Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults

doi:10.1136/bmj.320.7228.150

BMJ 2000;320:150-154 ( 15 January )

General Practice

Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults

Editorial by Del Mar

Sjoerd Zwart, senior researcher, ^a Alfred P E Sachs, senior researcher, ^a Gijs J H M Ruijs, clinical microbiologist, ^b Jan W Gubbels, statistician, ^c Arno W Hoes, professor of clinical epidemiology, ^a Ruut A de Melker, formerly professor of general practice. ^a

^a Julius Center for General Practice and Patient-oriented Research, University Medical Center Utrecht, 3584 CG Utrecht, Netherlands, ^b Laboratory for Microbiology and Infectious Diseases, Isala Clinics, Zwolle, Netherlands, ^c Organisation for Advice on Research and Policymaking, Grave, Netherlands

Correspondence to: S Zwart s.zwart{at}med.uu.nl

Objective: To assess whether treatment with penicillinfor three days and the traditional treatment for seven days wereequally as effective at accelerating resolution of symptoms inpatients with sore throat compared withplacebo.
Design: Randomised double blind placebo controlledtrial.
Setting: 43 family practices in theNetherlands.
Participants: 561 patients, aged 15-60 years, with sorethroat for less than seven days and at least three of the fourCentor criteria $---$ that is, history of fever, absence of cough, swollentender anterior cervical lymph nodes, and tonsillar exudate. 142patients were excluded for medical reasons and 73 neededpenicillin.
Interventions: Patients were randomly assigned to penicillinV for seven days, penicillin V for three days followed by placebofor four days, or placebo for sevendays.
Main outcome measures: Resolution of symptoms in the first week,eradication of bacteria after two weeks, and recurrences of sorethroat after two, four, and sixmonths.
Results: Symptoms resolved 1.9 and 1.7 days earlierin patients taking penicillin for seven days than in those takingpenicillin for three days or placebo respectively. Symptoms resolved2.5 days earlier in patients with group A streptococci and 1.3days earlier in patients with high colony counts of non-groupA streptococci. 23 (13%) of the placebo group had to be givenantibiotics later in the week because of clinical deterioration;three developed a peritonsillar abscess. The eradication ratefor group A streptococci was 72% in the seven day penicillin group,41% in the three day penicillin group, and 7% in the placebo group.Sore throat recurred more often in the three day penicillin groupthan in the seven day penicillin or placebogroups.
Conclusion: Penicillin treatment for seven days was superiorto treatment for three days or placebo in resolving symptoms ofsore throat in patients with group A streptococcal pharyngitisand, possibly, in those with non-group A streptococcalpharyngitis.

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Rapid Responses:

Read all Rapid Responses

Length of penicillin treatment of streptococcal infections: Dan Michaeli
bmj.com, 15 Jan 2000 [Full text]
The problem with seven day treatment of group A streptococcus tonsillitis /pharyngitis: Munir E Nassar
bmj.com, 17 Jan 2000 [Full text]
Antibiotics for sore throats? inappropriate therapy in the new mellennium: R Fleetcroft
bmj.com, 19 Jan 2000 [Full text]
On the seventh day ye shall NOT rest: Gary Zentner
bmj.com, 20 Jan 2000 [Full text]
For sore throats, seven days of penicillin is not superior.: Erdem I Cantekin
bmj.com, 20 Jan 2000 [Full text]
Re: For sore throats, seven days of penicillin is not superior.: Peter Burke
bmj.com, 24 Jan 2000 [Full text]
Importance and generaliseability of trial data: Paul Little
bmj.com, 25 Jan 2000 [Full text]
Authors' response: Sjoerd Zwart
bmj.com, 22 Feb 2000 [Full text]