Discussion

We demonstrated that a nurse-initiated penicillin allergy questionnaire can be successfully implemented to delabel or relabel inpatients with penicillin allergy labels based on history alone, without skin testing or oral challenge. Although only a small proportion of patients were delabeled with this questionnaire, these were patients who otherwise were not likely to have had their penicillin allergy labels removed during their hospital admission. This nurse-led and history-driven approach to delabeling also has the additional benefit of not requiring the cost, time, and resources of specialist testing in the appropriate setting. We have shown that nurses can play a key role in allergy assessment, which is critical for designing an interprofessional antimicrobial stewardship approach. ^{Reference Carter, Greendyke and Furuya6–8} Some nurses may be hesitant to override documented drug allergies, but our intervention was performed by nurse leaders and incorporated specialist physician validation, which may be important in implementing a nurse-led intervention. ^{Reference Carter, Greendyke and Furuya6,Reference Powell, Wilcock, Roberts, Sandoe and Tonkin-Crine9} An additional benefit to the nurse-initiated process is that it provided patients with allergy education and an opportunity to undergo further outpatient evaluation, thus having a potentially larger impact beyond bedside evaluation. One limitation of our study was that we did not assess uptake of outpatient allergy evaluation when offered in this context or the long-term durability of delabeling, both of which should be assessed in future interventions.

Interestingly, some patients declined delabeling, with a substantial proportion giving reasons that suggested a lack of trust or interest in allergy delabeling by history. Only some of these patients were amenable to outpatient allergy evaluation and/or skin testing, and others did not ever want their label removed or did not think it was important. Although limited by a small sample size, our findings supplement other studies in highlighting potential patient barriers to penicillin allergy evaluation and delabeling. ^{Reference Powell, Wilcock, Roberts, Sandoe and Tonkin-Crine9,Reference Wanat, Anthierens and Butler10} These findings suggest that effective interventions will likely need to focus on communication and education strategies that highlight the importance of penicillin allergies in patient outcomes, in addition to addressing other logistical barriers. The results of this study can inform augmented future delabeling efforts by identifying and addressing specific barriers, improving the clarity of the questionnaire for both nurses and patients, and providing opportunity for follow up allergy assessment for interested patients. Future studies should continue to investigate the optimal methods to implement penicillin delabeling interventions to improve patient outcomes.