British Society For Allergy And Clinical Immunology Research Articles

Clinical Spectrum of Patients Admitted with Hymenoptera (Bees and Wasps) Stings in a Medical College Hospital of Himachal Pradesh, India.

Objective: Hymenoptera (bees and wasps) stings are a common health hazard in the tropics, particularly in rural areas. The study was planned to describe the clinical spectrum of patients with Hymenoptera (bees and wasps) stings admitted to a medical college hospital in Himachal Pradesh, India. Materials and methods: This was a hospital-based open cohort prospective study conducted on patients admitted with a history of Hymenoptera (bees and wasps) stings. The study period was 1 year, and patients were recruited using a nonprobability sampling method. Demography, clinical and laboratory data, complications, and outcomes were recorded and analyzed. Systemic allergic reactions were classified according to the British Society for Allergy and Clinical Immunology (BSACI) guidelines. Results: A total of 44 patients (25 males and 19 females) were included in the study. All the patients reported in the warmer months from April to November were stung between 6 am and 8 pm and reported within three from the time of the incident. The most common local symptoms of pain and pruritus were reported by 100 and 31.8% of patients, respectively. Features of systemic envenomation reported were dizziness, nausea, vomiting, decreased urine output, hematuria and cola-colored urine, pain abdomen, cough, and wheezing. On examination, local redness and swelling were observed at 100 and 72.7%, respectively. The size of swellings was <10 cm in all of the patients. As per BSACI guidelines, the severity of systemic allergic reactions was mild, moderate, and severe in 70.4, 13.6, and 15.9%, respectively. Transaminases were observed in 40.9% of patients. Acute kidney injury (AKI) developed in 22.7% of patients. The mortality was 4.5% in this study. Conclusion: This is one of the largest studies on Hymenoptera envenomation in India and contributes to our understanding of the subject. How to cite this article: KP MS, Raina S, Kaul R, et al. Clinical Spectrum of Patients Admitted with Hymenoptera (Bees and Wasps) Stings in a Medical College Hospital of Himachal Pradesh, India. J Assoc Physicians India 2023;71(10):57-63.

BSACI guideline for the set-up of penicillin allergy de-labelling services by non-allergists working in a hospital setting.

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de-labelling service for their patients. It is intended to supplement the BSACI 2015 guideline "Management of allergy to penicillin and other beta-lactams" and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta-lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non-allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.

Contributions of nurse specialists in the allergy and immunology service and patient care.

Specialist nurses have a crucial role within the allergy and immunology specialty that reflects their competence in an increasingly complex area of work and ability to use advanced diagnostic testing and therapeutic modalities. A specialist nurse in Qatar follows the local Hamad Medical Cooperation (HMC) guidelines and the competency published by the British Society for Allergy and Clinical Immunology (BSACI).Specialist Allergy NursesLearning domain: Learn and review the written standard operating procedure (SOP) and protocols for all diagnostic and therapeutic allergy procedures, including skin prick testing (inhaled, food, and others), intradermal testing, skin patch testing, penicillin testing, food and drug challenges, different desensitization protocols, and biologics and other medication administration. In addition, learn the protocol for immunotherapy administration and maintain an updated knowledge of trends and developments in the field by reading relevant articles, journals, and related material and attending seminars and conferences, as needed.Maintain a safe work environment: Perform all the above procedures and medication administration with a high grade of competency under physician supervision. Apply quality measures to ensure safety. Furthermore, perform stocktaking by regularly checking procedure requirements, availability of items and consumables, date of expiry of items, and medications. Monitor the patients closely during drug and food allergy challenge procedures and record and report patients’ vitals and reactions to treating physicians. Ensure that a patient stays the required observation time after injection(s).General care: Assess patient needs and suggest solutions to patient care problems. Provide education and resources for the patient and family support as needed. React appropriately and on time during patient reaction situations to mitigate early adverse reactions. Maintain patient, employee, and clinic confidentiality.Specialist Immunology Nurses• Develop specialist knowledge and experience in immunology.• Develop nurse-led clinics for administering immunoglobulin replacement therapy safely and effectively based on patients’ preferences (IV vs. SC and in-hospital vs. home programs).• Coordinate communication between members of the multidisciplinary team to facilitate the appropriate delivery of care.• Provide education and resources for the patient and family support (insurance issues, resources for vaccination recommendations, concerns regarding traveling and vacations, pregnancy, and any other lifecycle changes).

Consider testing all hospital patients with a record of penicillin allergy, says new guidance

Guidelines for penicillin allergy de-labelling services have been published by the British Society for Allergy and Clinical Immunology (BSACI). The new guidelines recommend that “all patients labelled as ‘penicillin allergic’ attending secondary or tertiary care should be considered for penicillin allergy testing, as these patients often receive alternative antibiotics that are sub-optimal and can lead […]

BSACI 2021 guideline for the management of egg allergy

This guideline advises on the management of patients with egg allergy. Most commonly egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history will confirm the diagnosis in most cases. Investigation by measuring egg-specific IgE (by skin prick testing or specific IgE assay) is useful in moderate-severe cases or where there is diagnostic uncertainty. Following an acute allergic reaction, egg avoidance advice should be provided. Egg allergy usually resolves, and reintroduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive the MMR vaccine. Most adults and children with egg allergy can receive the influenza vaccine in primary care, unless they have had anaphylaxis to egg requiring intensive care support. Yellow Fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence based. Where evidence was lacking, consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.

UK allergy and immunology in a post‐COVID‐19 era

UK allergy and immunology in a post‐COVID‐19 era

Management of nut allergy in primary care.

Nut allergy presents a growing public health burden and is the most common cause of fatal anaphylaxis in the UK.1 Adults and children commonly present to primary care with suspected reactions to nuts. The UK has a nut allergy prevalence of 0.7–2.5%.2 The British Society for Allergy and Clinical Immunology (BSACI) released their Guideline for the Diagnosis and Management of Peanut and Tree Nut Allergy 2 in July 2017 and the National Institute for Health and Care Excellence (NICE) Quality Standard Food Allerg y (QS118)3 reinforces expectations in food allergy management. Life-threatening primary nut allergy most often arises in early childhood, and is caused by the production of specific IgE (sIgE) antibodies, which recognise heat-resistant nut proteins. Signs of a reaction usually develop within a few minutes of ingestion, and include vomiting, oral tingling, itching, urticaria, and lip and eyelid angioedema. Symptoms such as airway swelling, hoarse voice, breathing impairment, and drowsiness are often not correctly recognised as indicating anaphylaxis. Not all patients who report oral symptoms, facial swelling, and urticaria shortly after eating nuts have life-threatening primary nut allergy. Patients with seasonal allergic rhinitis may develop cross-sensitisation between pollen allergens and structurally similar heat-labile proteins within nuts, which can present as pollen food syndrome (PFS). In these cases, the majority of IgE-mediated symptoms are oral-gastric because the labile nut proteins are broken down by gastric acid. Therefore, PFS rarely induces systemic symptoms and the prescription …

Specialist perioperative allergy clinic services in the UK 2016: Results from the Royal College of Anaesthetists Sixth National Audit Project.

Guidelines for investigation of perioperative drug allergy exist, but the quality of services is unknown. Specialist perioperative anaphylaxis services were surveyed through the Royal College of Anaesthetists 6th National Audit Project. We compare self-declared UK practice in specialist perioperative allergy services with national recommendations. A SurveyMonkey™ questionnaire was distributed to providers of allergy services in the UK. Responses were assessed for adherence to the best practice recommendations of the British Society for Allergy and Clinical Immunology (BSACI), the Association of Anaesthetists of Great Britain and Ireland and the National Institute for Health and Care Excellence (NICE) Guidance on Drug Allergy-CG183. Over 1200 patients were evaluated in 44 centres annually. Variation in workload, waiting times, access, staffing and diagnostic approach was noted. Paediatric centres had the longest routine waiting times (most wait >13 weeks) in contrast to adult centres (most wait <12 weeks). Service leads are allergists/immunologists (91%) or anaesthetists (7%). Potentially important differences were seen in: testing repertoire [10/44 (23%) lacked BSACI compliant neuromuscular blocking agent (NMBA) panels and 17/44 (39%) lacked a NAP6-defined extended panel; many failed to screen all cases for chlorhexidine 19/44 (43%) or latex 21/44 (48%)], staffing [only 26/44 (59%) had specialist nurses and 18/44 (41%) an anaesthetist] and provision of information [18/44 (41%) gave immediate information in clinic and 5/44 (11%) sign-posted support groups]. Most centres were able to provide diagnostic challenges to antibiotics [40/44 (91%]) and local anaesthetics [41/44 (93%)]. Diagnostic testing is not harmonized, with marked variability in the NMBA panels used to identify safe alternatives. Chlorhexidine and latex are not part of routine testing in many centres. Poor access to services and patient information provision require attention. Harmonization of diagnostic approach is desirable, particularly with regard to a minimum NMBA panel for identification of safe alternatives.

NICE food allergy and anaphylaxis quality standards: a review of the 2016 quality standards.

The National Institute for Health and Care Excellence (NICE) has in the last 5 years published guidance on several aspects of clinical allergy. In March 2016 they published quality standards on food allergy (QS 118)1 and anaphylaxis (QS 119).2 Despite the recent increase in allergy guidance, not only from NICE but also in the form of a Department of Health Commissioned Pathway Project with the Royal College of Paediatrics and Child Health (RCPCH),3 and several NICE-accredited guidelines from the British Society for Allergy and Clinical Immunology (BSACI), inconsistencies remain in the management of food allergy and anaphylaxis. The National Review of Asthma Deaths highlights that some deaths may have been prevented had there been better management of those with asthma and allergies. Recognition that in uncontrolled asthma, allergic triggers such as food allergy should be considered and also acknowledging that having asthma increases the risk of life-threatening reactions in, for example, those with food allergies, may have prevented some of the deaths.4 It is hoped that these quality standards, accompanied by their performance measures, may drive a further awareness of ideal care of those with suspected food allergy and/or anaphylaxis. The quality standards are divided into six statements for food allergy and four for anaphylaxis. They are based on the corresponding NICE guidelines. ### Quality statement 1: history Identifying the possibility of food allergy comes from taking what NICE terms an allergy-focused clinical history. …

LEVOFLOXACIN ORAL CHALLENGE TEST

Drug allergy is one type of adverse reaction to drugs and encompasses a spectrum of hypersensitivity reactions with heterogeneous mechanisms and clinical presentations. It has been defined by the British Society for Allergy and Clinical Immunology (BSACI) as 'an ADR with an established immunological mechanism' 1,2 . Diagnostic procedures in allergy diagnosis can be classified into the patient's history, in vivo skin testing, in vitro laboratory tests and provocation tests 3 . In situations in which there is a definite medical need for a particular agent, no suitable alternative agent exists, there are primarily two options for the patient with a drug allergy; a procedure to induce temporary drug tolerance can be performed to allow the patient to take the drug safely or a test dose or graded challenge can be administered to determine whether the patient is currently allergic to the particular drug .4 JMS 2016; 19(2):97-98

BSACI guideline: prescribing an adrenaline auto‐injector

SummaryThis guidance for the prescription of an adrenaline auto‐injector has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). There is insufficient quality evidence‐based data in some areas, including the question of how often a second dose is required, and the optimal dose and absorption after subcutaneous vs. intramuscular injection. Thus, indications for adrenaline (which are partly opinion based) in guidelines from different countries vary slightly. The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Evidence from randomized controlled trials is lacking in anaphylaxis for ethical reasons. Consensus was reached by the experts on the committee. Included in this guideline are aetiology, risk of recurrence and management of anaphylaxis (after treatment of the acute episode), including allergen avoidance and written treatment plans. There are sections on dose and absorption of adrenaline, and adrenaline auto‐injectors, including indications for their prescription, risk assessment for the number required and training in their use. The guidelines are not intended to be prescriptive, and clinicians should use their clinical judgement. Finally, we have made recommendations for potential areas of future research.

The impact of national guidelines on venom immunotherapy practice in the United Kingdom.

Venom immunotherapy (VIT) is the only effective treatment for prevention of further anaphylactic reactions to bee and wasp stings in allergic individuals. A previous national survey carried out in 2006/2007 revealed significant heterogeneity in UK practice 1. The British Society for Allergy and Clinical Immunology (BSACI) guidelines for the diagnosis and management of hymenoptera venom (HV) allergy were subsequently published in 2011 2 (Table 1). Table 1 Results of the VIT UK national surveys This repeat survey was carried out to assess whether publication of BSACI guidelines helped improve the diagnosis and management of HV allergy in the UK National Health Service (NHS).

Drug allergy: diagnosis and management of drug allergy in adults, children and young people; a look at NICE guidance

When any patient uses a medicine, it has the ability to cause a noxious and unintended response known as an ‘adverse drug reaction’ (ADR). A drug allergy is defined as an ADR with specific clinical features compatible with an immunological mechanism that re-occurs on re-exposure to that offending drug. Sometimes, it can be a challenge to decide from the clinical history alone as to whether a drug reaction is allergic or not without the need for further investigations. In September 2014, the National Institute for Health and Care Excellence (NICE) published a guideline entitled ‘Drug allergy: diagnosis and management of drug allergy in adults, children and young people’.1 This was developed due to variation in provision of care for people with a suspected drug allergy and to optimise best practice advice on the diagnosis, documentation and communication of drug allergy. Our focus here will be on the recommendations for children and young people. The British Society for Allergy and Clinical Immunology (BSACI) guidelines for the management of drug allergy were published in 20082 with an update which can be found in box 1. The European Association of Allergy and Clinical Immunology (EAACI) also published an international consensus of drug allergy in February 2014.3 Both of these look at the management of drug allergy within the secondary-care and tertiary-care setting, including details on specialist investigations, in contrast to the NICE guideline, which is aimed at all health professionals who review and manage children including in primary care. Differences between these guidelines are demonstrated in table 1. View this table: Table 1 Comparison of guidelines Box 1 ### Resources

Knowledge, practice, and views on precautionary allergen labeling for the management of patients with IgE-mediated food allergy—a survey of Australasian and UK health care professionals

The use of precautionary allergen labeling (PAL) is voluntary and in general unregulated in the vast majority of countries including Australia and the United Kingdom (UK). There is a growing consensus that PAL, in its current forms, is unhelpful to allergic consumers, their families, and health care professionals (HCPs). Issues highlighted include the absence of standardized nomenclature, lack of regulatory oversight, poor consumer understanding and trust, and inconsistent advice from HCPs about which foods are safe for allergic consumers to eat. Despite several studies investigating consumer attitudes to PAL, no study has specifically sought to understand how HCPs currently incorporate PAL into patient management, and whether current approaches (such as the VITAL initiative) are of value. We sought to examine current knowledge and its impact on clinical practice with regard to PAL from a range of HCPs actively engaged in the management of food-allergic patients. A 28-item online survey (Table E1, available in this article’s Online Repository at www.jaci-inpractice.org) was circulated to members of the Australasian Society for Clinical Immunology and Allergy (ASCIA), British Society for Allergy and Clinical Immunology (BSACI), and Allergy Academy (UK) between September and November 2014. Three questions from a previous survey conducted on allergic consumers in Australia were incorporated to allow comparison between consumers and their HCPs. Participants were asked to respond only if they were actively engaged in the clinical management of adults and/or children with IgE-mediated food allergy. We compared responses between the groups using Pearson c tests. Local Human Research Ethics Committees did not require ethical approval for the survey. There were 161 respondents, 84 (52%) from the UK, and 77 (48%) from Australia/New Zealand. The majority cared for exclusively food-allergic children (109, 68%) with the remainder caring for both adults and children (31, 19%) or adults only (21, 13%). Specialist allergists made up half of the respondents (80) with dieticians (30), allergy nurses (21), and general physicians (23) all contributing. There was no significant difference in HCP practice type (adult and/or child) across regions; however, there were more UK-based general physicians than in Australasia (P < .05). Responses are summarized in Figure E1 (available in this article’s Online Repository at www.jaci-inpractice.org).

An Observational Study of the Diagnosis and Management of Chronic Urticaria in the UK

Background: Patients with chronic urticaria (CU) in the UK could be referred to health care professionals (HCPs) with diverse specialties using different guidelines. The aims of the present study were to determine which CU guidelines HCPs in the UK use, which tests they use for the diagnosis of CU, and how they manage CU. Methods: In this UK-wide survey, we designed a questionnaire covering the diagnosis and management of CU based on current guidelines. The link to the questionnaire was sent to the British Society for Allergy and Clinical Immunology (BSACI), the British Association of Dermatologists (BAD), the British Society of Immunology (BSI), and the Food Allergy and Intolerance Specialist Group (FAISG) of the British Dietetic Association (BDA), who distributed the link to their members. Results: The questionnaire was completed by 55 allergists/immunologists, 64 dermatologists, and 43 dietitians. More dermatologists used the BAD guidelines in comparison with allergists and immunologists (93.6 vs. 12.5%; p < 0.001). On the other hand, the BSACI guidelines (83.3 vs. 14.9%; p < 0.001) and the European Academy of Allergy and Clinical Immunology (EAACI)/Global Allergy and Asthma European Network (GA²LEN)/European Dermatology Forum (EDF)/World Allergy Organization (WAO) guidelines (2013) (52.1 vs. 10.6%; p < 0.001) were used by more allergists and immunologists compared to dermatologists. Differences were found between allergists/immunologists and dermatologists with regard to guidelines used, investigations performed, preference of first-line antihistamine, and prescription of alternative treatment methods. Conclusion: In conclusion, differences in the diagnosis and management of CU between HCPs of diverse specialties were identified, which reflected differences among the guidelines used.

BSACI guideline for the management of chronic urticaria and angioedema

This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web-based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.

Management of allergy to penicillins and other beta-lactams.

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non-immediate allergic reactions to penicillins and other beta-lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web-based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta-lactams, molecular structure, formulations available in the UK and a description of known beta-lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross-reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta-lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age- and disease-specific history with relevant allergy tests including detection of milk-specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.

A UK national survey of investigations for beta‐lactam hypersensitivity – heterogeneity in practice and a need for national guidelines – on behalf of British Society for Allergy and Clinical Immunology (BSACI)

Beta lactams (BL) are the most widely prescribed antibiotics in the UK and the commonest cause of hypersensitivity reactions. There are no UK guidelines for BL testing and the most relevant guidelines were devised by the European Network for Drug Allergy (ENDA) on behalf of the European Academy of Allergy and Clinical Immunology. Delivery of allergy services differs across Europe, so this survey was designed to investigate how closely UK practice adhered to these guidelines. An online survey, using surveymonkey.com software, was sent to all consultants offering an allergy service in the UK and who were members of either BSACI or 'Travellers' (Immunology consultant group). The response rate was 48% (n=81/165) and BL allergy testing was undertaken by 78% of respondents. All responders requested SsIgE, although four responders stated they rarely requested. Skin testing was undertaken by 87% of respondents who perform beta lactam testing with 17% undertaking skin prick testing (SPT) only, 77% SPT followed by intra-dermal testing (IDT) if the former were negative or indeterminate and 6% SPT and IDT in all cases. The drugs, doses and protocols for skin testing varied considerably. Drug provocation testing was undertaken by 87% of respondents who undertake beta lactam testing with significant heterogeneity in protocols. Respondents that investigated ≤ 20 patients per year demonstrated lower adherence to ENDA recommendations compared to those who saw > 20. Following positive testing, 79% advised avoidance of all penicillins only and the remainder advised additional drug avoidance. This survey revealed variation in the investigation and management of BL hypersensitivity in the UK with some centres reporting procedures that could potentially put patients at risk of anaphylaxis if allergy was falsely excluded. This survey highlights an urgent need for evidence based national guidelines and standardisation of practice.

Issue Highlights—May 2013

Issue Highlights—May 2013