Outpatient and Primary Care Direct Provocation Challenges for Antibiotic Allergy in Children

To evaluate the effectiveness of a simplified antibiotic allergy questionnaire in stratifying pediatric patients across diverse clinical settings for direct delabeling or safe progression to oral provocation challenge.A total of 313 children aged 2 to 16 years with 325 recorded antibiotic allergies and no previous testing. The cohort included children seen in the emergency department between June 2018 and May 2019 or identified from 4 primary care centers in Sheffield, England. Of the 313 participants (51.4% girls, median age 9.5 years), 87% had beta-lactam allergy labels. The prevalence of antibiotic allergy labels in the primary care cohort was 2.7%.Children in the cohort were invited to complete a standardized allergy questionnaire. Responses were evaluated using a clinical decision-making algorithm to determine whether the allergy label could be removed immediately or if the child was eligible for an oral antibiotic challenge. Oral challenges involved supervised administration of a single antibiotic dose, followed by 1 hour of observation and a follow-up call after a 4-day course to assess delayed reactions.Fifteen children were delabeled without undergoing a challenge based on their clinical history. Of the 140 oral challenges performed, 127 (90.7%) were completed without any reaction. Nine children (6.4%) developed mild, delayed symptoms—such as rash, facial swelling, rhinorrhea, abdominal pain, reduced appetite, vomiting, or diarrhea—that did not require medical attention. Four challenges (2.4%) were inconclusive due to either nonspecific symptoms or incomplete antibiotic courses. There was no consistent relationship between the symptoms reported at the time of the original allergy diagnosis and the outcomes of the challenge. However, 14.3% of children who had experienced swelling during their initial reaction reacted during the challenge, compared with only 4.7% of those without prior swelling.The study found that 96% of children with reported antibiotic allergies were eligible for delabeling through history review or oral challenge. No severe reactions occurred, and none of the children required skin or blood testing. Outpatient oral challenges were feasible, with up to 12 conducted in a single 6-hour clinic session by 1 clinician, suggesting an estimated cost savings of 60%. Despite being provided detailed educational materials and follow-up calls, approximately 25% of families declined participation due to fear of severe reactions, highlighting the need for improved public health messaging. Overall, the study supports a practical, safe, and resource-efficient delabeling approach that can be implemented across community settings.Inaccurate antibiotic allergy labels are common, with up to 90% found to be incorrect. These mislabels often result in the use of broader-spectrum, less effective antibiotics—contributing to increased antibiotic resistance, avoidable adverse events, and higher health care costs. To address this, systematic delabeling efforts should be implemented across all points of care. Educating both patients and clinicians, along with offering simplified oral challenges for low-risk patients, represents a feasible and effective strategy to improve antibiotic stewardship.