Beta-lactam de-labelling as a core antimicrobial stewardship strategy in the era of the antimicrobial resistance pandemic: a narrative review

PURPOSE OF REVIEW: Antimicrobial resistance (AMR) is increasingly recognised as a global public health emergency that threatens the foundations of modern medicine. While much attention has focused on antimicrobial overuse, under-emphasised drivers such as inaccurate drug allergy labels continue to undermine antibiotic stewardship efforts. Beta-lactam allergy (BLA) labels, particularly penicillin allergy labels, are among the most prevalent and most consequential of these inaccuracies. Mounting evidence demonstrates that the vast majority of individuals labelled as beta-lactam allergic are not truly allergic, yet these labels persist across healthcare systems and generations, driving the use of broader-spectrum, less effective, more toxic and resistance-promoting antibiotics. In this timely review, we argue that beta-lactam de-labelling should no longer be viewed as a niche allergy intervention but as a core antimicrobial stewardship strategy and an ethical obligation in the era of the AMR pandemic. RECENT FINDINGS: Drawing on emerging inpatient and outpatient evidence, including recent paediatric inpatient de-labelling studies, we examine clinical, behavioural, system-level and ethical barriers to de-labelling and propose a reframing of beta-lactam de-labelling as a public health intervention essential for preserving antibiotic effectiveness. SUMMARY: We conclude by outlining policy-relevant recommendations for embedding de-labelling into routine care pathways, particularly in low and middle-income countries (LMICs), where the consequences of AMR are likely to be most severe.