Roughly 30 million Americans carry a penicillin allergy label, yet fewer than 5% have a true allergy. (1) This mislabeling drives unnecessary use of broad-spectrum antibiotics, increases antimicrobial resistance and raises the risk of adverse outcomes. Despite clear evidence and national guidelines supporting proactive penicillin allergy evaluation and delabeling, the process remains far from routine across most health care settings.
Where we’re making progress and where we’re not
Across U.S. hospitals, penicillin allergy evaluation and delabeling are gaining momentum. A recent survey of the Society for Healthcare Epidemiology of America Research Network institutions found that nearly 90% have active delabeling initiatives, most led by pharmacists or infectious diseases clinicians rather than allergy specialists. (2)
Yet fewer than half of hospitals systematically track key outcomes, such as rates of delabeling, relabeling, adverse events or cost savings, and only a small fraction have electronic health record tools that support automated identification or documentation. Without consistent outcome measurement and EHR integration, it remains difficult to demonstrate impact, justify investment and sustain progress. The infrastructure for delabeling exists, but implementation remains fragmented.
The gap: Long-term care left behind
Long-term care settings tell a different story. In Massachusetts, a statewide survey of LTC facilities found a penicillin allergy prevalence of 23%, more than twice that observed in the general population. (3) More than 90% of those allergy records were incomplete, lacking information about reaction type or severity. (3) Follow-up analyses showed that residents with a documented penicillin allergy were 95% less likely to receive beta-lactam antibiotics for common infections. (4) LTC residents with incomplete β-lactam allergy documentation were six times more likely to receive high-risk antibiotics for Clostridioides difficile infection. (5)
These findings highlight how incomplete antibiotic allergy documentation in LTC facilities contributes to greater use of fluoroquinolones and other broad-spectrum agents, reinforcing the need for improved documentation and safer prescribing practices. Unlike hospitals, most LTC facilities face high staff turnover, competing regulatory priorities and limited resources to support this work. (6) These systemic barriers allow inaccurate penicillin allergy labels to persist, shaping prescribing practices and exposing residents to broader-spectrum and higher-risk antibiotics. Persistent disparities underscore the need for policy solutions that extend beyond hospital walls.
The opportunity: Federal momentum meets practice gaps
Federal policy attention is building. The Penicillin Allergy Verification and Evaluation (PAVE) Act (H.R. 5736), reintroduced in the House of Representatives in October 2025, would include penicillin allergy verification and evaluation as part of the Medicare Initial Preventive Physical Examination and Annual Wellness Visit. (7) As of early November 2025, H.R. 5736 had been referred to the Energy and Commerce and Ways and Means committees, respectively, in the House.
The American Academy of Allergy, Asthma & Immunology and IDSA have expressed strong support for the bill, noting that improved penicillin allergy evaluation can enhance patient outcomes, reduce healthcare expenditures, and help combat antimicrobial resistance. (8)
The bill’s current focus is on outpatient preventive visits and does not explicitly address residents of LTC or other high-acuity Medicare settings, populations that experience some of the highest rates of inaccurate penicillin allergy labeling and antibiotic exposure. Inclusion of these groups in future legislative or reimbursement frameworks would help ensure the benefits of penicillin allergy evaluation reach those most likely to benefit from it.
The next step: Align data, reimbursement and the workforce
Making penicillin allergy evaluation and delabeling routine will require better infrastructure, reimbursement and a trained clinical workforce. Reimbursement mechanisms should support evaluation and delabeling services in hospitals, outpatient clinics and LTC facilities. EHRs need integrated risk-stratification tools and clinical alerts to help identify low-risk patients at the point of care. Training programs can empower pharmacists, nurses, and other non-allergist clinicians to safely lead delabeling efforts.
Finally, standardized outcome measures, such as delabeling rates, relabeling frequency, adverse reactions, antibiotic spectrum indices and cost savings, are essential to demonstrate impact and ensure accountability. Together, these steps would extend the reach of antimicrobial stewardship and help translate national policy into measurable, patient-level improvement across systems of care.
True stewardship means ensuring penicillin allergy evaluation and delabeling are accessible across the care continuum, from academic hospitals to nursing homes. The PAVE Act represents an important step toward federal recognition of this issue, but sustained progress will depend on integrating data systems, reimbursement pathways and workforce training across settings. With coordinated investment and inclusion of Medicare and LTC populations, penicillin allergy evaluation and delabeling can move from aspiration to standard practice, advancing antibiotic safety and promoting equitable access to high-quality care.
Acknowledgement: The illustration accompanying this blog post was created using an AI tool.
References
- Shenoy ES, Macy E, Rowe T, et al. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199.
- Foong KS, Erdil R, Campion M, et al. Penicillin allergy delabeling practices and barriers across SHEA research network US institutions: a cross-sectional survey. Infect Control Hosp Epidemiol. 2025:1-4.
- Foong KS, Fowle L, Doron S, et al. Antibiotic allergy prevalence and documentation quality in Massachusetts long-term care facilities: A cross-sectional survey. Ann Allergy Asthma Immunol. 2024;133(3):335-340.e1.
- Foong KS, Doron S, Fowle L, et al. Documented penicillin allergy and beta-lactam antibiotic use in Massachusetts long-term care facilities: opportunities for penicillin allergy delabeling. Antimicro Steward Healthc Epidemiol. 2024;4(1):e166.
- Foong KS, Doron S, Wurcel A. Incomplete documentation of β-lactam allergy in long-term care facility residents increases risk of high-risk antibiotic use for Clostridioides difficile infection. Am J Health Syst Pharm. 2025;82(14):770-771.
- Foong KS, Doron S, Wurcel A. Penicillin allergy delabeling in long-term care facilities: if not now, then when? Antimicrob Steward Healthc Epidemiol. 2025;5(1):e61.
- H.R.5736: PAVE Act.
- American Academy of Allergy, Asthma & Immunology. AAAAI Reintroduces Bill to Support Penicillin Allergy Delabeling.