Table 1.

Risk Stratification and Intervention Recommendation Pathway Based on Reaction(s)

Risk Stratification	Recommendation
No risk Family history only Tolerated the medication without reaction since initial documentation Isolated GI upset Isolated headache or fatigue	If family history only or has since tolerated without reaction, remove allergy in EHR; If isolated GI upset, headache, or fatigue only, update “allergy” to “intolerance” in EHR
Low risk Itching only Non-urticarial rash Remote (>10 yr) history of non-anaphylactic IgE-­mediated reaction Unknown reaction without features of IgE	Oral amoxicillin challenge for qualifying allergens
Moderate risk Immediate (within 24 hr) development of urticarial rash Other possible non-anaphylactic IgE-mediated reactions occurring within last 10 yr	Penicillin skin testing followed by oral amoxicillin challenge for qualifying allergens
High risk Immediate (within 1 hr) anaphylaxis requiring ­hospitalization Steven-Johnson ­syndrome, toxic epidermal necrolysis, or drug rash with ­eosinophilia and systemic symptoms Serum sickness Acute interstitial nephritis or any organ involvement Drug-induced anemia Blistering rash Joint pain Drug-induced exfoliative dermatitis Acute generalized exanthematous pustulosis Vasculitis Recurrent reaction with re-exposure	Avoid penicillin and recommend allergist referral outpatient; Inpatient penicillin skin testing may be considered for history of anaphylaxis >5 yr ago

EHR, electronic health record; GI, gastrointestinal; IgE, immunoglobulin E