D1.381 - Antibiotic Allergy De-labelling in Children: Outcomes of Drug Provocation Testing and Feasibility of Non-Specialist Pathways to de-labelling

Penicillin allergy is reported in approximately 5.6% of the population; however, true allergy is significantly less common in children than in adults. Many children are inaccurately labelled as penicillin-allergic without formal evaluation, and these labels frequently persist into adulthood. This leads to poor antibiotic stewardship, suboptimal treatment choices, and increased morbidity. Drug provocation testing (DPT) remains the gold standard for confirming or excluding drug allergy but is largely limited to specialist allergy services with constrained capacity. In 2022, the British Society for Allergy and Clinical Immunology (BSACI) published guidelines to support penicillin allergy de-labelling by non-allergists in hospital settings.

Aims

To evaluate outcomes of paediatric DPTs performed in a specialist allergy clinic and to retrospectively assess patient suitability for DPT in non-specialist hospital settings using BSACI risk stratification criteria.

Methods

A retrospective case note audit was conducted of paediatric DPTs performed between December 2019 and May 2025. Data collected included culprit drug, index reaction history, and DPT outcome. Initial reaction histories were retrospectively assessed against BSACI-defined low-risk symptoms and exclusion criteria to determine suitability for non-specialist DPT pathways.

Thirty-three DPTs were included, of which 23 (69%) were performed for suspected antibiotic allergy. All antibiotic DPTs were negative, allowing successful de-labelling. One child developed delayed symptoms post-challenge, and one patient is awaiting further intravenous cephalosporin challenge in an adult allergy service. Retrospective risk stratification demonstrated that 4 patients (17%) met criteria for safe DPT in a non-specialist hospital setting.

Drug provocation testing is a safe and effective method for confirming or excluding suspected drug allergy in appropriately selected paediatric patients. Application of validated risk stratification tools and robust safety protocols may allow extension of DPTs into non-specialist hospital environments, such as emergency departments or paediatric assessment units, improving access to de-labelling and reducing unnecessary lifelong penicillin allergy labels. A local quality improvement programme has been initiated to support this approach.