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Medical Journal Review

December 2022

WAO Reviews – Editors' Choice

The WAO Reviews editors, Juan Carlos Ivancevich, MD, and John J. Oppenheimer, MD - FACAAI - FAAAAI, select articles on a monthly basis for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases.

Improving antimicrobial stewardship with penicillin allergy testing: A review of current practices and unmet needs
Mabilat C, Gros MF, Van Belkum A et al
JAC – Antimicrobial Resistance 2022;4(6):dlac116 (19 November)

Penicillin allergy, the most frequently reported drug allergy, has been associated with suboptimal antibiotic therapy, resulting in increased antimicrobial resistance, increased rates of Clostridioides difficile colonization and infection, as well as extended hospital length of stay and overall increased cost. Although up to 10% of all patients may report penicillin allergy, most penicillin allergies are not confirmed. In essence, most patients with a penicillin allergy can still safely use penicillin and related drugs following a more precise assessment. In this review authors explore the current practices and unmet needs in penicillin allergy testing. The diagnostic algorithm is mostly based on a clinical history assessment followed by in vivo testing, i.e., skin test, and/or drug challenge. As these tests are labor/ resource intensive, there is increased interest in point-of care penicillin allergy de-labelling solutions incorporated into Antimicrobial Stewardship Programs including digital assessment tools. As noted by the authors, reducing residual risk remains essential and in vivo drug challenge and/or skin testing should be systematically encouraged. Gradual understanding and convergence of the risk stratification of the clinical presentation of penicillin allergy is enabling a wider implementation of this essential aspect of antimicrobial stewardship through digitalized decision tools and in vivo testing. As noted by the authors, further research is needed to deliver point of care in vitro diagnostic tools to democratize this de-labelling practice, which would be highly beneficial to patient care.

Monitoring of molecular profiling of allergen-antibody responses in HDM-immunotherapy patients
Nittner-Marszalaka M, Kopeć A, Foks-Ciekalska A, et al
Human Vaccines & Immunotherapeutics 2022; Published online ahead of print (29 November)

Among the potential hazards of house dust mite (HDM) immunotherapy (AIT) with HDM allergenic extracts is the possible initiation of de novo sensitizations caused by a lack of complementarity between a given HDM vaccine’s content and a patient’s molecular sensitization profile. The aim was to investigate whether immunotherapy with HDM extracts affects changes in the profile of sensitizations to allergens contained within the extract and whether neo sensitizations occur. Serum samples from patients with HDM allergies (N=63) who received 1 year of treatment with subcutaneous AIT were tested for allergen-specific IgE (sIgE) reactivity to 7 microarrayed HDM allergen molecules (Der p 1, 2,10,11,23; D far 1 and 2) with ImmunoCAP. The HDM non-AIT patients (N=22), who did not receive immunotherapy constituted the study’s control group with data analyzed at baseline and after 6 and 12 months. In the HDM-AIT group, no neo sensitizations after 6 and 12 months of immunotherapy were reported, while in the HDM non-AIT group, only neo sensitizations to Der p 10 were observed. In the study group, sIgE levels against the HDM extract of D. pteronyssinus, D. farinae, rDer p 1, rDer p 2, and Der f 2 decreased after 12 months of AIT (p< .05). SIgE levels against Der f 1, Der p 10, 11 and 23 remained unchanged in the course of 12 months of immunotherapy. Furthermore, in patients with allergic rhinitis with or without concomitant HDM-induced asthma treated with HDM AIT for 12 months, no neo sensitizations related to the examined HDM molecules were observed.

A confluence of advanced treatment options for atopic dermatitis, eosinophilic lung diseases and chronic urticarial brought about by the revolutionary discovery of biologics and Janus kinase inhibitors
Bellanti JA, Settipane RA
Allergy and Asthma Proceedings 2022;43(6):471-473

In this editorial Drs. Bellanti and Settipane highlight the most recent issue of Allergy and Asthma Proceedings which explored the complexities of asthma, COVID-19, monkeypox, hereditary angioedema, pet allergies, food allergy, eosinophilic lung disease, chronic urticaria, anaphylaxis, contact dermatitis, and atopic dermatitis with practical information focused on aiding the practicing allergist.

Higher risk for influenza-associated pulmonary aspergillosis (IAPA) in asthmatic patients: A Swiss multicenter cohort study on IAPA in critically ill influenza patients
Waldeck F, Boroli F, Zingg S et al
Influenza and Other Respiratory Viruses 2022; Published online ahead of print (16 November)

Influenza-associated pulmonary aspergillosis (IAPA) is an important complication of severe influenza with associated high morbidity and mortality. To better understand this association, the authors performed a retrospective multicenter study in tertiary hospitals in Switzerland during 2017/2018 and 2019/2020 influenza seasons. All adults with PCR-confirmed influenza infection and treatment in the intensive-care unit (ICU) for >24 h were included. IAPA was diagnosed according to previously published clinical, radiological, and microbiological criteria. From this data, the authors explored risk factors for IAPA and predictors for poor outcome, which was a composite of in-hospital mortality, ICU length of stay ≥7 days, mechanical ventilation ≥7 days, or extracorporeal membrane oxygenation. They found that asthma was more common in IAPA patients (17% vs. 4% in non-IAPA, P = 0.05). Asthma (OR 12.0 [95% CI 2.1–67.2]) and days of mechanical ventilation (OR 1.1 [1.1–1.2]) were associated with IAPA. IAPA patients frequently required organ supportive therapies including mechanical ventilation (88% in IAPA vs. 53% in non-IAPA, P = 0.001) and vasoactive support (75% vs. 45%, P = 0.03) and had more complications including ARDS (53% vs. 26%, P = 0.04), respiratory bacterial infections (65% vs. 37%, P = 0.04), and higher ICU-mortality (35% vs. 16.4%, P = 0.05). IAPA (OR 28.8 [3.3–253.4]), influenza A (OR 3.3 [1.4–7.8]), and higher SAPS II score (OR 1.07 [1.05–1.10]) were independent predictors of poor outcome. Overall, this data suggest that high clinical suspicion, early diagnostics, and therapy are indicated in IAPA because of high morbidity and mortality and that asthma is likely an underappreciated risk factor for IAPA.

As-needed intranasal corticosteroid spray for allergic rhinitis: A systematic review and meta-analysis
Hoang MP, Chitsuthipakorn W, Seresirikachorn K, Snidvongs K
Rhinology 2022;60(4):242-251

As-needed intranasal corticosteroid spray (INCS) is commonly used by patients with allergic rhinitis (AR) who have suboptimal symptom control. Thus far, several small studies have demonstrated somewhat conflicting results, thus this systematic review aimed to assess the effectiveness of as-needed INCS for treating AR with primary outcomes being total nasal symptom score (TNSS) and disease-specific quality of life (DSQoL). Through analysis of the 8 studies (882 participants) that met the criteria the authors found that regular use of INCS showed greater improvements than as-needed INCS in TNSS, DSQoL, nasal peak inspiratory flow, sneezing, and nasal congestion scores with small effect sizes. There were, however, no differences between regular and as-needed INCS usage for ocular symptoms, symptom-free days, nasal itching, and rhinorrhea scores. As-needed INCS was superior to as-needed antihistamine and placebo with medium effect sizes. There were no differences in risk of adverse events between the groups in all three comparisons. Overall, the study demonstrated that regular use of INCS improved total nasal symptoms score and DSQoL better than as-needed INCS. However, as-needed INCS improved TNSS better than as-needed antihistamine and placebo, while the effects of as-needed INCS were closer to regular INCS usage than to placebo or as-needed AH use.

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