Penicillin Allergy Evaluation and Delabeling in Nursing Homes: An Implementation Science-Guided, Multi-stakeholder Qualitative Study
Abstract
Background: Penicillin allergy labels (PALs) are common and often inaccurate, contributing to suboptimal antibiotic prescribing and adverse outcomes. These challenges are particularly pronounced in nursing homes (NH), where PAL prevalence and antibiotic exposure are high, yet penicillin allergy evaluation and delabeling are rarely implemented and stakeholder perspectives are poorly understood. We sought to identify barriers and facilitators to implementing penicillin allergy evaluation and delabeling in NH, incorporating resident, caregiver, and healthcare professional (HCP) perspectives.
Methods: Between July and December 2025, we conducted semi-structured interviews with NH residents, a caregiver, and HCPs across 5 Massachusetts facilities. Interview guides were informed by the updated Consolidated Framework for Implementation Research. Data were analyzed using rapid thematic analysis with a structured matrix approach.
Results: Twenty-five participants (13 residents, 1 caregiver, 11 HCPs) were included. Five cross-cutting themes emerged: (1) PALs persist unquestioned, (2) skepticism about labels coexists with reluctance to delabel, (3) structural barriers are decisive, (4) feasibility is facility- and method-specific, and (5) education and trust enable engagement, but receptiveness cannot be assumed. HCPs cited residents’ cognitive impairment as a barrier, yet 13 of 21 residents screened could provide meaningful histories and participate in decision-making. History-based assessment was considered most feasible, whereas views on direct oral challenge and skin testing were divided.
Conclusions: Many NH residents can engage in penicillin allergy evaluation; capacity should be assessed individually. Implementation is constrained primarily by structural barriers rather than lack of interest. Low-resource, history-based, trust-building strategies may support adoption in NH.
Related
- Penicillin allergy delabeling in a German University Hospital—implementation in inpatient settings: the PenGuin Pilot Study
- Stakeholder perspectives on sustainable antenatal point-of-care ultrasound (APOCUS) implementation in rural Australia: a qualitative study of professional body submissions and clinician focus groups.
- Pre-implementation barriers and facilitators to implementing a physical activity guideline for community-dwelling older adults with mild cognitive impairment: a qualitative stakeholder study
- Beyond delabeling: long-term penicillin use and avoidance following negative penicillin challenge in children.
- Direct Oral Challenge for Penicillin Allergy: A Hospital Implementation Evaluation Via the International Network of Antibiotic Allergy Nations (iNAAN) Study
BibTeX
@article{foong2026penicillin,
title = {{Penicillin Allergy Evaluation and Delabeling in Nursing Homes: An Implementation Science-Guided, Multi-stakeholder Qualitative Study}},
author = {Kap Sum Foong and Amy M LeClair and Majd Alsoubani and Shira Doron and Alysse G Wurcel},
journal = {Open Forum Infectious Diseases},
year = {2026},
month = oct,
doi = {10.1093/ofid/ofag693},
url = {https://doi.org/10.1093/ofid/ofag693},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Penicillin Allergy Evaluation and Delabeling in Nursing Homes: An Implementation Science-Guided, Multi-stakeholder Qualitative Study
AU - Kap Sum Foong
AU - Amy M LeClair
AU - Majd Alsoubani
AU - Shira Doron
AU - Alysse G Wurcel
PY - 2026
DA - 2026/10/23
JO - Open Forum Infectious Diseases
DO - 10.1093/ofid/ofag693
UR - https://doi.org/10.1093/ofid/ofag693
AB - Background: Penicillin allergy labels (PALs) are common and often inaccurate, contributing to suboptimal antibiotic prescribing and adverse outcomes. These challenges are particularly pronounced in nursing homes (NH), where PAL prevalence and antibiotic exposure are high, yet penicillin allergy evaluation and delabeling are rarely implemented and stakeholder perspectives are poorly understood. We sought to identify barriers and facilitators to implementing penicillin allergy evaluation and delabeling in NH, incorporating resident, caregiver, and healthcare professional (HCP) perspectives. Methods: Between July and December 2025, we conducted semi-structured interviews with NH residents, a caregiver, and HCPs across 5 Massachusetts facilities. Interview guides were informed by the updated Consolidated Framework for Implementation Research. Data were analyzed using rapid thematic analysis with a structured matrix approach. Results: Twenty-five participants (13 residents, 1 caregiver, 11 HCPs) were included. Five cross-cutting themes emerged: (1) PALs persist unquestioned, (2) skepticism about labels coexists with reluctance to delabel, (3) structural barriers are decisive, (4) feasibility is facility- and method-specific, and (5) education and trust enable engagement, but receptiveness cannot be assumed. HCPs cited residents’ cognitive impairment as a barrier, yet 13 of 21 residents screened could provide meaningful histories and participate in decision-making. History-based assessment was considered most feasible, whereas views on direct oral challenge and skin testing were divided. Conclusions: Many NH residents can engage in penicillin allergy evaluation; capacity should be assessed individually. Implementation is constrained primarily by structural barriers rather than lack of interest. Low-resource, history-based, trust-building strategies may support adoption in NH.
SN - 2328-8957
ER -