Background. Beta-lactam allergy (BLA) labels are common in pediatric patients, but are often inaccurate, leading to unnecessary use of second line antibiotics. While direct oral challenge tests (OCTs) are effective for de-labeling, their incorporation in pediatric inpatient setting remains underexplored. This study aimed to assess the feasibility of implementing an inpatient pediatric BLA de-labeling program. Methods. A prospective study conducted in a pediatric ward involved inpatients undergoing a 2-step graded OCT. In-house pediatricians completed surveys to assess beliefs and barriers regarding inpatient OCT implementation. Follow-up included caregiver surveys and review of hospital and Health Maintenance Organization (HMO) electronic medical records (EMRs). Results. Of 192 eligible BLA-labeled patients, 32 (16.6%) were recruited, 93.8% carrying an amoxicillin allergy label and the vast majority without other drug allergy labels. All patients had a history of a mild reaction, 100% presented with a benign rash. 30/32 (93.4%) had a negative OCT. Pediatricians faced challenges such as workload pressures, staff shortages and overestimation of severe reaction risks, all serving as barriers for patient recruitment. At follow-up (median 37 months), 35.7% of caregivers reported de-labeling, while EMRs documented higher rates (HMO: 80%l; hospital: 70%). Despite successful OCTs, gaps in caregiver understanding and pediatrician support persisted. Conclusions. While direct OCTs are proved to be effective in de-labeling BLA, significant challenges persist in implementing inpatient de-labeling and ensuring their long-term success. These include low recruitment rates, pediatricians’ misconceptions and incomplete integration into EMRs. Addressing these barriers requires targeted education, improved communication and streamlined processes to improve de-labeling outcomes and support antibiotic stewardship.
