An algorithm for safe de‐labelling of antibiotic allergy in adult hospital in‐patients

Tackling inappropriate penicillin allergy labelling is important because a “penicillin allergy” label potentially leads to the use of sub‐optimal alternative antibiotics (e.g. vancomycin instead of flucloxacillin) and is associated with poorer outcomes including increased risk of Clostridioides (C) difficile, antimicrobial resistant infections, longer hospital stay and other adverse events^1,2. It is therefore beneficial to assess whether patients have experienced a true allergic reaction and to consider removing their allergy label. Increasing evidence supports removal of penicillin allergy status by non‐specialists using an oral challenge test. The Scottish Antimicrobial Prescribing Group (SAPG) therefore convened a multi‐professional steering group including lay representatives to scope, develop and test a process for penicillin allergy de‐labelling (PADL) across several hospitals. TheScoping work involved audits (supplementary material) to confirm the prevalence and nature of reported penicillin allergy in the Scottish in‐patient population and a systematic review of the safety and efficacy of oral challenge3. Risk assessment development involved development of a risk algorithm (Figure 1) using an iterative process along with supporting information for clinical teams and patients (Additional Figure 1 supplementary material). Pilot of PADL process involved in‐patients in medical wards (Infectious Diseases, Respiratory, Medical Admissions) or attending pre‐operative assessment clinics. Patients who were immunocompromised were not included. Suitable patients were identified using the algorithm, and provided written consent for oral challenge after reading an information leaflet and discussing with the clinical team. These teams included training grade medical staff and the majority of the PADL oral challenges were supervised by infectious disease teams (consultants, registrars and nurses). Clinicians involved in the pilot and patients who participated were given the opportunity to provide feedback on their experience of the process.