Direct single dose mass delabelling of antibiotic allergy in pediatrics

TL;DR

This study shows that safely removing incorrect antibiotic allergy labels in children is possible on a large scale without prior testing.

Contribution

A simplified, multi-patient protocol for pediatric antibiotic allergy delabeling is proposed and validated.

Findings

92.6% of patients tolerated the antibiotic challenge without severe reactions.

High-risk patients were no more likely to react than low/intermediate-risk patients.

Current adult-based risk tools are not suitable for pediatric delabeling models.

Abstract

Unsubstantiated antibiotic allergy labels affect between 8% and 25% of the population worldwide. Current risk stratification tools, derived from adult data, are not validated for children. A simplified, multi‐patient protocol with minimal exclusion criteria is required to tackle the scale of this public health issue.

Patients with possible antibiotic allergy were recruited from the Children's Health Ireland (CHI) allergy waiting list. Exclusion criteria were a serum sickness like reaction (SSLR), severe cutaneous adverse reaction (SCARs), anaphylaxis, or non‐allergic symptoms. No prior allergy testing was performed. Dosing was direct single observed dosing in dedicated mass delabelling clinics, followed by a two‐day home antibiotic course.

Consenting patients (n = 162) were seen over 6 clinics with gradually increasing clinic sizes (Range 18 to 62, average 23). One patient only was excluded based on the severity of their index event. Average age was 7 years, n = 90/162 (55.6%) were female. Most were avoiding amoxicillin, n = 137/162 (84.6%). Negative challenge rates were similar to previous studies, n = 150/162 (92.6%), 3 had immediate reactions and 9 delayed (all non‐severe). Patients retrospectively underwent risk stratification according to the 2024 EAACI position paper, high risk n = 38/162 (23.5%), intermediate risk n = 74/162 (45.7%) and low risk n = 50/162 (30.9%). Those deemed high risk were no more likely to have a positive challenge than those deemed low/intermediate risk (n = 2/38, 5.3% vs. n = 10/124, 8.1%, p = .56).

Antibiotic allergy delabelling in pediatrics is low risk and can be done safely in high patient load without prior allergy testing. Current risk stratification tools are not suitable for pediatric‐specific models of care.

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