Table 1.

Penicillin Allergy Risk Stratification and Recommendation Algorithm

Risk Stratification	Typical Assessment Features	Recommended Actiona
No increased risk	Prior index reaction with proven safe receipt of a penicillin after, family history	Remove penicillin allergy label; no need for challenge. Provide delabeling card, document, and alert Patient Aligned Care Team
Intolerance	Nonallergy symptoms (eg, gastrointestinal upset)	As above or direct oral amoxicillin challengeb
Low risk	Self-limited rash/pruritus (at any point), urticaria only >10 y ago, unknown reaction >10 y ago	Direct oral amoxicillin challengeb
Moderate-high risk	Anaphylaxis or angioedema at any point Any of the following within last 10 y: urticaria, bronchospasm, loss of consciousness, severe gastrointestinal symptoms, or unknown reaction	Consider Community Care Consult for Allergy and penicillin skin testing
Very high risk	Severe cutaneous adverse reactions, delayed severe reactions (eg, AGEP, SJS, DRESS, TEN), serum sickness, acute interstitial nephritis, DILI	Do not challenge with amoxicillin; infectious diseases can be consulted for alternative antimicrobials and Community Care Consult for Allergy can be considered for further opinion

Abbreviations: AGEP, acute generalized exanthematous pustulosis; DILI, drug-induced liver injury; DRESS, drug rash with eosinophilia and systemic symptoms; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis.

^aThis risk stratification is a guide only. Providers ought to use their discretion to accommodate individual circumstances, including patient preferences for outpatient allergy evaluations.

^bPatients that successfully underwent oral amoxicillin challenge were also provided with a delabeling card, had their allergy documentation adjusted, and notification sent to the Patient Aligned Care Team.