Quality and Consistency of Penicillin Allergy Delabelling Guidelines: A Systematic Review

Penicillin allergy delabelling (PADL) is increasingly recognised as a key antimicrobial stewardship strategy and important public health priority. Over the past decade, multiple PADL guidelines (PADLGs) have been published, yet the consistency of their recommendations and overall quality have not been systematically reviewed. This review compared the scope, purpose, and recommendations of internationally published PADLGs, and assessed their quality using the Appraisal of Guidelines for Research and Evaluation II instrument. Eighteen guidelines published between 2014 and 2024 were identified, representing twelve countries across four regions. Most guidelines provided recommendations for risk stratification, testing, and delabelling methods, with many supporting direct delabelling/direct challenge in low-risk patients. However, substantial variation was observed in risk assessment tools, eligibility criteria, and post-test delabelling strategies, highlighting opportunities for greater standardisation. Overall, the quality of PADLGs was low, with only two meeting predefined high-quality criteria. Critical gaps included limited methodological rigour, poor stakeholder involvement, and lack of guidance for real-world implementation. PADLGs also demonstrated variation in scope, target users, and clinical recommendations, both within and across clinical settings. To support safe and scalable PADL approaches, clearer, more consistent, and methodologically robust guidelines are needed to address the global burden of inappropriate penicillin allergy labels.