Quality and Consistency of Penicillin Allergy Delabelling Guidelines: A Systematic Review

This systematic review compared the scope, purpose, and recommendations of internationally published penicillin allergy delabelling guidelines (PADLGs) and assessed their quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

A systematic search of MEDLINE, EMBASE, and CINAHL databases, and Google, Google Scholar, websites of professional allergy societies (n = 95), and guideline repositories (n = 16) was conducted to August 2024.

Any document that reported itself as being an evidence-based guideline, practice guideline, expert recommendation, consensus statement, position paper, or practice parameter for penicillin allergy delabelling ('PADL-G') was eligible for inclusion. Only those developed for use by health care professionals were included. Guidelines for community or patient use and hospital protocols or fact sheets were excluded.

Eighteen guidelines published between 2014 and 2024 were identified, representing 12 countries across four regions. PADLGs varied in scope, target users, and clinical recommendations, both within and across clinical settings. Most provided recommendations for risk stratification, testing, and delabelling methods, with many supporting direct delabelling/direct challenge in low-risk patients. Substantial variation was observed in risk assessment tools, eligibility criteria, and post-test delabelling strategies. Overall, the quality of PADLGs was low, with only two meeting predefined high-quality criteria. Critical gaps included limited methodological rigour, poor stakeholder involvement, and lack of guidance for real-world implementation.

To support safe and scalable PADL approaches, clearer, more consistent, and methodologically robust guidelines are needed to address the global burden of inappropriate penicillin allergy labels.

The protocol for this review was prospectively registered at Open Science Framework: osf.io/9fvr7.