Discussion

This survey highlights heterogeneity in PAD practices across U.S. SRN institutions, underscoring both progress and persistent gaps. Although all respondent institutions reported having an ASP, delabeling activities and their implementation varied considerably. While the majority of institutions offered educational materials and tools, access to inpatient allergist consultation remained inconsistent, and delabeling was often led by non-allergist clinicians such as pharmacists and ID specialists. This pattern mirrors national data showing wide disparities in penicillin allergy evaluation resources and infrastructure. ^{Reference Staicu, Vyles and Shenoy3,Reference Mancini, Fu and Zhang4} These findings also emphasize that while clinical guidelines support delabeling efforts, operationalization is constrained by institutional capacity. ^{Reference Staicu, Vyles and Shenoy3,Reference Samarakoon, Accarino, Wurcel, Jaggers, Judd and Blumenthal6} Expanding structured PAD workflow to non-allergist and non-ID providers during routine patient care rounds may help bridge these capacity gaps.

Fewer than half the institutions tracked delabeling outcomes, and only one-third reported the number of patients successfully delabeled. Lack of systematic outcome measurements represents missed opportunities to quantify impact and guide quality improvement. Literature shows that delabeling improves antibiotic selection, reduces broad-spectrum antibiotic use, lowers costs, and minimizes adverse events. ^{Reference Krah, Jones, Lake and Hersh2,Reference Dong, Zembles, Nimmer, Brousseau and Vyles8–Reference Staub, Nelson and Byrge10} Without outcome tracking, institutions cannot demonstrate these benefits or refine processes. Standardizing outcome metrics, such as delabeling rates, relabeling rates, rates of adverse reactions, and antimicrobial spectrum indices, should be a future priority. ^{Reference Dong, Zembles, Nimmer, Brousseau and Vyles8,Reference Staub, Nelson and Byrge10}

Time constraints and lack of trained healthcare personnel remain pervasive barriers, consistent with previous studies highlighting workforce limitations as a key impediment to delabeling scalability. ^{Reference Staicu, Vyles and Shenoy3–Reference Chow, McDanel, Turner and Copaescu5} Non-allergist-led delabeling programs, including pharmacist- or ID specialist-driven programs, have shown the potential to fill this gap. ^{Reference Staicu, Vyles and Shenoy3,Reference Chow, McDanel, Turner and Copaescu5} Incorporating delabeling into existing ASPs, supported by algorithm-driven risk assessment, could facilitate more efficient and sustainable models of care. ^{Reference Chow, McDanel, Turner and Copaescu5,Reference Samarakoon, Accarino, Wurcel, Jaggers, Judd and Blumenthal6}

Despite increasing evidence that EHR-integrated tools can improve allergy documentation, facilitate risk stratification, and support point-of-care delabeling, adoption remains limited. ^{Reference Samarakoon, Accarino, Wurcel, Jaggers, Judd and Blumenthal6,Reference Powell, Elkhalifa, Guyer, Garcez, Sandoe and Zhou7} Enhanced EHR decision support, including automated alerts for eligible patients or integrated risk assessment algorithms, could address barriers related to time constraints and shortages of trained personnel. ^{Reference Samarakoon, Accarino, Wurcel, Jaggers, Judd and Blumenthal6,Reference Powell, Elkhalifa, Guyer, Garcez, Sandoe and Zhou7} However, EHR tool deployment requires system-level investment, leadership buy-in, and alignment among stakeholders.

PAD was infrequently performed in EDs and primary care offices, despite growing evidence that delabeling in these settings is safe, feasible, and may prevent downstream consequences of inaccurate PALs. ^{Reference Staicu, Vyles and Shenoy3,Reference Chow, McDanel, Turner and Copaescu5,Reference Dong, Zembles, Nimmer, Brousseau and Vyles8} Expanding delabeling programs beyond inpatient settings is critical to reaching the large population of patients who have inaccurate PALs and reducing inappropriate antibiotic use across the continuum of care. ^{Reference Staicu, Vyles and Shenoy3,Reference Chow, McDanel, Turner and Copaescu5,Reference Samarakoon, Accarino, Wurcel, Jaggers, Judd and Blumenthal6}

This study has several limitations. First, our survey relied on self-reported data from a convenience sample of SRN institutions, which may be subject to reporting bias. Second, our survey had a relatively small sample size. However, the response rate was consistent with previously published SRN surveys and reflects typical engagement levels for this type of work. Third, although the SRN includes diverse institutions, the sample was predominantly academic medical centers, which may limit generalizability to non-academic or community settings. Lastly, definitions of delabeling, risk stratification, and outcome metrics may vary across institutions, and survey responses may also be subject to interpretation variability. Nonetheless, this study provides important insights into current delabeling practices and barriers across a range of healthcare settings.