A narrative review in the Journal of General Internal Medicine (September 2026) summarises the evidence for delabelling penicillin allergy as routine inpatient practice.
About 10% of patients report a penicillin allergy, yet most can safely take beta-lactams. On the ward, the label drives broader-spectrum antibiotics, more healthcare-associated infection and resistance, longer stays and higher cost. The PEN-FAST decision rule identifies patients at low risk of true allergy. The PALACE randomised trial showed that in low-risk adults, a direct oral penicillin challenge was non-inferior to traditional skin testing, with very low rates of adverse reactions.
The review adds no new data, and it does not replace local allergy services or protocols. But it removes the main barrier: the belief that delabelling requires a skin-test service most hospitals do not have.
For a physician with an inpatient who carries a low-risk label and needs a beta-lactam, a supervised oral challenge is the evidence-based route, and the result belongs in the discharge summary and primary care record.
- Score every inpatient with a penicillin allergy label using PEN-FAST
- Offer a supervised direct oral amoxicillin challenge to low-risk patients, following local protocol
- Refer patients with a history of severe reactions — anaphylaxis, severe skin reactions or organ involvement — to allergy services instead
- Remove the label in the hospital record and tell the patient and their GP in writing
- Treat a vague or childhood-only reaction as a prompt to assess, not a reason to avoid beta-lactams
Why it matters
It turns delabelling from a specialist service into something a ward team can do, with a direct effect on antibiotic choice and resistance.
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