European Network on Drug Allergy (ENDA) has proposed an algorithm for diagnosing immediate beta-lactam (BL) allergy. We evaluated its performance in real life. During 1994-2014, 1779 patients with suspected immediate reactions to BL were evaluated following ENDA's short diagnostic algorithm. Five hundred and nine patients (28.6%) were diagnosed of BL hypersensitivity. Of them, 457 (25.7%) were at first evaluation [403 by skin tests (ST), 12 by positive IgE and 42 by controlled provocation tests (CPT)]. At second evaluation (SE), 52 additional patients (10.2% of allergic patients) were diagnosed, [50 (2.8%) by ST and 2 (0.1%) by CPT]. Time between reaction and study was significantly longer in patients diagnosed at SE (median 5 vs 42 months; IQR 34 vs 170; P < 0.0001). Anaphylaxis was significantly associated with a diagnosis at SE. European Network on Drug Allergy/EAACI protocol was appropriate and safe when evaluating BL immediate reactions. Re-evaluation should be performed, particularly when anaphylaxis and long interval to diagnosis are present.

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Background: Being labeled as allergic to penicillin (unverified ß-lactam allergy) can result in patients receiving broader-spectrum antibiotics than necessary that may be more toxic, less effective, and/or more expensive than alternative options. Objective: We aimed to evaluate the real costs of evaluating ß-lactam allergy. Methods: We performed a prospective real-life observational study designed to evaluate all adult patients who consulted for suspected ß-lactam allergy over a 1-year period. Direct and indirect costs were systematically recorded. Direct health costs were calculated based on the number of visits and all additional and diagnostic tests performed, direct nonhealth costs based on the number of visits and the distance from their homes to the Allergy Department, and indirect costs based on absenteeism. Results: A total of 296 patients with suspected allergy to ß-lactams were evaluated in our outpatient clinic from June 1, 2017 to May 31, 2018. Total direct health care costs were €28 176.70, with a mean (SD) cost of €95.19 (37.20). Direct nonhealth costs reached €6551.73, that is, €22.13 (40.44) per patient. Indirect health costs reached €20 769.20, with a mean of €70.17 (127.40). In summary, the total cost was €55 497.63, that is, a cost per patient of €187.49 (148.14). Conclusions: When all possible costs are taken into account, the evaluation of ß-lactam allergy is not expensive and can reduce future expense arising from unnecessary use of more expensive and less effective antibiotics.

Delayed-reading intradermal tests and patch tests are useful tools in the diagnosis of nonimmediate reactions to pyrazolones and should be considered the first step when evaluating these type of reactions. Intradermal test appears to be more sensitive than patch test. The positivity of skin tests suggests an immunological reaction, probably mediated by T lymphocytes, but further studies are required.

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A prospective study of costs associated to the evaluation of non-steroidal anti-inflammatory hypersensitivity reactions To the Editor, Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most frequent causes of drug hypersensitivity reactions, affecting 1%-3% of general population; the prevalence of NSAID hypersensitivity is higher in patients with chronic rhinosinusitis, nasal polyposis, asthma, or chronic urticaria, affecting up to 30% of patients 1. The importance of its evaluation resides in the need of NSAIDs as analgesic/anti-inflammatory or antiplatelet therapy 2. This is a prospective, real-life, observational study aimed to evaluate all direct and indirect health costs of patients that consulted in our outpatient clinic for suspected NSAID hypersensitivity reactions. The study lasted from June 1, 2017, to May 31, 2018. The protocol was approved by the local Ethics Committee (code PI4505/2017) and all patients signed an informed written consent. Diagnostic procedures were carried out following the European Network of Drug Allergy/ European Academy of Allergy and Clinical Immunology (ENDA/EAACI) protocol 3. Data concerning medication used for the study (consumption and costs) were collected in a structured way; data costs were provided by the Hospital Pharmacy Service (Table S1). Data about personnel, materials, and infrastructure costs were provided by the Bureau of Management of the Hospital (Table S2). Direct health costs were calculated considering the number of visits, complementary and diagnostic tests performed, and costs for personnel and materials used during the study. Direct nonhealth costs were calculated considering the number of travels and the distance in kilometers from patients' residences to the Allergy Service, applying the amount that the Spanish Authorities pay to public officials for the use of their private car and has been considered as locomotion expenses (€ 0.19 per kilometer) 4 (Figure S1). Indirect costs were based on loss of working hours (absenteeism). The average hourly labor cost in 2018 was estimated at € 27.4 in the European Union (EU) 5. However, this average conceals significant differences between EU Member States. For more details about methods, see Appendix S1. A total of 233 patients were evaluated. Of these, 212 (90.99%) completed the study. Mean age was 50.99 ± 17.56 years. Median age was 52 and interquartile range 38-64 years. There was a predominance of females (67.38%). In 43 out of 233 patients (18.45%), hypersensitivity to NSAIDs was demonstrated. Regarding the type of reaction, in concordance with data published by Doña et al 6 , the number of anaphylaxis was appreciable (eight patients, 18.60%), 29 patients (67.44%) had had skin reactions (10 acute, 16 delayed and three unknown), and six respiratory symptoms (13.95%). Crossreactivity reactions were observed in 25 patients (58.14%), whereas 18 patients were single-drug reactors (Table 1).

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