87 - Penicillin Allergy De-labeling in a Pediatric Primary Care Setting through Quality Improvement

Publication Number: 4085.87

Calista L. Dominy, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Kate E.. Zendell, Weill Cornell Medicine, New York, NY, United States; Cassandra Grello, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Samantha Kanter, Weill Cornell Medicine, NY, NY, United States; Victoria Koa, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Laura Loeser, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Margaret Magovern, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Catherine Roukhadze, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Talia Segal, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Sarah SA Smith, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Kendra A. Willis, Weill Cornell Medicine, New York, NY, United States; Lauren E. Yue, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, NY, United States; Lori Zomback, NewYork-Presbyterian Komansky Children’s Hospital, New York, NY, United States; Kevin Strobino, Weill Cornell Medicine, New York, NY, United States; Snezana Nena Osorio, Weill Cornell Medicine, New York, NY, United States; Miriam Samstein, New York Presbyterian Cornell, New York, NY, United States

Background: Pediatric patients are frequently mislabeled as penicillin-allergic, leading to suboptimal antibiotic prescribing throughout childhood and into adulthood. Up to 10% of the U.S. population carries a penicillin allergy label, yet >90% of pediatric patients with such a label tolerate penicillins upon testing. Mislabeling contributes to use of broader-spectrum, less effective, and more costly antibiotics, as well as higher rates of antibiotic-resistant infections. The American Academy of Pediatrics recommends formal allergy assessment and delabeling when appropriate to optimize antibiotic stewardship.

Objective: To increase accurate documentation of penicillin-type allergy status among labeled patients to ≥80% by July 2027 in a resident-run, Medicaid-serving pediatric primary care clinic.

Design/Methods: Using the Model for Improvement, we developed a key driver diagram (Figure 1) and implemented sequential Plan-Do-Study-Act (PDSA) cycles. Interventions included staff and resident education on penicillin allergy delabeling and electronic health record (EHR) modifications to standardize documentation and prompt allergy referrals. Measures included proportion of patients with accurate allergy labeling (outcome), percentage of labeled patients referred for allergy evaluation and percentage who successfully booked an allergy appointment (process), as well as time to appointment and allergy clinic no-show rate (balancing). Data were analyzed using run charts. IHI rules were applied to detect special cause variation.

Results: From January 2024 through August 2025, we reviewed 418 visits from 141 unique patients with penicillin-type allergy labels. The proportion of labeled patients referred for allergy evaluation increased from 13% to 42% following initial interventions (Figure 2). The percentage of referred patients who successfully booked appointments rose from 50% to 83% (Figure 3). No special-cause variation was observed, suggesting early but stable improvement.

Conclusion(s): Implementation of a structured QI initiative increased referrals and booking rates for allergy evaluation, an essential step toward accurate delabeling. The most recent intervention (automatic EHR note template) is not yet reflected in current data and is expected to further improve performance. Next steps include continued PDSA cycles to optimize documentation and longitudinal follow-up to measure delabeling rates and antibiotic prescribing patterns. Sustained resident education and workflow integration will be critical for maintaining gains.

Figure 1 - Key Driver
A Key Driver diagram showing key stakeholders and possible interventions for penicillin allergy delabelling

Figure 2 - Referral Rate
Run Chart showing the percent of eligible patients receiving an allergy referral
increased from 13% to 42%


Figure 3 - Appointments Booked
Run chart showing The percent of referred patients who
booked appointments increased from 50% to 83%