Penicillin Allergy Evaluation and Delabeling in Nursing Homes: An Implementation Science-Guided, Multi-stakeholder Qualitative Study

Penicillin allergy labels (PALs) are common and often inaccurate, contributing to suboptimal antibiotic prescribing and adverse outcomes. These challenges are particularly pronounced in nursing homes (NH), where PAL prevalence and antibiotic exposure are high, yet penicillin allergy evaluation and delabeling are rarely implemented and stakeholder perspectives are poorly understood. We sought to identify barriers and facilitators to implementing penicillin allergy evaluation and delabeling in NH, incorporating resident, caregiver, and healthcare professional (HCP) perspectives.

Between July and December 2025, we conducted semi-structured interviews with NH residents, a caregiver, and HCPs across 5 Massachusetts facilities. Interview guides were informed by the updated Consolidated Framework for Implementation Research. Data were analyzed using rapid thematic analysis with a structured matrix approach.

Twenty-five participants (13 residents, 1 caregiver, 11 HCPs) were included. Five cross-cutting themes emerged: (1) PALs persist unquestioned, (2) skepticism about labels coexists with reluctance to delabel, (3) structural barriers are decisive, (4) feasibility is facility- and method-specific, and (5) education and trust enable engagement, but receptiveness cannot be assumed. HCPs cited residents' cognitive impairment as a barrier, yet 13 of 21 residents screened could provide meaningful histories and participate in decision-making. History-based assessment was considered most feasible, whereas views on direct oral challenge and skin testing were divided.

Many NH residents can engage in penicillin allergy evaluation; capacity should be assessed individually. Implementation is constrained primarily by structural barriers rather than lack of interest. Low-resource, history-based, trust-building strategies may support adoption in NH.