherapy regime.

BACKGROUND: Compliance with an allergy immunotherapy regimen is obviously the difference between a potentially successful or unsuccessful outcome. OBJECTIVE: The purpose of this study was to assess retrospectively compliance of patients receiving immunotherapy in a private allergy practice. METHODS: The study evaluated retrospectively patient compliance with prescribed allergy injections for a private practice in Atlanta, Georgia. Patients who ordered allergy extract material for their injection immunotherapy program during an 18-month period served as the index population for this study. For the purposes of this study, noncompliance was defined as stopping the allergy injection program without the approval of the prescribing physician. Part of this investigation was to determine whether there were compliance differences between those who received their allergy injections within the confines of the clinic and those who received their injections at outside physician offices. A 12-month period of review was considered adequate to monitor compliance because of the 12-month expiration date placed on the allergy extracts. RESULTS: There was a noncompliance rate of 10: 77% for those who received their injections within the clinic. This contrasted with the noncompliance rate in the remote population of 34.82%. The difference between these two groups was statistically significant (P < .01). There were no statistical differences with respect to sex or diagnostic category. Significant differences were found between age groups in those receiving injections within or outside the clinic. CONCLUSIONS: There is a much higher rate of noncompliance in those who receive their injections in facilities outside the allergist's office. This suggests that to ensure better compliance either individuals should either be encouraged to receive their injections at the allergist's office, or better communications should be established between the referring allergist and the nonallergy physicians who are administering the injections.

Evaluation of postimmunization pneumococcal titers in children with recurrent infections and normal levels of immunoglobulin.

Seven children were evaluated who had recurrent sinusitis, acute otitis media, pneumonia, and mastoiditis. All children had normal or near normal levels of IgG, IgA, and IgM. One child displayed a poor antibody response following tetanus and diphtheria immunization. Another child was noted to be atopic as determined by allergy skin tests. A polyvalent pneumococcal vaccine was administered to all children after 24 months of age, with the average age of administration being 33 months. Titers were obtained 3 to 6 weeks following immunization and were evaluated to 12 serotypes using radioimmunoassay. All seven patients failed to mount an adequate response to immunization and were treated with a course of intravenous gammaglobulin. Five of seven children showed a distinct improvement in clinical course. Children with recurrent infections and normal levels of IgG may have a depressed ability to respond to pneumococcal antigen. Evaluation of their response to pneumococcal vaccine can be used as a marker to determine their ability to make antibody specific responses to multiple infectious agents. The failure to make a specific antibody response may be one factor in the susceptibility of these patients to recurrent infections.

Effect of intravenous gammaglobulin therapy in IgG2 deficient and IgG2 sufficient children with recurrent infections and poor response to immunization with Hemophilus influenzae type b capsular polysaccharide antigen.

Nine children with recurrent sinopulmonary infections and normal IgG levels failed to improve after a 12-month period of prophylactic antibiotic therapy with trimethoprim-sulfamethoxazole. Five of these children had selective deficiency of IgG2 subclass, while the other four did not, but all nine children had a poor response to immunization with Hemophilus influenzae type b (Hib) capsular polysaccharide. Following the institution of intravenous immunoglobulin (IVIG) therapy, there was a significant decrease in the episodes of sinusitis and otitis media in all patients. Intravenous immunoglobulin therapy resulted in a significant increase in total serum IgG, IgG2, and IgG anti-Hib antibody levels. Discontinuation of IVIG therapy was followed by the return of recurrent infections. This preliminary study demonstrates that IVIG replacement therapy in children with recurrent infections and selective antibody deficiency is associated with a significant reduction in the frequency of sinopulmonary infections.

Clinical and bacteriologic features of chronic sinusitis in children.

The clinical and bacteriologic aspects of chronic sinusitis in childhood were studied. Of 35 children who underwent surgical procedures for chronic sinusitis, 22 had positive bacteriologic cultures of aspirates from the sinus. The most common organisms isolated were Haemophilus influenzae, Streptococcus pneumoniae, and Branhamella catarrhalis. Five of eight S pneumoniae strains were relatively resistant to penicillin and resistant to sulfamethoxazole-trimethoprim. All of the B catarrhalis and 20% of the H influenzae organisms were beta-lactamase positive. Overall, 14 of 28 of the bacteria were penicillin resistant. In addition, all 12 children 2 years of age or younger had a positive bacterial culture as compared with much lower rates in older children. Although the incidence of S pneumoniae strains that are relatively resistant seems to be rising, to our knowledge we report the first description of these organisms as significant pathogens in chronic childhood sinusitis. These results indicate that chronic, difficult to manage sinusitis in very young children is frequently bacterial in origin, especially if the patient is 2 years old or younger. In light of the frequent failure of antibiotic therapy and considering the incidence of relatively resistant S pneumoniae strains, puncture of the sinus should be considered early in the course of chronic sinusitis to isolate pathogenic organisms and determine appropriate antimicrobial therapy.

Fatal varicella in steroid-dependent asthma.

Disseminated varicella infection is a potentially life-threatening complication of chronic high-dose corticosteroid (CS) or immunosuppressive therapy. A review of the literature indicates that, with one possible exception, this complication has not occurred in a CS-dependent subject with asthma. We present in this article the clinical features and autopsy findings of a steroid-dependent subject with asthma who died of acute, disseminated varicella. A 16-year-old poorly compliant, steroid-dependent subject with asthma received two courses of high-dose intravenous methylprednisolone during a 3-week period, followed by a tapering schedule of oral prednisone. During this time, she was exposed to chickenpox. She subsequently developed a classic varicella rash, sever back pain, rapidly progressive hepatic failure, pneumonitis, and encephalopathy. Death ensued 3 days after the onset of the rash. Evidence of disseminated varicella infection was confirmed at autopsy. This case illustrates that a small number of subjects with severe asthma receiving high-dose CS need to be considered as a separate, high-risk group for developing disseminated varicella. We recommend that the immune status of these patients to varicella-zoster virus be assessed by a serum titer. If these patients are nonimmune, they would be candidates for varicella-zoster immune globulin on exposure, and for acyclovir therapy should varicella dissemination occur.