Introduction
Beta-lactams are the commonest antibiotic class reported to cause
allergy, yet globally, there is a large burden of patients mis-labeled
as having a Beta-lactam allergy (BLA) (1). In high income countries
(HICs) 6-25% of the population are labeled as having a BLA, but only
1-10% of the population have a true BLA. In keeping with this low
prevalence rate, the prevalence of life-threating anaphylaxis to
beta-lactams is estimated to be 0.02-0.04%, a rate unchanged in the
last sixty years (1-3). While the epidemiology of BLA in HICs is well
described, there is no published epidemiological data available on BLA
in Africa or other low- and middle -income countries (LMIC)(4).
Being labeled with a BLA is harmful to patients, including the risk of
antibiotic failure (1), increased duration of hospital stay (5), higher
rates of post operative sepsis (6, 7), and adverse reactions to
prescribed alternative antibiotics(1). In addition to increased patient
risk there is an additional financial cost to the health care system
with the increased cost of broad-spectrum antibiotics, longer duration
of hospital admission, and higher rates of readmission (8, 9). Globally
BLA drives antibiotic resistance (ABR) due to the increased use of
broader-spectrum antibiotics than the penicillins. This results in
increased risks of infection with vancomycin resistant enterococci (VRE)
(5), methicillin resistant Staphylococcus aureus (MRSA) (10), andClostridiodes difficile (1, 11). In 2019, 4.95 million people
worldwide died with an antibiotic resistant bacterial infection, and 1.3
million of those were as a direct result of bacteria being resistant to
antibiotics(12). The burden of ABR is highest in low-income countries
(LIC) (4, 13, 14). Western-sub-Saharan Africa has the highest all-age
death rate attributable to ABR (27.3 deaths per 100 000 [CI
20.9-35.3])(14). The high mortality due to ABR in sub-Saharan Africa
makes de-labeling BLA a public health and antibiotic stewardship
priority.
The success of programmatic antibiotic allergy testing incorporated into
antibiotic stewardship programs has been increasingly reported with the
use of clinical decision tools that can be used by allergists and
non-allergists (15). Direct de-labeling of inpatients is safe and
effective, with rates of negative testing being comparable to the
outpatient setting(16). The need to establish the true prevalence and
incidence of BLA in LMICs is paramount to improve our management of
beta-lactam allergy in settings with the highest burden of infectious
diseases (4).