Current state of follow-up care for patients with Hymenoptera venom anaphylaxis in southwest Germany: Major impact of early information

Abstract

Background: Up to 3.5% of the population experience anaphylactic reactions in response to Hymenoptera stings. Current guidelines are in place for the diagnostic workup and follow-up care of patients with Hymenoptera venom anaphylaxis (HVA). However, little is known about the degree of implementation of the recommendations and patient attitudes toward the recommendations in the general patient population.

Methods: For the analysis of the follow-up care in real life, a retrospective questionnaire-based study was conducted in unselected patients who had received treatment from an emergency medical response team for HVA, as documented in records of three regional Medical Emergency Response Centers.

Results: From over 125,000 cases, a filtered list of 1895 patients that coded for anaphylaxis was generated and examination of paper records identified 548 patients with a documented insect sting anaphylaxis. Patients were sent a standardized questionnaire addressing different aspects of diagnostics and follow-up care. Almost 40% of the patients did not receive a referral to an allergist at the emergency center, over 50% did not consult an allergy specialist at any time after the index sting, 25% did not receive any form of diagnostic workup, over 30% did not receive any information about venom immunotherapy (VIT) as treatment option, and only 50% were eventually started on VIT. Emergency medication was prescribed in 90% of the cases, 77% including an adrenalin auto injector, of which 47% were expired at the time of the survey. Patients who were informed about diagnostic and treatment options early during the index event, i. e., during the stay in the emergency department, displayed a higher rate of referral to an allergist (70% vs. 17%), higher rate of diagnostic workup (88% vs. 59%), and a higher rate of initiation of VIT (89% vs. 64%), as compared to patients who did not.

Conclusion: Our results demonstrate that there are missed opportunities for secondary and tertiary prevention of anaphylaxis due to insect venom allergy and that early information on required diagnostics and treatment options has a major impact on the degree of proper follow-up care in line with current guideline recommendations.

Keywords: Anaphylaxis; Follow-up care; Guideline; Insect venom allergy.

Fig. 1

a Frequency of patients who carry emergency medications. b Patient attitudes toward emergency medications

Fig. 2

a Physician(s) with whom diagnostic testing was undertaken. b Results of diagnostic testing. c Time interval from index event to diagnostics performed

Fig. 3

Influence of index sting severity grade according to Ring and Messmer [16] on patient follow-up care with regard to early recommendation for follow-up received, referral to allergist, diagnostics performed, information regarding venom immunotherapy (VIT) received, and VIT initiated

Fig. 4

a Rate of emergency medication prescribed, rate of referrals to an allergist, rate of diagnostics performed and rate of venom immunotherapy (VIT) initiated in patients who received an early recommendation for follow-up during the acute treatment phase (n = 69) as compared to patients who did not receive this recommendation during acute treatment (n = 46), or did not remember/did not answer if a recommendation was received during acute treatment (n = 11). b–d Tree diagram of treatment paths reported by patients who received an early recommendation for follow-up (n = 69) (b), by patients who did not receive an early recommendation for follow-up (n = 46) (c) or did not remember/did not answer if a recommendation was received during acute treatment (n = 11) (d). Relevant endpoints: (1) early recommendation for follow-up received (b) not received (c), unknown (d)

Fig. 4 (Continued)

(2) referral to an allergist received, (3) prescription for emergency medications received, (4) diagnostic testing performed, (5) results of diagnostic testing (positive for bee and/or wasp venom or not), (6) information about VIT as treatment option received, (7) VIT initiated. The treatment/follow-up that is not in line with the current guideline recommendations is highlighted in black. (Recommendation follow-up recommendation during acute treatment; Allergist referral to allergist received; E-meds received a prescription for emergency medications; Dx Test received diagnostic testing; VIT Info informed about venom immunotherapy as treatment option; VIT venom immunotherapy initiated; (y) = yes; (n) = no; (+) = positive; (–) = negative)