Is 5 Days of Penicillin For Strep Pharyngitis Enough?

November 11, 2019

Written by Clay Smith

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A 5-day course of penicillin was non-inferior to a 10-day course for group A streptococcal pharyngitis (GASP).

Why does this matter?
Ten days of penicillin is typical for GASP. This duration was chosen because it was shown effective in reducing acute rheumatic fever (ARF). Currently, ARF is extremely rare in higher-income countries. Treatment is largely to reduce the burden of symptoms. So, would a shorter course be effective?

GASP! Just 5 days?
This was a multicenter, open-label RCT in Sweden that included 433 patients over age 6 with 3 out of 4 Centor criteria plus a positive rapid strep test. They were randomized to receive either penicillin V 800mg po QID x 5 days (16g total dose) or 1000mg po TID x 10 days (30g total dose). The lower dose regimen was non-inferior to the higher dose regimen for the primary outcome of clinical cure: 89.6% vs. 93.3%, respectively (95%CI -9.7 to 2.2). Secondary outcomes were similar with two possible areas of interest. First, bacterial eradication was a bit higher in the longer duration group. But there were more minor adverse events in the longer duration group. Time to symptom improvement was better in the shorter duration group.

Source
Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019 Oct 4;367:l5337. doi: 10.1136/bmj.l5337.

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