Penicillin Allergy De-Labeling in Older Adults and Long-Term Care Residents: A Clinical Review

Penicillin allergy labels are common in older adults and long-term care (LTC) residents, contributing to inappropriate antibiotic use, adverse outcomes, and increased healthcare costs. This review examines the prevalence, impact, safety, and barriers to penicillin allergy evaluation and de-labeling in these populations.

This review synthesizes findings from studies on penicillin allergy prevalence, evaluation, and de-labeling practices in older adults and LTC settings. Articles were identified using searches in PubMed, Embase, and Cochrane databases. Key data presented include de-labeling prevalence, safety of testing strategies including direct oral challenges, and barriers to implementation.

Older adults and LTC residents exhibit higher penicillin allergy label prevalence than other populations, though true penicillin allergies are confirmed in a minority of tested individuals. Penicillin allergy labels result in reliance on second-line antibiotics, which can be less effective and more broad-spectrum, leading to increased multidrug-resistant infections, healthcare-associated infections, and higher healthcare costs. Penicillin allergy evaluation using risk stratification and procedures, including direct oral challenges, has been shown to be safe, with minimal adverse reactions in older adults. Many patients with low-risk histories have been shown to be de-labeled by history alone, reducing the need for specialized allergy evaluation and testing. Barriers to implementation of de-labeling in older adults and LTC facilities include resource limitations, knowledge gaps, and safety concerns, whereas facilitators include multidisciplinary support, standardized protocols, and patient engagement.

Penicillin allergy evaluation and de-labeling of inaccurate penicillin allergies in older adults and LTC settings is both feasible and safe, offering substantial benefits for individual patient care and broadly for antibiotic stewardship. Addressing implementation barriers through standardized protocols, provider education, and multidisciplinary collaboration may improve adoption and outcomes.