The first EAACI position paper on immunotherapy with Hymenoptera venoms was published in 1987 (1). Six years later a revised version appeared (2). As then many papers on the diagnosis and treatment of Hymenoptera venom allergy have been published, making a review of the last EAACI position paper necessary. This paper focuses on Hymenoptera venom allergy, as allergic reactions caused by stings of insects other than Hymenoptera are rare and standardized extracts for the diagnosis and treatment of allergic reactions to nonHymenoptera insects are not available (3). TaxonomyMost authors follow the Chinery classification (4), although over the last few years a few minor changes have been introduced. Aculeatae are a suborder of Hymenoptera (Fig. 1).The family Apidae consists of the honeybees (Apis mellifera) who are brown in color and moderately hairy and the bumblebees (Genus Bombus) which are bigger than honeybees, much more hairy and characterized by distinct yellow or white bands on their abdomen. Vespidae are divided into the Vespinae and Polistinae subfamilies, with differences at the junction of the thorax and abdomen. Vespinae have a truncated junction while Polistinae are more oval in shape. Vespidae are almost hairless and have black and yellow striped abdomens.Vespula, Dolichovespula and Vespa make up the three genera of the Vespinae. Vespula (called wasps in Europe, yellow jackets in the USA) are the most important species in Europe. The Vespula spp. (V. germanica and The purpose of diagnostic procedure is to classify a sting reaction by history, identify the underlying pathogenetic mechanism, and identify the offending insect. Diagnosis of Hymenoptera venom allergy thus forms the basis for the treatment. In the central and northern Europe vespid (mainly Vespula spp.) and honeybee stings are the most prevalent, whereas in the Mediterranean area stings from Polistes and Vespula are more frequent than honeybee stings; bumblebee stings are rare throughout Europe and more of an occupational hazard. Several major allergens, usually glycoproteins with a molecular weight of 10-50 kDa, have been identified in venoms of bees, vespids. and ants. The sequences and structures of the majority of venom allergens have been determined and several have been expressed in recombinant form. A particular problem in the field of cross-reactivity are specific immunoglobulin E (IgE) antibodies directed against carbohydrate epitopes, which may induce multiple positive test results (skin test, in vitro tests) of still unknown clinical significance. Venom hypersensitivity may be mediated by immunologic mechanisms (IgE-mediated or non-IgE-mediated venom allergy) but also by nonimmunologic mechanisms. Reactions to Hymenoptera stings are classified into normal local reactions, large local reactions, systemic toxic reactions, systemic anaphylactic reactions, and unusual reactions. For most venom-allergic patients an anaphylactic reaction after a sting is very traumatic event, resulting in an altered health-related quality of life. Risk f...

Based on the knowledge of the living conditions and habitat of social Aculeatae a series of recommendations have been formulated which can potentially greatly minimize the risk of field re‐sting. After a systemic sting reaction, patients should be referred to an allergy specialist for evaluation of their allergy, and if necessary venom immunotherapy (VIT). An emergency medical kit should be supplied, its use clearly demonstrated and repeatably practised until perfected. This should be done under the supervision of a doctor or a trained nurse. Epinephrine by intramuscolar injection is regarded as the treatment of choice for acute anaphylaxis. H1‐antihistamines alone or in combination with corticosteroids may be effective in mild to moderate reactions confined to the skin and may support the value of treatment with epinephrine in full‐blown anaphylaxis. Up to 75% of the patients with a history of systemic anaphylactic sting reaction develop systemic symptoms once again when re‐stung. Venom immunotherapy is a highly effective treatment for individuals with a history of systemic reaction and who have specific IgE to venom allergens. The efficacy of VIT in yellow jacket venom allergic patients has been demonstrated also by assessing health‐related quality of life. If both skin tests and serum venom specific IgE turn negative, VIT may be stopped after 3 years. After VIT lasting 3–5 years, most patients with mild to moderate anaphylactic symptoms remain protected following discontinuation of VIT even with positive skin tests. Longer term or lifelong treatment should be considered in high‐risk patients. Because of the small but relevant risk of re‐sting reactions, in these patients, emergency kits, including epinephrine auto‐injectors, should be discussed with every patient when stopping VIT.

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