Low-risk penicillin allergy delabeling: a scoping review of direct oral challenge practice, implementation, and multi-disciplinary approaches

ABSTRACT

Introduction

Penicillin allergy is common, and there is increased clinician interest in direct oral challenge (DOC) as a testing strategy for low-risk penicillin allergy. To aid wider implementation of DOC, consensus definitions of low-risk penicillin allergy phenotypes, and standardized approaches to assessment, DOC procedures, and evaluation, are required.

Areas covered

This review systematically reviews studies that have utilized penicillin DOC in healthcare settings to identify heterogeneity in implementation approaches and synthesize low-risk definitions, procedures, and evaluation.

Expert opinion

Opportunity exists to standardize penicillin DOC procedures in patients with a low-risk penicillin allergy to optimize antimicrobial prescribing and reduce the burden of penicillin allergy. Standardizing the definitions of ‘low-risk’ and ‘positive challenge,’ and improving the evaluation of patient safety, alongside the development of a unified approach to the structure of undertaking an oral challenge, is likely to increase uptake and confidence among non-allergist clinicians.

KEYWORDS:

• Allergy
• antibiotic
• antimicrobial stewardship
• delabeling
• oral challenge
• penicillin

Article highlights

• Direct oral challenge (DOC) is an increasingly common and effective strategy utilized to delabel low-risk penicillin allergy in hospital inpatient, outpatient, and community settings.

• Significant heterogeneity exists in the definition of a ‘low-risk’ penicillin allergy with numerous validated scales and institution-specific definitions being utilized to assess risk.

• The design of DOC programs is variable, with diverse approaches to challenge drug, dose, observation period, and healthcare discipline performing the procedure.

• In evaluating the outcomes of penicillin DOC, variability exists in the definition of a safe challenge and a positive challenge result.

• Further research, particularly in under-represented populations and settings, is required to progress standardization of the delivery and evaluation of penicillin DOC programs, and to aid implementation, particularly by clinicians involved in antimicrobial stewardship.

Declaration of interest

E Mitri is supported by a PhD Scholarship from the Australian Government funded National Allergy Centre of Excellence (NACE), hosted by the Murdoch Children’s Research Institute (MCRI), and their work was supported by the Victorian Government’s Operational Infrastructure Support Program. G Reynolds receives NHMRC PhD scholarship #2013970. J A Trubiano is supported by the National Health and Medical Research Council Emerging Leadership Fellowship (1139902).

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/14787210.2023.2296068.

Additional information

Funding

This paper was not funded.