Penicillin-binding protein (PBP) inhibitor development: A 10-year chemical perspective.

Bacterial cell wall formation is essential for cellular survival and morphogenesis. The peptidoglycan (PG), a heteropolymer that surrounds the bacterial membrane, is a key component of the cell wall, and its multistep biosynthetic process is an attractive antibacterial development target. Penicillin-binding proteins (PBPs) are responsible for cross-linking PG stem peptides, and their central role in bacterial cell wall synthesis has made them the target of successful antibiotics, including ß-lactams, that have been used worldwide for decades. Following the discovery of penicillin, several other compounds with antibiotic activity have been discovered and, since then, have saved millions of lives. However, since pathogens inevitably become resistant to antibiotics, the search for new active compounds is continuous. The present review highlights the ongoing development of inhibitors acting mainly in the transpeptidase domain of PBPs with potential therapeutic applications for the development of new antibiotic agents. Both the critical aspects of the strategy, design, and structure-activity relationships (SAR) are discussed, covering the main published articles over the last 10 years. Some of the molecules described display activities against main bacterial pathogens and could open avenues toward the development of new, efficient antibacterial drugs.

Green Multiplex Chromatographic Determination of Nine Penicillin Antibiotics Residues in Industrial Air Dust and Wastewater Environmental Samples.

Determination of penicillin residues in different industrial effluents including wastewater and air samples is important to prevent exposure to residual amounts of penicillin and the development of antibiotic resistance. A green high performance liquid chromatography (HPLC) method coupled with diode array detection has been developed and validated for multiplex determination of nine penicillin antibiotics in the industrial air dust and wastewater environmental samples of penicillin facility in addition to the monitoring of facility surface cleaning. Separation was performed on C18 column with gradient elution of methanol and phosphate buffer (pH 4) at a flow rate of 1.5 mL min-1 and ultra violet (UV) detection at 220 nm. Low limits of detection were achieved (0.1-0.3 µg mL-1) indicating good sensitivity of the proposed. The method was applied for ensuring the efficiency of cleaning validation after worst-case selection. Recovery studies of the studied penicillins from fortified stainless steel and polycarbonate surfaces and swabs were between 91.91 and 100.22% with relative standard deviation 0.11-1.79%. The presence of any of the studied penicillins in wastewater samples from penicillin plant drainage was checked. Also, total air dust concentration (mg m-3) and % of penicillin active material residues in air dust were calculated from the area of the exposed group in suspension, tablet and vial production lines. The proposed method can be recommended for routine analysis of air and wastewater environmental samples for the detection of penicillin antibiotics at low levels as well as monitoring of facility surface cleaning with high accuracy and precision.

Effects of pH and Metal Ions on the Hydrothermal Treatment of Penicillin: Kinetic, Pathway, and Antibacterial Activity.

Antibiotic residues lead to the risk of resistance gene enrichment, which is the main reason why penicillin mycelial dreg (PMD) is defined as hazardous waste. Hydrothermal treatment (HT) is an effective method to treat penicillin mycelial dreg, but the degradation mechanism of penicillin is unclear. In the study, we researched the effects of pH (4-10) at 80-100 °C and metal ions (Mn2+, Fe2+, Cu2+, and Zn2+) at several concentrations on the HT of penicillin, identified the degradation products (DPs) under different conditions, and evaluated the antibacterial activity of hydrothermally treated samples. The results show that penicillin degradation kinetics highly consistent with pseudo-first-order model (R2 = 0.9447-0.9999). The degradation rates (k) at pH = 4, 7, and 10 were 0.1603, 0.0039, and 0.0485 min-1, indicating acidic conditions were more conducive to penicillin degradation. Among the four tested metal ions, Zn2+ had the most significant catalytic effect. Adding 5 mg·L-1 Zn2+ caused 100% degradation rate at pH = 7 after HT for 60 min. Six degradation products (DPs) with low mass-to-charge (m/z ≤ 335) were detected under acidic condition. However, only two and three DPs were observed in the samples catalyzed by Zn2+ and alkali, respectively, and penilloic acid (m/z = 309) was the main DPs under these conditions. Furthermore, no antibacterial activity to Bacillus pumilus was detected in the medium with up to 50% addition of the treated samples under acidic condition. Even though acid, alkali, and some metal ions can improve the degradation ability of penicillin, it was found that the most effective way for removing its anti-bacterial activity was under the acidic condition. Therefore, resistance residue indicates the amount of additive in the process of resource utilization, and avoids the enrichment of resistance genes.

Spectroscopic studies reveal details of substrate-induced conformational changes distant from the active site in isopenicillin N synthase.

Isopenicillin N synthase (IPNS) catalyzes formation of the ß-lactam and thiazolidine rings of isopenicillin N from its linear tripeptide l-δ-(α-aminoadipoyl)-l-cysteinyl-d-valine (ACV) substrate in an iron- and dioxygen (O2)-dependent four-electron oxidation without precedent in current synthetic chemistry. Recent X-ray free-electron laser studies including time-resolved serial femtosecond crystallography show that binding of O2 to the IPNS-Fe(II)-ACV complex induces unexpected conformational changes in α-helices on the surface of IPNS, in particular in α3 and α10. However, how substrate binding leads to conformational changes away from the active site is unknown. Here, using detailed 19F NMR and electron paramagnetic resonance experiments with labeled IPNS variants, we investigated motions in α3 and α10 induced by binding of ferrous iron, ACV, and the O2 analog nitric oxide, using the less mobile α6 for comparison. 19F NMR studies were carried out on singly and doubly labeled α3, α6, and α10 variants at different temperatures. In addition, double electron-electron resonance electron paramagnetic resonance analysis was carried out on doubly spin-labeled variants. The combined spectroscopic and crystallographic results reveal that substantial conformational changes in regions of IPNS including α3 and α10 are induced by binding of ACV and nitric oxide. Since IPNS is a member of the structural superfamily of 2-oxoglutarate-dependent oxygenases and related enzymes, related conformational changes may be of general importance in nonheme oxygenase catalysis.

Towards Multi-Analyte Detection with Field-Effect Capacitors Modified with Tobacco Mosaic Virus Bioparticles as Enzyme Nanocarriers.

Utilizing an appropriate enzyme immobilization strategy is crucial for designing enzyme-based biosensors. Plant virus-like particles represent ideal nanoscaffolds for an extremely dense and precise immobilization of enzymes, due to their regular shape, high surface-to-volume ratio and high density of surface binding sites. In the present work, tobacco mosaic virus (TMV) particles were applied for the co-immobilization of penicillinase and urease onto the gate surface of a field-effect electrolyte-insulator-semiconductor capacitor (EISCAP) with a p-Si-SiO2-Ta2O5 layer structure for the sequential detection of penicillin and urea. The TMV-assisted bi-enzyme EISCAP biosensor exhibited a high urea and penicillin sensitivity of 54 and 85 mV/dec, respectively, in the concentration range of 0.1-3 mM. For comparison, the characteristics of single-enzyme EISCAP biosensors modified with TMV particles immobilized with either penicillinase or urease were also investigated. The surface morphology of the TMV-modified Ta2O5-gate was analyzed by scanning electron microscopy. Additionally, the bi-enzyme EISCAP was applied to mimic an XOR (Exclusive OR) enzyme logic gate.

Transfer of certain beta-lactam antibiotics from cow's milk to fresh cheese and whey.

The aim of this study was to investigate the transfer of cephalexin, penicillin-G, and ampicillin & cloxacillin from cow's milk to cheese and whey. For this purpose, raw milk was artificially contaminated to different antibiotic levels and then heat-treated to prepare fresh cheese from it. Antibiotic levels of the milk, whey and cheese were measured with LC-MS/MS. The extent of heat degradation was not sufficient to remove the antibiotic residues from milk. Antibiotic concentrations in whey and fresh cheese were in good accordance with the concentration of the same compound in milk suggesting that contamination of the milk will result in contamination of the product. The investigated antibiotics were transferred less into the cheese curd (1.6-12.5% of the original amount), than into the whey (33.2-74.1%). For penicillin-G even 100% (complete removal) was experienced.

New Methods for the Synthesis of Spirocyclic Cephalosporin Analogues.

Spiro compounds provide attractive targets in drug discovery due to their inherent three-dimensional structures, which enhance protein interactions, aid solubility and facilitate molecular modelling. However, synthetic methodology for the spiro-functionalisation of important classes of penicillin and cephalosporin ß-lactam antibiotics is comparatively limited. We report a novel method for the generation of spiro-cephalosporin compounds through a Michael-type addition to the dihydrothiazine ring. Coupling of a range of catechols is achieved under mildly basic conditions (K2CO3, DMF), giving the stereoselective formation of spiro-cephalosporins (d.r. 14:1 to 8:1) in moderate to good yields (28-65%).

X-ray free-electron laser studies reveal correlated motion during isopenicillin N synthase catalysis.

Isopenicillin N synthase (IPNS) catalyzes the unique reaction of l-δ-(α-aminoadipoyl)-l-cysteinyl-d-valine (ACV) with dioxygen giving isopenicillin N (IPN), the precursor of all natural penicillins and cephalosporins. X-ray free-electron laser studies including time-resolved crystallography and emission spectroscopy reveal how reaction of IPNS:Fe(II):ACV with dioxygen to yield an Fe(III) superoxide causes differences in active site volume and unexpected conformational changes that propagate to structurally remote regions. Combined with solution studies, the results reveal the importance of protein dynamics in regulating intermediate conformations during conversion of ACV to IPN. The results have implications for catalysis by multiple IPNS-related oxygenases, including those involved in the human hypoxic response, and highlight the power of serial femtosecond crystallography to provide insight into long-range enzyme dynamics during reactions presently impossible for nonprotein catalysts.

Reversible Structural Transformation of CuI-TbIII Heterometallic MOFs with Highly Efficient Detection Capability toward Penicillin.

A CuI-TbIII heterometallic MOF, namely 1·DMF, was obtained via a coordination assembly process of isonicotinic acid with CuI and TbIII. 1·DMF can be switched to 1·MeOH in methanol with a luminescent emission response. Meanwhile, 1·MeOH exhibits a reversible single-crystal transformation to 1·DMF after immersion in DMF. Both MOFs have superior physicochemical stability. The 1·DMF-based biosensor has a remarkable sensing performance toward penicillin.

Design, synthesis and cytotoxic evaluation of peptoid analogs of an anticancer active triazolylpeptidyl penicillin.

Aim: Encouraged by the antitumor activity exhibited by triazolylpeptidyl penicillins, we decided to synthesize and evaluate a library of peptoid analogs. Results: The replacement of the dipeptide unit of the reference compound, TAP7f, was investigated. In addition, the effect of the triazole linking group on the biological activity of these new derivatives was evaluated, exchanging it with a glycine spacer. The cytotoxic effect of the library compounds was determined in the B16-F0 cell line and compared with the effects on normal murine mammary gland cells. Conclusion: Among the tested compounds, peptoid 4e exhibited the highest antiproliferative activity.

6-Halopyridylmethylidene Penicillin-Based Sulfones Efficiently Inactivate the Natural Resistance of Pseudomonas aeruginosa to ß-Lactam Antibiotics.

Pseudomonas aeruginosa, a major cause of nosocomial infections, is considered a paradigm of antimicrobial resistance, largely due to hyperproduction of chromosomal cephalosporinase AmpC. Here, we explore the ability of 6-pyridylmethylidene penicillin-based sulfones 1-3 to inactivate the AmpC ß-lactamase and thus rescue the activity of the antipseudomonal ceftazidime. These compounds increased the susceptibility to ceftazidime in a collection of clinical isolates and PAO1 mutant strains with different ampC expression levels and also improved the inhibition kinetics relative to avibactam, displaying a slow deacylation rate and involving the formation of an indolizine adduct. Bromide 2 was the inhibitor with the lowest KI (15.6 nM) and the highest inhibitory efficiency (kinact/KI). Computational studies using diverse AmpC enzymes revealed that the aromatic moiety in 1-3 targets a tunnel-like site adjacent to the catalytic serine and induces the folding of the H10 helix, indicating the potential value of this not-always-evident pocket in drug design.

PenA, a penicillin-binding protein-type thioesterase specialized for small peptide cyclization.

Penicillin-binding protein-type thioesterases (PBP-type TEs) are a recently identified group of peptide cyclases that catalyze head-to-tail macrolactamization of nonribosomal peptides. PenA, a new member of this group, is involved in the biosyntheses of cyclic pentapeptides. In this study, we demonstrated the enzymatic activity of PenA in vitro, and analyzed its substrate scope with a series of synthetic substrates. A comparison of the reaction profiles between PenA and SurE, a representative PBP-type TE, showed that PenA is more specialized for small peptide cyclization. A computational model provided a possible structural rationale for the altered specificity for substrate chain lengths.

Hemostatic and antibacterial PVA/Kaolin composite sponges loaded with penicillin-streptomycin for wound dressing applications.

Hemorrhage is the major hindrance over the wound healing, which triggers microbial infections and might provoke traumatic death. Herein, new hemostatic and antibacterial PVA/Kaolin composite sponges were crosslinked using a freeze-thawing approach and boosted by penicillin-streptomycin (Pen-Strep). Physicochemical characteristics of developed membranes were analyzed adopting Fourier transformed infrared spectroscopy (FT-IR), scanning electron microscopy (SEM), a thermal gravimetric analyzer (TGA), and differential scanning calorimetry (DSC). Furthermore, the impacts of kaolin concentrations on porosity, swelling behavior, gel fraction, and degradation of the membranes were investigated. SEM analyses revealed a spongy-like structure of hydrogels associated with high dispersion of kaolin inside PVA matrix. The thermal characteristics of PVA/Kaolin were significantly ameliorated compared to the prime PVA. Moreover, the results exhibited significant variations of swelling performance, surface roughness and pore capacity due to the alterations of kaolin contents. Besides, the adhesive strength ability was manifestly enhanced for PVA-K0.1 sponge. Biomedical evaluations including antibacterial activity, blood clotting index and thrombogenicity of the membranes were studied. The contact of PVA/Kaolin to blood revealed notable augmentation in blood clotting. Furthermore, the incorporation of kaolin into PVA presented mild diminution in antibacterial activities. Moreover, PVA/Kaolin composites illustrated no cellular toxicity towards fibroblast cells. These remarkable features substantiate that the PVA-K0.1 sponge could be applied as a multifunctional wound dressing.

Isopenicillin†N Synthase: Crystallographic Studies.

Isopenicillin N synthase (IPNS) is a non-heme iron oxidase (NHIO) that catalyses the cyclisation of tripeptide δ-(l-α-aminoadipoyl)-l-cysteinyl-d-valine (ACV) to bicyclic isopenicillin N (IPN). Over the last 25 years, crystallography has shed considerable light on the mechanism of IPNS catalysis. The first crystal structure, for apo-IPNS with Mn bound in place of Fe at the active site, reported in 1995, was also the first structure for a member of the wider NHIO family. This was followed by the anaerobic enzyme-substrate complex IPNS-Fe-ACV (1997), this complex plus nitric oxide as a surrogate for co-substrate dioxygen (1997), and an enzyme product complex (1999). Since then, crystallography has been used to probe many aspects of the IPNS reaction mechanism, by crystallising the protein with a diversity of substrate analogues and triggering the oxidative reaction by using elevated oxygen pressures to force the gaseous co-substrate throughout protein crystals and maximise synchronicity of turnover in crystallo. In this way, X-ray structures have been elucidated for a range of complexes closely related to and/or directly derived from key intermediates in the catalytic cycle, thereby answering numerous mechanistic questions that had arisen from solution-phase experiments, and posing many new ones. The results of these crystallographic studies have, in turn, informed computational experiments that have brought further insight. These combined crystallographic and computational investigations augment and extend the results of earlier spectroscopic analyses and solution phase studies of IPNS turnover, to enrich our understanding of this important protein and the wider NHIO enzyme family.

Novel Hybrid Molecules Based on triazole-ß-lactam as Potential Biological Agents.

Triazole ring is a cyclic scaffold containing three heteroatoms of nitrogen. They display a broad variety of biological activities. The uncatalyzed/catalyzed 1,3-dipolar cycloadditions are a chemical reaction between a 1,3-dipole and a dipolarophile to achieve 1,2,3-triazoles. The hybrid approach is an innovative and powerful synthetic tool for the synthesis of two or more distinct entities in one molecule with novel biological activities. Owing to the high potential of ß-lactams to display noticeable biological properties, these compounds have been one of the important ingredients in hybrid molecules. The four-membered lactams have been recognized as a part of penicillin. There are various synthetic protocols for the synthesis of ß-lactams. Staudinger reaction of the Schiff bases with diphenylketenes is a successful and famous strategy for the synthesis of these products. Even though, the number of heterocyclic compounds is limited, plenty of hybrids based on heterocyclic compounds can be designed and prepared. The synthesis of hybrid products of triazole-ß-lactam has proved to be highly challenging. The current review article outlines the diversity and creativity in the elegant synthesis of triazole-ß-lactam hybrids as potential biological agents. Molecules including isatin, ferrocene, bile acid, chalcone, and etc were attached to ß-lactam with triazole linker, as well.

Mechanistic Insights into the Oxidative Ring Expansion from Penicillin N to Deacetoxycephalosporin C Catalyzed by a Nonheme Iron(II) and α-KG-Dependent Oxygenase.

Deacetoxycephalosporin C synthase (DAOCS) is a nonheme iron(II) and 2-oxoglutarate (α-KG)-dependent oxygenase that catalyzes the oxidative ring expansion of penicillin N (penN) to deacetoxycephalosporin C (DAOC). Earlier reported crystal structures of DAOCS indicated that the substrate penicillin binds at the same site of succinate, leading to the proposal of the unusual "ping-pong" mechanism. However, more recent data provided evidence of the formation of ternary DAOCS·α-KG·penN complex, and thus DAOCS should follow the usual consensus mechanism of α-KG-dependent nonheme iron(II) oxygenases. Nevertheless, how DAOCS catalyzes the ring expansion is unknown. In this paper, on the basis of the crystal structure, we constructed two reactant models and performed a series of combined quantum mechanics/molecular mechanics (QM/MM) calculations to illuminate the catalysis of DAOCS. The binding mode of substrate was found to be crucial in determining which hydrogen atom in two methyl groups is first abstracted and whether the second H-abstraction to be abstracted in the final desaturation step locates in a suitable orientation. The highly reactive FeIV-oxo species prefers to abstract a hydrogen atom from one of two methyl groups in penN to trigger the ring arrangement. After the H-abstraction, the generated methylene radical intermediate can easily initiate the ring arrangement. First, the C-S bond cleaves to generate a thiyl radical, which is in concert with the formation of the terminal C═C double bond; the newly generated thiyl radical then rapidly shifts to the more stable tertiary C atom to complete ring expansion. In the final step, the FeIII-OH species abstracts the second hydrogen to give the desaturated DAOC product. During the catalysis, no active site residue is directly involved in the chemistry, which implies that the other pocket residues except the coordinate ones with iron play a role only in anchoring the substrate.

Functionalization and antimicrobial evaluation of ampicillin, penicillin and vancomycin with Pyrenacantha grandiflora Baill and silver nanoparticles.

Some antibiotics have lost their efficacy over common infections and this has led to the search for new antibiotics and chemically altering existing ones for a better control of infectious diseases. In the present study, Pyrenacantha grandiflora tubers extracts were conjugated with ampicillin, penicillin, vancomycin and silver nanoparticles and their antimicrobial activity was evaluated against Escherichia coli, Staphylococcus aureus and Klebsiella Pneumoniae. The reactions were confirmed by formation of new functional groups that were identified by Fourier transmission infrared spectroscopy (FTIR). Minimum inhibitory concentrations were determined using the microdilution assay. Minimum bactericidal concentrations and the fractional inhibition concentration index were also determined. FTIR analysis indicated different functional group associated with conjugation. The activity of ampicillin was improved when conjugated with silver nanoparticles against K. pneumonia and E. coli. Vancomycin showed improvement of activity when conjugated to silver nanoparticles against K. pneumonia. Penicillin was improved by acetone extracts and vancomycin showed to be more effective when conjugated with silver nanoparticles and water extracts. The conjugation of P. grandiflora with penicillin, ampicillin and vancomycin in the presence of silver nanoparticles improved their biological activities. Therefore, the conjugates are medicinally important and can be used to improve the activity of existing antibiotics.

On Column Binding a Real-Time Biosensor for ß-lactam Antibiotics Quantification.

This work aimed to develop accurate, quick, and practical tools for the detection of residues of penicillin G antibiotic in biological and non-biological samples. The assays were developed based on the binding mechanism of ß-lactam to penicillin-binding proteins; samples of different concentrations of penicillin G were incubated with in vitro expressed 6X-Histidine-tagged soluble penicillin-binding protein (PBP2x*) of Streptococcus pneumoniae (S. pneumoniae), whereby penicillin G in samples specifically binds to PBP2x*. The fluorescent-labeled ß-lactam analogue Bocillin FL was used as a competent substrate, and two different routes estimated the amounts of the penicillin G. The first route was established based on the differences in the concentration of non-bounded Bocillin FL molecules within the reactions while using a real-time polymerase chain reaction (PCR)-based method for fluorescence detection. The second route depended on the amount of the relative intensity of Bocillin FL bounded to Soluble PBP-2x*, being run on sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-page), visualized by a ChemiDoc-It®2 Imager, and quantified based on the fluorescence affinity of the competent substrate. While both of the methods gave a broad range of linearity and high sensitivity, the on column based real-time method is fast, non-time consuming, and highly sensitive. The method identified traces of antibiotic in the range 0.01-0.2 nM in addition to higher accuracy in comparison to the SDS-based detection method, while the sensitivity of the SDS-based method ranged between 0.015 and 2 µM). Thus, the on column based real time assay is a fast novel method, which was developed for the first time based on the binding inhibition of a fluorescence competitor material and it can be adapted to screen traces of penicillin G in any biological and environmental samples.

Antibiotic loading and development of antibacterial capsules by using porous CaCO3 microparticles as starting material.

Porous calcium carbonate (CaCO3) particles have been shown to be highly advantageous for biological applications, mainly due to their large surface area and their stability in physiological media. Also, developing appropriate antibacterial materials presenting the benefits of non-formation of harmful compounds is of major interest. Two characteristics of CaCO3 particles were investigated herein: (i) antibiotic-loading capacity and (ii) the possibility of using CaCO3 particles as a template for the fabrication of biocapsules presenting inherent antibacterial capacity. The particles were tested against two representative pathogenic bacteria (Staphylococcus aureus and Escherichia coli). On one hand, a method for antibiotic (namely penicillin, ampicillin and ciprofloxacin) loading inside calcium carbonate particles was developed and antibacterial activity was investigated. Encapsulation efficiency and loading content were 95% and 5%, respectively. We showed that antibiotics prevented bacterial growth within 2 h, with no evidence of bacterial regrowth within 16 h; bactericidal effects were also observed. On the other hand, the self-assembly of charged polysaccharides, namely chitosan (chi+) and dextran sulfate (dex-), were assessed on calcium carbonate microparticles used as a sacrificial matrix. During bacterial growth in a liquid medium, an inhibitory effect of these particles was observed, i.e. Staphylococcus aureus (Gram-positive) (from 16.3% to 48.8% for (chi+/dex-)n-chi+ coated CaCO3 materials and from 41.9% to 93.0% for (chi+/dex-)n-chi+ capsules) and Escherichia coli (Gram-negative) (from 18.2% to 45.5% for (chi+/dex-)n-chi+ coated CaCO3 materials and from 40.0% to 89.1% for (chi+/dex-)n-chi+ capsules). Staining with acridine orange highlighted the bactericidal effect of the designed particles. These findings demonstrate the excellent potential of using calcium carbonate particles in antibiotic therapy as a starting point for the development of smart materials.

The challenge of de-labeling penicillin allergy.

BACKGROUND: Even though 8%-25% of most populations studied globally are labeled as penicillin allergic, most diagnoses of penicillin allergy are made in childhood and relate to events that are either not allergic in nature, are low risk for immediate hypersensitivity, or are a potential true allergy that has waned over time. Penicillin allergy labels directly impact antimicrobial stewardship by leading to use of less effective and broader spectrum antimicrobials and are associated with antimicrobial resistance. They may also delay appropriate antimicrobial therapy and lead to increased risk of specific adverse healthcare outcomes. Operationalizing penicillin allergy de-labeling into a new arm of antimicrobial stewardship programs (ASPs) has become an increasing global focus. METHODS: We performed an evidence-based narrative review of the literature of penicillin allergy label carriage, the adverse effects of penicillin allergy labels, and current approaches and barriers to penicillin allergy de-labeling. Over the period 1928-2018 in Pubmed and Medline, search terms used included "penicillin allergy" or "penicillin hypersensitivity" alone or in combination with "adverse events," "testing," "evaluation," "effects," "label," "de-labeling," "prick or epicutaneous," and "intradermal" skin testing, "oral challenge or provocation," "cross-reactivity," and "antimicrobial stewardship". RESULTS: Penicillin allergy labels are highly prevalent, largely inaccurate and their carriage may lead to unnecessary treatment and inferior outcomes with alternative agents as well as adverse public health outcomes such as antibiotic resistance. CONCLUSIONS: Operationalizing penicillin allergy de-labeling as an aspect of ASP has become an increasing global focus. There is a need for validated approaches that optimally combine the use of history and ingestion challenge with or without proceeding formal skin testing to tackle penicillin allergy efficiently within complex healthcare systems. At the same time, there is great promise for penicillin allergy evaluation and de-labeling as an individual and public health strategy to reduce adverse healthcare outcomes, improve antimicrobial stewardship, and decrease healthcare costs.