ABSTRACT

Objective

Anaphylaxis is a life-threatening reaction characterized by sudden symptoms affecting different organ systems, and healthcare professionals must recognize and urgently treat anaphylaxis. In this study, we aimed to evaluate the knowledge and attitudes of family physicians in Türkiye about the diagnosis and treatment of anaphylaxis, use of adrenaline auto-injector, and factors affecting these attitudes.

Methods

This was a cross-sectional descriptive survey study. An online questionnaire was administered to family physicians to evaluate their knowledge levels regarding the diagnosis and treatment of anaphylaxis and the use of AAI.

Results

The study was completed with 207 participants, mean age was 33.8±8.5 years and mean professional experience was 8.5±8.3 years. 93.7% of the participants stated that the first-line treatment of anaphylaxis was adrenaline, 85.5% the correct route of adrenaline administration was intramuscular, 79.2% the right place of adrenaline administration, 75.4% the dose of adrenaline in children, 61.8% of them answered the adrenaline dose correctly in adults. 51.2% of the participants stated that they knew about the use of AAI, and 24.6% had received training on this subject. The average number of professional years of participants who knew that the first-line treatment was adrenaline, the correct route and place of administration of adrenaline, and knew how to use auto-injectors were statistically significantly lower (p=0.031, p<0.001, p<0.001, p=0.041, respectively). Family physicians who received post-graduation training on anaphylaxis; the rate of knowing that the first-line treatment of anaphylaxis was adrenaline, the correct route and place of administration of adrenaline, and the rate of knowing the use of auto-injectors were statistically significantly higher (p=0.013, p=0.037, p=0.024, p=0.011, respectively).

Conclusion

The most significant outcome of our study is family physicians’ knowledge of the diagnosis and treatment of anaphylaxis is higher when their training at medical faculty and specialist training is more recent and when they undergo post-graduation training. With post-graduation training programs, family physicians can become more competent in life-threatening anaphylaxis. However, physicians’ knowledge of adrenaline auto-injector therapy is insufficient. Family physicians should be trained on the use of this essential and life-saving drug for those at risk of anaphylaxis.

INTRODUCTION

Anaphylaxis is a life-threatening condition characterized by the acute onset of symptoms involving different organ systems, and it requires immediate medical intervention. All healthcare professionals need to recognize and treat anaphylaxis (1). With correct and rapid treatment, the risk of mortality can be minimized.

Estimated prevalence is 0.3-5.1% according to diagnostic criteria used in previous studies (2). Although the frequency of hospitalization due to food-and drug-induced anaphylaxis has increased in recent years, death from anaphylaxis remains very infrequent and stands at 0.35-1.06 deaths per million people per year, with no increase observed in the last 10 years (2, 3).

The clinical signs and symptoms of anaphylaxis are highly variable, depending on the organ and system affected. Skin and mucosal symptoms occur most frequently (>90% of cases), followed by symptoms involving the respiratory and cardiovascular systems (>50% of cases) (1). The prevalence of various causes of anaphylaxis is age-dependent and varies in different geographical regions. Food, drug, and Hymenoptera venom are the most common factors of anaphylactic reactions (4, 5). Anaphylaxis in children is most commonly caused by food, and bronchospasm is a common symptom. There is usually a background of atopy and asthma. In adults, venom- and drug-induced anaphylaxis are more common, and hypotension is more likely to occur (6).

In patients with previous anaphylaxis, it is essential to educate the patient and family about allergen avoidance. Adrenaline auto-injectors (AAI) should be recommended for emergency use in appropriate patients, and patients should be educated about their use (1). It is important that family physicians performing primary health care recognize and treat the signs and symptoms of anaphylaxis, a rare but life-threatening condition.

In this study, we aimed to evaluate the knowledge and attitudes of family physicians in Türkiye about the diagnosis and treatment of anaphylaxis and use of AAI and the factors affecting these attitudes.

METHODS

The study was conducted as a cross-sectional descriptive survey between June 2022 and August 2022. The questionnaire was prepared by a specialist family physician and pediatric allergist based on current information. The survey, consisting of 31 questions prepared online using the Google Forms application, was sent to family physicians via social media (WhatsApp) and e-mail. The first part of the survey included the purpose and content of the study and the information and consent of the researchers. Participants who provided consent answered the survey questions fully.

The contents of the questions in the survey were as follows:

1. Questions to determine demographic information, such as gender, age, and professional years.

2. Questions about whether he received post-graduation education on anaphylaxis.

3. General information about anaphylaxis (most common causes of anaphylaxis), diagnosis (clinical symptoms), and questions about experience (previous encounter with an anaphylaxis patient and treatment of an anaphylaxis patient).

4. Questions about anaphylaxis treatment (positioning of the anaphylaxis patient, first-line drug in anaphylaxis, method-place-dose of adrenaline administration).

5. Question about whether the institution where you work has the necessary drugs and equipment for anaphylaxis treatment.

6. There are questions to determine their knowledge and experience regarding the use of AAI.

Study Population

Family physicians actively working in Türkiye were included. The study was completed with 207 participants who participated in the survey.

Statistical Analysis

The data were analyzed using International Business Machines Statistical Package for the Social Sciences statistics 22.0. Kolmogorov-Smirnov test was used for the normal distribution of data. The mean differences between two groups with variables that are not distributed normally was assessed using Mann-Whitney U test. The distribution of categorical variables between groups were analyzed using χ² (chi-square) test. Mean, standard deviation, median (1^st and 3^rd, 4^st), frequency, and percentage are descriptive statistics. The threshold of statistical significance was regarded as p<0.05.

Ethical Issues

This study was approved by the Bezmialem Vakıf University Rectorate Non-interventional Research Ethics Committee (approval number: 2021/173, date: 19.05.2021). The study was conducted according to the principles of the Declaration of Helsinki.

RESULTS

The study was completed with 207 participants, and 58.5% (n=121) of them were female. Their mean age was 33.8±8.5 years (range 24-67 years), and their mean professional experience was 8.5±8.3 years (range 1-43 years). The rate of postgraduate training on anaphylaxis was 40.6% (n=84). Approximately half of the participants (47.3%, n=98) encountered anaphylaxis patients, and 38.6% (n=80) took part in the treatment of anaphylaxis patients. In Family Health Centers, the availability of drugs and equipment was assessed to evaluate the capacity of treating patients with anaphylaxis (Figure 1). Adrenaline was present in 98.6% (n=204), and the least available drug was glucagon (30%, n=62).

General Information About Anaphylaxis and Its Affecting Factors

The majority of participants correctly identified the most common cause of anaphylaxis in children and adults (food in children 76.8%, n=159, drugs in adults 79.2%, n=164). Furthermore, 30.4% of family physicians knew that all of the signs and symptoms given in the questionnaire could be during anaphylaxis (n=63). This rate was not statistically significantly associated with age, professional experience, and post-graduate education (p=0.564, p=0.426, p=0.454 respectively). The proportion of family physicians who were involved in the treatment of patients with anaphylaxis was significantly higher than that of those who were not involved in the treatment (p=0.03). The signs and symptoms most associated with anaphylaxis were dyspnea (96.6%, n=200), hypotension (94.7%, n=196), and angioedema (94.2%, n=195). The ratio of family physicians to signs and symptoms in the questionnaire regarding anaphylaxis is shown in Figure 2.

Knowledge and Factors Affecting Anaphylaxis Treatment

Participants knew correctly as correct position to be given to the patient during anaphylaxis (if there is no respiratory distress, lay the patient on his back and raise his feet at an angle of 30-45 degrees) in an 81.6% ratio. 93.7% of the participants stated that the first-line treatment of anaphylaxis was adrenaline, 85.5% the correct route of adrenaline administration was intramuscular, 79.2% the right place of administration of adrenaline, 75.4% the dose of adrenaline in children, and 61.8% of them answered the adrenaline dose correctly in adults.

The average age and professional years of the participants who knew the right route of adrenaline administration and the right place of administration of adrenaline were statistically significantly lower (p<0.001, p<0.001, p<0.001, p<0.001, respectively). The average number of professional years of physicians who knew that the first drug to be administered was adrenaline was statistically significantly less (p=0.031). The results are shown in Table 1.

Family physicians who received post-graduation training on anaphylaxis; the rate of knowing that the first drug to be administered in the treatment of anaphylaxis was adrenaline, the correct route of administration of adrenaline, and the right place of administration of adrenaline were significantly higher (p=0.013, p=0.037, p=0.024, respectively).

Family physicians giving correct answers to questions about the diagnosis and treatment of anaphylaxis; the statistical relationship between age, professional year, post-graduate training in anaphylaxis, and participation in anaphylaxis treatment is presented in Table 1.

Knowledge and Factors Affecting the Use of AAI

The mean age and professional experience of family physicians who stated that they knew how to use auto-injectors were lower (p=0.006, p=0.041, respectively). The rate of knowing the use of auto-injectors was significantly higher among those who received postgraduate education on anaphylaxis (p=0.011).

The statistical relationships between family physicians’ AAI usage information, age, professional experience, post-graduate training on anaphylaxis, and participation in anaphylaxis treatment are presented in Table 2.

DISCUSSION

Anaphylaxis is an acute life-threatening emergency condition that requires immediate treatment to prevent further progression and complications. In our country, some medical interventions, including childhood and adult vaccination practices and intramuscular injections, are carried out at family health centers that are established for primary health care. Therefore, it is vital for family health centers to possess essential medications and equipment as well as for family physicians to be competent in the diagnosis and treatment of anaphylaxis.

Knowledge of Family Physicians Regarding Anaphylaxis Diagnosis, Treatment and AAI

Approximately one-third of the participants in our study knew that all symptoms and clinical findings may occur during anaphylaxis. These results indicate that the multiorgan and multisystem findings of anaphylaxis are not sufficiently valuable. Under these circumstances, underdiagnosis and undertreatment may occur. Many studies have reported the underdiagnosis and undertreatment of anaphylaxis (7, 8).

Nearly all family physicians in our study (93.7%) considered adrenaline as a first-line treatment for anaphylaxis. This ratio is similar to a study on family physicians in our country (9), whereas two other studies report significantly lower percentage of 50% (10, 11). Research on different health professionals reported similar and lower ratios (12-19).

Most of our participants knew the correct route (85%) and location (79%) of adrenaline administration, although their knowledge of the correct dose (for pediatric dose 75% and for adult dose 61%) was inadequate. Nevertheless, the ratios in 2 other studies on family physicians in our country were lower (9, 11). Similar or lower results have been reported in studies including different health professionals (12, 17-23). Most of our participants were informed about the correct positioning of patients with anaphylaxis, whereas the literature results were lower (19).

The average professional experience of participants who knew adrenaline was a first-line drug in the treatment of anaphylaxis and could administer adrenaline by correct route and location was significantly lower in our study. This may be the result of more recent and up-to-date education for younger physicians. Additionally, the former recommendation of subcutaneous administration of adrenaline in the treatment of anaphylaxis may have an impact on the less accurate knowledge of senior physicians regarding the correct administration route. The research proposes that at any age, adrenaline reaches the maximal plasma concentration when administered IM rather than SC route (24, 25). Thus, adrenaline is recommended to be administered to the lateral thigh by the IM route according to current guidelines (1, 26). Another study on family physicians in our country found significantly higher rates of knowledge of the correct route and site of administration of adrenaline in the group with less professional experience, whereas no significant difference was determined for the knowledge of adrenaline as first-line treatment (9). In another study including general practitioners, no difference was demonstrated accordingthe general practitioners no difference according to professional experience in terms of knowledge of adrenaline as a first-line treatment and its proper route of administration (10). On the contrary, in a comprehensive survey conducted on healthcare professionals in Mexico, the most correct answers were among those with professional experience over 30 years (19).

Anaphylaxis is a recurring condition, so AAI must be prescribed to those that experience anaphylaxis, and they should be trained on how to use it. Healthcare professionals who care for patients at risk of anaphylaxis should also be educated on the use of AAI. Half of the family physicians in our study stated that they knew how to use and obtain adrenaline auto-injector and would prescribe it to patients with anaphylaxis. Nevertheless, only a quarter of the participants had undergone training on the use of adrenaline auto-injector. Our survey was conducted online and was based on the statements of the physicians; their proficiency could not be evaluated. Therefore, comparisons with other studies are not applicable. Knowledge regarding the correct use of AAI was found to be inconclusive in studies conducted on healthcare professionals working in primary, secondary, or tertiary healthcare centers in our country and worldwide (27-30). The rate of prescribing adrenaline to patients who develop anaphylaxis has increased over time (31) but is still insufficient (32-35).

Factors Affecting the Knowledge of Family Physicians About Anaphylaxis Diagnosis, Treatment, and AAI

In our survey, the rate of knowledge of adrenaline as the first-line treatment in anaphylaxis, the correct route and site of administration of adrenaline, the use of adrenaline auto-injector, and how to obtain it was higher among family physicians who had undergone training on anaphylaxis during residency and after graduation. This finding clearly indicates the need for post-graduate education programs on anaphylaxis to allow physicians to update their knowledge. Less than half of our participants had undergone postgraduate education on anaphylaxis. This is considered inadequate. When the proficiency levels of those who underwent training and those who did not are compared, the necessity for periodic and comprehensive training for updating should be considered. In a similar study of different healthcare professionals, the ratio of family physicians to receive training on anaphylaxis was lower than that of other groups (12).

Most family physicians referred patients with anaphylaxis to pediatric or adult allergy and immunology clinics. The guidelines recommend the referral of patients with anaphylaxis to allergy and immunology specialists for confirmation of the suspected trigger, counseling on preventive measures, and use of allergen immunotherapy (i.e., bee venom) when necessary (1, 26).

CONCLUSION

The most significant outcome of our study is family physicians’ knowledge of the diagnosis and treatment of anaphylaxis is higher when their training at medical faculty and residency is more recent and when they undergo post-graduate training. Therefore, in-service training programs may increase the competency of physicians in handling life-threatening anaphylaxis. The physicians’ knowledge of adrenaline auto-injector treatment is inadequate. Family physicians should be trained on the use of this basic life-saving drug for those at risk of anaphylaxis.

References

Muraro A, Worm M, Alviani C, Cardona V, DunnGalvin A, Garvey LH, et al. EAACI guidelines: Anaphylaxis (2021 update). Allergy. 2022;77:357-7.

Tejedor Alonso MA, Moro Moro M, Múgica García MV. Epidemiology of anaphylaxis. Clin Exp Allergy. 2015;45:1027-39.

Turner PJ, Gowland MH, Sharma V, Ierodiakonou D, Harper N, Garcez T, et al. Increase in anaphylaxis-related hospitalizations but no increase in fatalities: an analysis of United Kingdom national anaphylaxis data, 1992-2012. J Allergy Clin Immunol. 2015;135:956-63.

Francuzik W, Ruëff F, Bauer A, Bilò MB, Cardona V, Christoff G, et al. Phenotype and risk factors of venom-induced anaphylaxis: A case-control study of the European Anaphylaxis Registry. J Allergy Clin Immunol. 2021;147:653-62.

Aurich S, Dölle-Bierke S, Francuzik W, Bilo MB, Christoff G, Fernandez-Rivas M, et al. Anaphylaxis in elderly patients data from the European Anaphylaxis Registry. Front Immunol. 2019;24:750.

Brown SG, Mullins RJ, Gold MS. Anaphylaxis: diagnosis and management. Med J Aust. 2006;185:283-9. Erratum in: Med J Aust. 2006;185:400

Kastner M, Harada L, Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature. Allergy. 2010;65:435-44.

Waserman S, Chad Z, Francoeur MJ, Small P, Stark D, Vander Leek TK, et al. Management of anaphylaxis in primary care: Canadian expert consensus recommendations. Allergy. 2010;65:1082-92.

Özkars MY. Anaphylaxis from the eyes of family physicians. J Curr Pediatr. 2019;17:34-44.

Bekdaş M, Dilek M, Açıkel E, Ağalday B, Erkoçoğlu M. Knowledge regarding diagnosis and treatment of anaphylaxis. Pamukkale Medical Journal. 2014;7:202-8.

Erkoçoğlu M, Civelek E, Azkur D, Özcan C, Öztürk K, Kaya A, et al. Knowledge and attitudes of primary care physicians regarding food allergy and anaphylaxis in Turkey. Allergol Immunopathol (Madr). 2013;41:292-7.

Sipahi Cimen S, Sayili SB. Level of knowledge among healthcare professionals regarding anaphylaxis. Asia Pac Allergy. 2022;12:e41.

Grossman SL, Baumann BM, Garcia Peña BM, Linares MY, Greenberg B, Hernandez-Trujillo VP. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey. J Pediatr. 2013;163:841-6.

Adiga S, Nayak V, Bairy KL. Treatment of anaphylaxis in adults: a questionnaire survey. Online J Health Allied Sci. 2008;7:3474-9.

Yıldız R, Gökmirza Özdemir P, Süt N, Yazıcıoğlu M. Physicians Working At Different Clinical Settings: Can They Recognize and Manage Anaphylaxis? Osmangazi Journal of Medicine. 2022;44:112-9.

Altman AM, Camargo CA Jr, Simons FE, Lieberman P, Sampson HA, Schwartz LB, et al. Anaphylaxis in America: A national physician survey. J Allergy Clin Immunol. 2015;135:830-3.

Baççıoğlu A, Yılmazel Uçar E. Level of knowledge about anaphylaxis among health care providers. Tuberk Toraks. 2013;61:140-6.

El-Sayed ZA, El-Owaidy R, Hussein SM, Hossam D, El-Sawi IH, Adel A, et al. Physicians’ knowledge and practice concerning diagnosis and management of anaphylaxis: The situation in Egypt. Afr J Emerg Med. 2021;11:464-70.

González-Díaz SN, Villarreal-González RV, Fuentes-Lara EI, Salinas-Díaz MDR, de Lira-Quezada CE, Macouzet-Sánchez C, et al. Knowledge of healthcare providers in the management of anaphylaxis. World Allergy Organ J. 2021;14:100599.

Fakheri S, Movahedi M, Gharagozlou M, Marashi SM, Baççıoğlu A. Pediatrican and pediatric residents’ knowledge about anaphylaxis in teaching hospitals of Tehran University of Medical Sciences. Med J Mashhad Univ Med Sci. 2017;60:359-68.

Haymore BR, Carr WW, Frank WT. Anaphylaxis and epinephrine prescribing patterns in a military hospital: underutilization of the intramuscular route. Allergy Asthma Proc. 2005;26:361-5.

Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J. 2007;120:U2492.

Plumb B, Bright P, Gompels MM, Unsworth DJ. Correct recognition and management of anaphylaxis: not much change over a decade. Postgrad Med J. 2015;91:3-7.

Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol. 1998;101:33-7.

Simons FE, Gu X, Simons KJ. Epinephrine absorption in adults: intramuscular versus subcutaneous injection. J Allergy Clin Immunol. 2001;108:871-3.

Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020;13:100472.

Arga M, Bakırtaş A, Türktaş İ, Demirsoy MS. Do pediatricians and the pediatric residents know how to use adrenalin autoinjector? Asthma Allergy Immunol. 2009;7:26-31.

Mehr S, Robinson M, Tang M. Doctor-how do I use my EpiPen? Pediatr Allergy Immunol. 2007;18:448-52.

Grouhi M, Alshehri M, Hummel D, Roifman CM. Anaphylaxis and epinephrine auto-injector training: who will teach the teachers? J Allergy Clin Immunol. 1999;104:190-3.

Sicherer SH, Forman JA, Noone SA. Use assessment of self-administered epinephrine among food-allergic children and pediatricians. Pediatrics. 2000;105:359-62.

Fuzak JK, Trainor J. Comparison of the incidence, etiology, and management of anaphylaxis over time. Pediatr Emerg Care. 2013;29:131-5.

Clausen SS, Stahlman SL. Food-allergy anaphylaxis and epinephrine autoinjector prescription fills, active component service members, U.S. Armed Forces, 2007-2016. MSMR. 2018;25:23-9.

Clark S, Bock SA, Gaeta TJ, Brenner BE, Cydulka RK, Camargo CA, et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;113:347-52.

Clark S, Long AA, Gaeta TJ, Camargo CA Jr. Multicenter study of emergency department visits for insect sting allergies. J Allergy Clin Immunol. 2005;116:643-9.

Sclar DA, Lieberman PL. Anaphylaxis: underdiagnosed, underreported, and undertreated. Am J Med. 2014;127(1 Suppl):1-5.

Evaluation of Knowledge of Family Physicians on the Diagnosis and Treatment of Anaphylaxis and Adrenaline Auto-injector Use in Türkiye