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Inpatient Penicillin Allergy Evaluation-Skin Testing Versus Direct Oral Challenge?

Deanna L McDanel1, Elise A Mitri2, James T Li3

  • 1Department of Internal Medicine, Division of Immunology, University of Iowa Health Care, Iowa City, Iowa; Department of Pharmacy, Division of Immunology, University of Iowa Health Care, Iowa City, Iowa; Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, Iowa.

The Journal of Allergy and Clinical Immunology. in Practice
|December 20, 2025
PubMed
Summary
This summary is machine-generated.

Penicillin allergy labels are common. Evaluating these allergies using penicillin skin testing (PST) or direct oral challenge (DOC) helps safely "delabel" patients, improving antibiotic use and reducing resistance.

Keywords:
Antimicrobial stewardshipBeta-lactam allergyDelabelingDrug challengeInpatientPenicillin allergySkin testing

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Area of Science:

  • Clinical Medicine
  • Infectious Diseases
  • Pharmacology

Background:

  • Penicillin allergy labels are frequently applied to patients requiring antibiotics, impacting treatment outcomes and public health.
  • Mislabeled allergies can lead to suboptimal antibiotic choices, increasing side effects and antimicrobial resistance, especially in hospitals.

Purpose of the Study:

  • To compare the advantages and disadvantages of penicillin skin testing (PST) and direct oral challenge (DOC) for penicillin allergy evaluation in inpatient settings.
  • To inform strategies for safe and effective "delabeling" of penicillin allergies to optimize antibiotic stewardship.

Main Methods:

  • Review of penicillin allergy evaluation strategies, focusing on penicillin skin testing (PST) and direct oral challenge (DOC).
  • Analysis of factors influencing the choice between PST and DOC, including risk stratification, resource availability, and provider/patient comfort.
  • Discussion of the pros and cons of each approach in the context of inpatient care.

Main Results:

  • Penicillin skin testing (PST) is the historical gold standard, safe for all risk groups but requires specialized training and resources.
  • Direct oral challenge (DOC) is simpler and effective for low-risk patients but carries higher risks if patient selection is not precise.
  • Both PST and DOC aim to safely "delabel" penicillin allergies but differ in process and limitations.

Conclusions:

  • Routine penicillin allergy evaluation is crucial for effective antibiotic stewardship in hospitals.
  • The choice between PST and DOC depends on patient risk, available resources, and clinical setting.
  • Optimizing penicillin allergy assessment can improve antibiotic prescribing and combat antimicrobial resistance.