Use of a beta-lactam graded challenge process for inpatients with self-reported penicillin allergies at an academic medical center

Shawnalyn W. Sunagawa, Scott J. Bergman, Emily Kreikemeier, Andrew B. Watkins, Bryan T. Alexander, Molly M. Miller, Danny Schroeder, Erica J. Stohs, Trevor C. Van Schooneveld, Sara M May

Research output: Contribution to journalArticlepeer-review


Background: The Antimicrobial Stewardship Program (ASP) at Nebraska Medicine collaborated with a board-certified allergist to develop a penicillin allergy guidance document for treating inpatients with self-reported allergy. This guidance contains an algorithm for evaluating and safely challenging penicillin-allergic patients with beta-lactams without inpatient allergy consults being available. Methods: Following multi-disciplinary review, an order set for beta-lactam graded challenges (GC) was implemented in 2018. This contains recommended monitoring and detailed medication orders to challenge patients with various beta-lactam agents. Inpatient orders for GC from 3/2018–6/2022 were retrospectively reviewed to evaluate ordering characteristics, outcomes of the challenge, and whether documentation of the allergy history was updated. All beta-lactam challenges administered to inpatients were included, and descriptive statistics were performed. Results: Overall, 157 GC were administered; 13 with oral amoxicillin and 144 with intravenous (IV) beta-lactams. Ceftriaxone accounted for the most challenges (43%). All oral challenges were recommended by an Infectious Diseases consult service, as were a majority of IV challenges (60%). Less than one in five were administered in an ICU (19%). Almost all (n = 150, 96%) were tolerated without any adverse event. There was one reaction (1%) of hives and six (4%) involving a rash, none of which had persistent effects. Allergy information was updated in the electronic health record after 92% of the challenges. Conclusion: Both intravenous and oral beta-lactam graded challenges were implemented successfully in a hospital without a regular inpatient allergy consult service. They were well-tolerated, administered primarily in non-ICU settings, and were often ordered by non-specialist services. In patients with a self-reported penicillin allergy, these results demonstrate the utility and safety of a broadly adopted beta-lactam GC process.

Original languageEnglish (US)
Article number1161683
JournalFrontiers in Allergy
StatePublished - 2023


  • graded challenge
  • graded challenge (test dose)
  • penicillin allergy
  • penicillin allergy delabelling
  • penicillin allergy screening algorithm

ASJC Scopus subject areas

  • Immunology and Allergy
  • Infectious Diseases


Dive into the research topics of 'Use of a beta-lactam graded challenge process for inpatients with self-reported penicillin allergies at an academic medical center'. Together they form a unique fingerprint.

Cite this