Penicillin V 4 times daily for 5 Days VS 3 times daily for 10 Days in Patients with Pharyngotonsillitis

Fig: Pharyngotonsillitis


  • It is important to optimize existing antibiotics in view of increasing antimicrobial resistance and paucity of new drugs in this class. One of the most common infections treated by primary care physicians is pharyngotonsillitis, and it is associated with a significant proportion of antibiotic prescriptions in Sweden.
  • This open-label Swedish study compared the outcomes in patients with streptococci A pharyngotonsillitis who were randomized to receive either a shorter and more frequent treatment regimen with penicillin V or the recommended 10-day treatment regimen. The investigators found both regimens to be noninferior in terms of clinical outcomes.

  • Changing the penicillin V treatment regimen from 10 days at three times daily to 5 days at four times daily could be an effective treatment and may help reduce the total consumption of penicillin V.

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To determine whether total exposure to penicillin V can be reduced while maintaining adequate clinical efficacy when treating pharyngotonsillitis caused by group A streptococci.


Open label, randomised controlled non-inferiority study.


17 primary healthcare centres in Sweden between September 2015 and February 2018.


Patients aged 6 years and over with pharyngotonsillitis caused by group A streptococci and three or four Centor criteria (fever ≥38.5°C, tender lymph nodes, coatings of the tonsils, and absence of cough).


Penicillin V 800 mg four times daily for five days (total 16 g) compared with the current recommended dose of 1000 mg three times daily for 10 days (total 30 g).


Primary outcome was clinical cure five to seven days after the end of antibiotic treatment. The non-inferiority margin was prespecified to 10 percentage points. Secondary outcomes were bacteriological eradication, time to relief of symptoms, frequency of relapses, complications and new tonsillitis, and patterns of adverse events.


Patients (n=433) were randomly allocated to the five day (n=215) or 10 day (n=218) regimen. Clinical cure in the per protocol population was 89.6% (n=181/202) in the five day group and 93.3% (n=182/195) in the 10 day group (95% confidence interval -9.7 to 2.2).

Bacteriological eradication was 80.4% (n=156/194) in the five day group and 90.7% (n=165/182) in the 10 day group. Eight and seven patients had relapses, no patients and four patients had complications, and six and 13 patients had new tonsillitis in the five day and 10 day groups, respectively.

Time to relief of symptoms was shorter in the five day group. Adverse events were mainly diarrhoea, nausea, and vulvovaginal disorders; the 10 day group had higher incidence and longer duration of adverse events.


Penicillin V four times daily for five days was non-inferior in clinical outcome to penicillin V three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci. The number of relapses and complications did not differ between the two intervention groups.

Five day treatment with penicillin V four times daily might be an alternative to the currently recommended 10 day regimen.

Practice Update
This is for informational purposes only. You should consult your clinical textbook for advising your patients.