The Feasibility and Applicability of Pediatric Inpatient Beta Lactam De-Labeling: From Bedside Challenge to Long-Term Follow Up.

Abstract

Background: Beta-lactam allergy (BLA) labels are common in pediatric patients but are often inaccurate, leading to unnecessary use of second-line antibiotics. While direct oral challenge tests (OCTs) are effective for de-labeling, their implementation in inpatient pediatric settings remains underexplored. This study aimed to evaluate the feasibility and barriers of an inpatient pediatric BLA de-labeling program, from bedside OCT to long-term follow-up and integration into electronic medical records (EMRs).

Materials and methods: We conducted a prospective interventional study in the pediatric ward between 2019 and 2024. Hospitalized children with a documented BLA were screened and eligible patients underwent a 2-step graded OCT. In-house pediatricians completed surveys to assess beliefs and barriers regarding inpatient OCT implementation. Long term follow-up included caregiver surveys and review of hospital and Health Maintenance Organization (HMO) EMRs to evaluate de-labeling documentation and subsequent beta-lactam use.

Results: Of 192 eligible BLA-labeled patients, 32 (16.6%) were recruited, 93.8% carrying an amoxicillin allergy label and the vast majority without other drug allergy labels. All patients had a history of a mild reaction, 100% presented with a benign rash. 30/32 (93.4%) had a negative OCT. Pediatricians faced challenges such as workload pressures, staff shortages and overestimation of severe reaction risks, all serving as barriers for patient recruitment. At follow-up (median 37 months), 35.7% of caregivers reported de-labeling, while EMRs documented higher rates (HMO: 80%; hospital: 70%). Despite successful OCTs, discrepancies between caregiver understanding, physician attitudes, and EMR documentation persisted.

Conclusion: While direct OCTs are proved to be effective in de-labeling BLA, significant challenges persist in implementing inpatient de-labeling and ensuring their long-term success. These include low recruitment rates, pediatricians' misconceptions and incomplete integration into EMRs. Addressing these barriers requires targeted education, improved communication, and streamlined processes to improve de-labeling outcomes and support antibiotic stewardship.