Penicillin allergy delabeling: Opportunities for implementation and dissemination

Although existing as a safety measure to prevent iatrogenic harm, unconfirmed penicillin allergy labels have a negative impact on personal and public health. One downstream effect of unconfirmed penicillin allergy is the continued emergence and transmission of resistant bacteria and their associated health care costs. Recognizing the consequences of inaccurate penicillin allergy labels, professional and public health organizations have started promoting the adoption of proactive penicillin allergy evaluations, with the ultimate goal of removing the penicillin allergy label when the allergy is disproved, also known as penicillin allergy "delabeling." A penicillin allergy evaluation includes a comprehensive allergy history often followed by drug challenge, sometimes with preceding skin testing. Currently, penicillin allergy delabeling is largely carried out by allergy specialists in outpatient settings. Penicillin allergy delabeling is performed on inpatients, albeit rarely, often at the time of need, as a point-of-care procedure. Access to penicillin allergy evaluation services is limited. Recent studies demonstrate the feasibility of expanding penicillin allergy evaluations and delabeling to internists, pediatricians, emergency medicine physicians, infectious diseases specialists, and clinical pharmacists. However, reducing the impact of mislabeled penicillin allergy will require comprehensive efforts and new investments. In this review, we summarize the current practices of penicillin allergy delabeling and discuss expansion opportunities for penicillin allergy delabeling as quality improvement.