Figure 1

Algorithm for the selection of venom for immunotherapy. A. Reliable visual identification of the culprit stinging insect or sufficiently certain identification based on additional sting-related information (patient’s location and activity, time of the year, presence of a stinger left in the skin): administer single VIT. B. Culprit insect not identified: administer single VIT in mono sensitized patients or if sensitization to a single venom is significantly stronger than to the other (i.e. at least one serological class and one concentration step in intradermal tests). Administer double VIT in patients with equal reactivity to both venoms. C. Patients reporting anaphylaxis to stings of both insects: administer single VIT in mono sensitized patients. Administer double VIT in all patients with double sensitization.* Consider double VIT if additional risk factors are present (e.g. comorbidities, severe anaphylaxis to index sting, high degree of exposure). Dashed boxes: patients receiving double VIT were not eligible for study inclusion.