Updated guidance regarding the risk of allergic reactions to COVID-19 vaccines and recommended evaluation and management: A GRADE assessment and international consensus approach.

This guidance updates 2021 GRADE (Grading of Recommendations Assessment, Development and Evaluation) recommendations regarding immediate allergic reactions following coronavirus disease 2019 (COVID-19) vaccines and addresses revaccinating individuals with first-dose allergic reactions and allergy testing to determine revaccination outcomes. Recent meta-analyses assessed the incidence of severe allergic reactions to initial COVID-19 vaccination, risk of mRNA-COVID-19 revaccination after an initial reaction, and diagnostic accuracy of COVID-19 vaccine and vaccine excipient testing in predicting reactions. GRADE methods informed rating the certainty of evidence and strength of recommendations. A modified Delphi panel consisting of experts in allergy, anaphylaxis, vaccinology, infectious diseases, emergency medicine, and primary care from Australia, Canada, Europe, Japan, South Africa, the United Kingdom, and the United States formed the recommendations. We recommend vaccination for persons without COVID-19 vaccine excipient allergy and revaccination after a prior immediate allergic reaction. We suggest against >15-minute postvaccination observation. We recommend against mRNA vaccine or excipient skin testing to predict outcomes. We suggest revaccination of persons with an immediate allergic reaction to the mRNA vaccine or excipients be performed by a person with vaccine allergy expertise in a properly equipped setting. We suggest against premedication, split-dosing, or special precautions because of a comorbid allergic history.

Group B streptococcal leptomeningitis, ventriculitis, right cerebellitis, and cerebritis in an immunocompetent patient.

BACKGROUND: Group B streptococcal (GBS) meningitis is uncommon in non-puerperal adults outside of significant immunocompromise or structural abnormalities. CASE PRESENTATION: We describe a relatively healthy 62-year-old man with GBS bacteremia, abnormal lumbar puncture, and MRI-confirmed leptomeningitis, ventriculitis, right cerebellitis, and cerebritis who presented without overt symptoms of meningitis. DIAGNOSIS: The suspected source of infection was a high-inoculum genitourinary infection in the setting of hydronephrosis and recent cystoscopy. We performed a literature review of previous cases and clusters of GBS meningitis. DISCUSSION: With increasing recognition of invasive GBS infection among adult patients, and in light of our patient's atypical presentation, we propose that an index of suspicion for GBS meningitis be maintained, even for patients who would traditionally have been considered at lower risk.

HISTORIQUE: La méningite à streptocoque du groupe B (SGB) est rare chez les adultes qui ne viennent pas d'accoucher s'ils ne présentent pas une immunodépression importante ou des anomalies structurelles. PRÉSENTATION DE CAS: Les chercheurs décrivent le cas d'un homme de 62 ans relativement en santé atteint d'une bactériémie à SGB qui présentait une ponction lombaire anormale, une léptoméningite confirmés par l'imagerie à résonance magnétique, une ventriculite, une cérébellite droite et une cérébrite qui se sont manifestées sans symptômes évidents de méningite. DIAGNOSTIC: La source présumée de l'infection était une infection génito-urinaire dans le contexte d'une hydronéphrose et d'une récente cytoscopie. Les chercheurs ont procédé à une analyse bibliographique des cas antérieurs et des grappes de méningite à SGB. DISCUSSION: Puisque les infections à SGB invasives sont de plus en plus diagnostiquées chez les patients adultes, et compte tenu de la présentation atypique du patient, les chercheurs proposent de savoir évoquer une méningite à SGB, même chez les patients qui seraient habituellement considérés comme à faible risque.

Failure of a single day metronidazole desensitization protocol, and success of a modified two-day protocol in an outpatient setting.

BACKGROUND: True allergy to metronidazole, a common anti-infective in clinical practice, is rarely reported in the literature. In the case of Trichomonas, there are few alternatives to the nitrimidazole class of drugs, and the alternatives that do exist are associated with worse clinical outcomes. Accordingly, for the rare patients with Type 1 hypersensitivity reactions to metronidazole but compelling need, desensitization protocols have been adapted previously. Reactions during these protocols appear common. Patients in previous regimens have required higher level care for observation, which is costly and resource-intensive. CASE PRESENTATION: We report here on a successful outpatient two-day regimen for metronidazole desensitization. Our patient had compelling indication for metronidazole, but reacted after receiving the very first dose of a previously described desensitization protocol. Accordingly, the protocol was adapted further. Despite this, she went on to develop objective hives prior to reaching the full intended dose. With appropriate symptom management and pre-medication on the second day in clinic, she was successfully desensitized and able to complete a week of full-dose metronidazole. No acute care resources were needed. CONCLUSION: We propose this two-day desensitization regimen for patients who react during the previously described desensitization protocols. This regimen was effective and safe, and did not necessitate the use of acute-care resources. Two-day desensitization protocols while relatively uncommon, can be successful.