Allergy Evaluation Research Articles

Food protein-induced enterocolitis syndrome: Healthcare utilization and referral patterns among a pediatric cohort.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated food allergy characterized by delayed, repetitive vomiting. FPIES is improving in recognition; however, there remains a lag in diagnosis. This study aimed to further explore this lag, as well as referral patterns and healthcare utilization, to help determine areas for earlier recognition. A retrospective chart review of pediatric FPIES patients at two hospital systems in New York was completed. Charts were reviewed for FPIES episodes and healthcare visits prior to diagnosis, and reason/source of referral to an allergist. A cohort of patients with IgE-mediated food allergy was reviewed for comparison of demographics and the time to the diagnosis. In total, 110 patients with FPIES were identified. The median time to diagnosis was 3 months, vs. 2 months in IgE-mediated food allergy (p < 0.05). Most referrals were from the pediatrician (68%) or gastroenterology (28%), none were from the ED. The most common reason for referral was concern of IgE-mediated allergy (51%), followed by FPIES (35%). There was a statistically significant difference in race/ethnicity between the FPIES cohort and IgE-mediated food allergy group (p < 0.0001), with a greater proportion of Caucasian patients in FPIES vs. IgE-mediated food allergy cohort. This study demonstrates a lag in the diagnosis of FPIES and a lack of recognition outside of the allergy community, as only one-third of patients were considered to have FPIES prior to an allergy evaluation.

Presentation and Evaluation of Food Allergy in IgE Deficient Patients: A Case Series

Presentation and Evaluation of Food Allergy in IgE Deficient Patients: A Case Series

A Nurse-Led, Protocol-Driven Penicillin Allergy Evaluation from the Hong Kong Drug Allergy Delabelling Initiative: Effectiveness, Safety and Real-World Outcomes

There is a high prevalence of misdiagnosed penicillin ‘allergy’, associated with a multitude of adverse clinical outcomes. With the overwhelming burden of incorrect labels and lack of allergy specialist services, new delabelling strategies are urgently needed. We compared the effectiveness, safety and real-world outcomes of a nurse-led, protocol-driven evaluation of penicillin allergy – Hong Kong Drug Allergy Delabelling Initiative (HK-DADI).

Assessing the Family-Level Impact of Pediatric Food Allergy: Development of the PEACH Tool

Psychosocial care for food allergy is a top stakeholder priority and requires consideration of the patient and larger family system in pediatrics. A valid, clinically useful tool capturing the full range of FA impacts on children and families is needed. Here we describe item generation and content validation processes for a first draft of the Psychosocial Evaluation of Allergy on Caregivers and Households (PEACH).

Proportion of Referred Patients Who Completed Recommended Drug Allergy Evaluation

Drug allergies are a frequent reason for referral to allergy/immunology and are an important source of morbidity and mortality. While patients are often de-labeled by allergists via skin testing (ST) and/or oral challenges (OC), this typically requires a second visit. We sought to evaluate the proportion of patients referred to a tertiary care academic allergy practice for drug allergy who completed evaluation.

Pilot Program utilizes telemedicine to expedite penicillin allergy de-labeling

Approximately 5% of children carry a penicillin (PCN) allergy label. Less than 10% of reported reactions are estimated to be IgE-mediated. Current guidelines recommend formal evaluation of all patients with unconfirmed PCN allergy labels, and dedicated PCN allergy clinics have proved to be effective for de-labeling. We piloted a new PCN allergy clinic utilizing telemedicine services to provide prompt PCN allergy evaluation.

A Quality Improvement Initiative to Increase Access to Penicillin Allergy Evaluations in Pediatric Surgical Patients

Surgical patients with a penicillin allergy label have worse clinical outcomes and increased healthcare costs compared to patients without a penicillin allergy label. Our aim is to decrease the number of pediatric patients presenting to surgery with a penicillin allergy label by increasing access to pre-operative penicillin allergy evaluation.

Low frequency of allergy referral for penicillin allergy evaluation in an urban Boston primary care setting.

A key strategy to combat the public health crisis of antimicrobial resistance is to use appropriate antibiotics, which is difficult in patients with a penicillin allergy label. Our aim was to investigate racial and ethnic differences related to penicillin allergy labeling and referral to allergy/immunology in primary care. This was a retrospective study of Tufts Medical Center's Boston-based primary care patients in 2019. Univariable and multivariable logistic regression models were used to examine demographic associations with (1) penicillin allergy label and (2) allergist referral. Of 21,918 primary care patients, 2,391 (11%) had a penicillin allergy label; of these, 249 (10%) had an allergist referral. In multivariable logistic regression models, older age (adjusted odds ratio [aOR]= 1.06 [95% CI= 1.04-1.09]) and female sex (aOR= 1.58 [95% CI = 1.44-1.74]) were associated with higher odds of penicillin allergy label carriage. Black race (aOR= 0.77 [95% CI= 0.69-0.87]) and Asian race (aOR= 0.47 [95%CI = 0.41-0.53]) were associated with lower odds of penicillin allergy label carriage. In multivariable regression, allergist referral was associated with female sex (aOR= 1.52 [95% CI= 1.10-2.10]) and Black race (aOR= 1.74 [95% CI= 1.25-2.45]). Of 93 patients (37%) who completed their allergy visit, 26 (28%) had received penicillin allergy evaluation or were scheduled to receive a penicillin allergy evaluation at a future visit. There were racial differences in penicillin allergy labeling and referral. Allergy referral for penicillin allergy assessment was rare. Larger studies are needed to assess penicillin allergy labeling and delabeling with an equity focus on optimizing patient health outcomes.

Improving Access To Penicillin Allergy Testing Among Pregnant Patients In An Obstetrics Clinic

Beta-lactam antibiotics are first-line for most infections during pregnancy and delivery. We assessed outcomes of proactive screening and referral from an obstetrics (OB) clinic for penicillin allergy evaluation.

Allergy evaluation in syphilis positive pregnant individuals with penicillin allergy: A cost effectiveness analysis

U.S. syphilis rates and vertical transmission have been increasing since 2001. The only treatment for syphilis in pregnancy is penicillin G (PCN). For those with a PCN allergy, no alternate antibiotics are effective, and they are recommended to be evaluated, desensitized if needed, and treated with PCN. Patients can either undergo allergy evaluation and risk stratification, or be directly desensitized at obstetric point of care. In this study, we evaluated allergy evaluation for PCN-allergic, syphilis-positive pregnant individuals as a means to prevent potential anaphylaxis with PCN exposure.

Evaluation of allergic reactions from different monoclonal antibodies used for COVID-19 in pregnancy

Evaluation of allergic reactions from different monoclonal antibodies used for COVID-19 in pregnancy

Perceived usefulness of a mnemonic to improve nurses' evaluation of reported penicillin allergies.

We surveyed clinicians to evaluate the perceived usefulness of a mnemonic, STORY, to improve penicillin allergy evaluation. Survey responses indicated that the perceived usefulness of STORY was high, and support for nurses' involvement in penicillin allergy assessment was high. Future research may evaluate the feasibility of STORY implementation in clinical care.

Challenges and opportunities related to penicillin allergy in the Veterans Health Administration: a narrative review.

The presence of a penicillin allergy label in a patient's medical chart is associated with negative clinical and economic outcomes. Given that less than 10% of reported reactions are truly immunoglobulin E-mediated, removal of unverified penicillin allergy labels is a public health priority and an area of ongoing implementation research. The Veterans Health Administration (VHA) is the largest integrated healthcare system in the United States, with almost 9 million veterans currently enrolled. However, studies analyzing the impact of the penicillin allergy label in this population are limited to single facilities and largely focus on short-term outcomes of allergy documentation correction, usage of β-lactams, and avoidance of antibiotic-related side effects. Broader, national VHA studies focusing on health outcomes and costs are lacking. As with non-VHA facilities, penicillin allergy evaluations are limited owing to the absence of formal allergy/immunology services at most VHA facilities. Pharmacy-driven screening and referral for clinic-based penicillin skin testing is a promising and frequently discussed modality in the literature, but its scalability within the VHA is not yet proven. Broader, evidence-based strategies that can be adapted to the available resources of individual VHA facilities, including those without on-site access to allergy providers, are needed.

Prospective Assessment of Penicillin Allergy (PAPA): Evaluating the performance of penicillin allergy testing and post-delabelling outcomes among Hong Kong Chinese.

Incorrect penicillin 'allergy' labels predispose patients to adverse outcomes but are under-recognised in many Asian countries. Studies on performance and post-delabelling outcomes of penicillin allergy evaluation among Chinese remain scarce. To evaluate the diagnostic performance of allergy testing and post-delabelling outcomes among Chinese patients in a prospective penicillin allergy cohort - Prospective Assessment of Penicillin Allergy (PAPA). All adult patients (age ≥ 18 years) who underwent penicillin allergy evaluation between January 2020 to December 2021 were recruited and prospectively reviewed by both medical records and individual interviews at least 6 months after delabelling or allergy confirmation. Out of 372 patients who completed penicillin allergy evaluation, 335 (90%) patients were delabelled. The overall negative predictive value of penicillin skin testing was 95%, but lower for patients with non-immediate type reactions (88%). History of non-immediate symptom onset (OR = 4.501 [95%CI = 2.085-9.716], p < 0.001) and duration since index reaction (OR = 0.942 [95%CI = 0.899-0.987], p = 0.012) were associated with positive skin testing. After at least 6 months, 60 (18%) of de-labelled patients had received penicillins again without any adverse reactions. Fluoroquinolone-use was significantly lower among delabelled patients compared to those with penicillin allergy (38[11%] vs 11[30%], p = 0.004). After at least 6 months, one in six delabelled patients already received penicillins again safely, with significantly lower fluoroquinolone usage. None experienced adverse reactions. History of non-immediate onset and shorter duration since index reaction were associated with genuine allergy. In patients with severe non-immediate reactions, skin tests should be supplemented with thorough clinical history and adjunct diagnostic evaluations.

Penicillin allergy evaluation in hospitalized patients with hematologic malignancy.

A penicillin allergy testing service (PATS) assessed penicillin allergy in patients with hematologic malignancies; 17 patients who met criteria had negative skin testing. Patients who underwent penicillin challenge passed and were delabeled. Of delabeled patients, 87% received and tolerated β-lactams during follow-up. Providers found the PATS valuable.

Barriers to paediatric penicillin allergy de-labelling in UK secondary care: a regional survey

BackgroundIncorrect penicillin allergy labels result in the use of inappropriately broad-spectrum antibiotics. De-labelling inaccurate penicillin allergy promotes antimicrobial stewardship and optimises prescribing practices. The objectives were to evaluate paediatric clinicians’...

1750. Evaluation of Antibiotic Allergy in the Ambulatory Setting

Abstract Background It is not uncommon for patients to have a labeled allergy to antibiotics without thorough investigation of their adverse reactions. The adverse reactions described by some patients are not immune-mediated and these patients are incorrectly labeled as having an antibiotic allergy. As clinical testing for antibiotic allergy is expensive and time intensive, recent initiatives have successfully used patient interviewing to differentiate non-immune mediated reactions from true antibiotic allergies. We investigated the prevalence of patients with non-immune mediated reactions to antibiotics among patients with documented antibiotic allergy by using a standardized questionnaire in the outpatient setting. Methods Patients with a documented antibiotic allergy were identified and recruited from 2 clinics located in the greater Chicagoland area. Subjects completed one standardized questionnaire regarding each of their previous adverse reaction to antibiotics. We then evaluated the questionnaire responses to extricate the non-immune-mediated adverse reactions. The full symptom classification can be found in Table 1 and Table 2. Results 98 patients were recruited with a total of 159 antibiotic questionnaires completed. At the patient level, 18 individuals had no immune-mediated reactions despite antibiotic allergy labels: 18.37% (95% CI: 10.7%, 26.3%). At the antibiotic level, 35 labels had corresponding clinical histories that were likely non-immune mediated: 22.0% (95% CI: 14.7%, 29.4%). Macrolides (8/11, 72.7%), nitrofurantoin (1/2, 50%), and amoxicillin/clavulanate (2/8, 25%) were the antibiotics with the highest percentage of corresponding clinical histories that were likely non-immune mediated (Figure 1). Penicillin was the most prevalently listed antibiotic allergy (43/159, 27.0%), followed by sulfonamides (25/159, 15.7%) and fluoroquinolones (21/159, 13.2%). Conclusion This study demonstrated the feasibility of using a standardized questionnaire to discern true antibiotic allergies from non-immune mediated adverse reactions. The improved accuracy of documented allergies allows for better optimization of antibiotic prescribing. Disclosures All Authors: No reported disclosures.

Penicillin Allergy Evaluation and Health Equity: A Call to Action

Allergists have been at the forefront of addressing the burden of unverified penicillin allergy labels. Coordinated national efforts with infectious diseases, antimicrobial stewardship experts, and pharmacy societies to advocate for formal evaluation of patient-reported penicillin allergy have resulted in improvements in delabeling efforts. Given the poorer health outcomes associated with the penicillin allergy label and the potential health benefits that can be gained with delabeling, improving access to penicillin allergy evaluation is of the utmost importance. Health disparities are widely recognized to impact all aspects of health care, and multilevel interventions at the patient, clinician, and systems level are required to ensure equitable care delivery. Structural racism underpins many social determinants of health and is a key driver of racial and ethnic health disparities. In this Rostrum, we use a conceptual framework from the 2015 National Academy of Medicine report Improving Diagnosis in Health Care to explore how inequities are related to the evaluation of penicillin allergy. We use the National Institute on Minority Health and Health Disparities Strategies to Advance Health Disparities to elucidate areas of important study. Building upon existing efforts to address disparities in Allergy/Immunology, we highlight the urgent importance of understanding and eliminating health disparities in penicillin allergy evaluation and delabeling.

Drug allergy evaluation in children with suspected mild antibiotic allergy.

Adverse antibiotic reactions caused by an immunological mechanism are known as allergic reactions. The percentage of reported antibiotic allergies is likely to differ from the one validated after a drug provocation test (DPT) with the culprit antibiotic. This study aimed to compare the percentage of children who were thought to be allergic to a certain antibiotic with those who have a true allergy, as confirmed by DPTs. We also validated Skin Prick Tests (SPTs) and Intradermal Tests (IDTs) by assessing their sensitivity and specificity, in diagnosing antibiotic allergies using DPT as the gold standard. Furthermore, we investigated epidemiological risk factors such as personal and family history of atopic disease and eosinophilia. Children with a history of possible allergic reaction to an antibiotic underwent a diagnostic procedure that included: (1) Eosinophil blood count, (2) SPTs, (3) IDTs and (4) DPTs. The parameters were compared with Pearson's Chi-Square and Fisher's Exact Test. Several risk factors that were found significant in univariate analysis, such as personal and family history of atopic disease, and positive SPTs and IDTs were examined with multiple logistic regression analysis to see if they were related to a higher risk for a positive DPT. Semi-synthetic penicillin was the most common group of antibiotics thought to cause allergic reactions in this study. Overall, 123 children with a personal history of an adverse reaction to a certain antibiotic, were evaluated. In 87.8% of the cases, the symptoms had occurred several hours after administration of the culprit antibiotic. Both SPTs and IDTs had low sensitivity but high specificity. Moreover, they had a high positive predictive value (PPV). In contrast, eosinophilia was not recognized as a risk factor. Seventeen patients (13.8%) had a true antibiotic allergy, as confirmed by a positive DPT. A positive IDT was a strong predictor of a positive DPT, along with a positive personal and family history of atopy. SPTs and IDTs are very reliable in confirming antibiotic allergy when found positive. A negative result of a SPT highly predicts a negative DPT. A positive IDT and a positive personal and family history of atopy were recognized as significant risk factors for antibiotic allergy.

Improving drug allergy label accuracy by supervised safety- and protocol-driven evaluation

Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels. All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded. A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited. Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.