Rising to the Challenge: An ID Provider–Led Initiative to Address Penicillin Allergy Labels at a Large Veterans Affairs Medical Center

Abstract

Background Given the negative consequences associated with a penicillin allergy label, broader penicillin allergy delabeling initiatives are highly desirable but hindered by the shortage of allergists in the United States. To address this problem at our facility, the Infectious Diseases section introduced a quality improvement initiative to evaluate and remove allergy labels among inpatient veterans. Methods Between November 15, 2022 and December 15, 2023, we identified inpatients with a penicillin allergy label. We subsequently interviewed eligible candidates to stratify penicillin allergy risk and attempt to remove the allergy label directly via chart review, following inpatient oral amoxicillin challenge or outpatient community care allergy referral. Delabeling outcomes, subsequent penicillin-class prescriptions, and relabeling were tracked after successful allergy label removal. Results We screened 272 veterans of whom 154 were interviewed for this intervention. A total of 53 patients were delabeled—26 directly, 23 following oral amoxicillin challenge, and 4 following outpatient allergy referrals. Of the patients who were delabeled, 25 received subsequent penicillin-class prescriptions. No adverse reactions occurred following inpatient oral amoxicillin challenges. Patients with a low-risk penicillin allergy history were more likely to undergo a challenge if admitted with an infectious diseases-related condition. Only one inappropriate relabeling event occurred during the study period, which was subsequently corrected. Conclusions An Infectious Diseases provider–led initiative resulted in penicillin allergy label removal in over a third of inpatients evaluated using direct removal or oral amoxicillin challenge. Efforts focused on patients who had been admitted for infections were particularly successful.