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).