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• Dental Abscess
  A dentoalveolar abscess is an acute lesion characterized by localization of pus in the structures that surround the teeth.
  Amoxicillin/clavulanic acid is as effective as penicillin in the treatment of acute dentoalveolar abscess.
  
  In a randomised, operator-blind, comparative clinical trial1, the efficacy of co-amoxiclav (250 mg amoxycillin plus 125 mg clavulanic acid, eight-hourly) was compared to that of penicillin V (250 mg phenoxymethylpenicillin, six-hourly) in the treatment of acute dentoalveolar abscess. Symptoms improved in all patients, however those receiving amoxicillin/clavulanic acid recorded a significantly greater decrease in pain during the second and third days of the treatment. Only one patient reported a significant adverse effect associated with drug therapy, and this was in the penicillin group.
• Streptococcal pharyngitis (Strep throat)
  Amoxicillin/clavulanic acid and penicillin V are similarly effective for the first treatment of strep throat. There is no evidence that amoxicillin/clavulanic acid is better than penicillin V2.
  
  One hundred and sixty-five consecutive patients ( > 2 years of age) with acute group A streptococcal (GAS) pharyngitis randomly received amoxicillin/clavulanic acid (79 patients) or penicillin V (86 patients). After 7 days, tonsillar cultures from seven patients (9.6%) in the penicillin V group grew group A streptococcus; three of these patients had tonsillitis symptoms. In the amoxicillin/clavulanic acid group these figures were three (3.8%) and two respectively. Within the 12 month follow up period, there were 4 clinical recurrences (6.1%) in the penicillin V group and 7 (9.3%) in the co-amoxiclav group. There is no evidence that amoxicillin/clavulanic acid is better than oral penicillin V for the first treatment of acute GAS pharyngitis, but bacteriological failure and clinical recurrence are strongly associated with the presence of beta-lactamase activity in commensal flora.
• Recurrent Streptococcal tonsillitis
  Amoxicillin/clavulanic acid may be more effective than penicillin V for prevention of recurrent infection.
  
  The failure of penicillin to eradicate Group A beta-haemolytic streptococcal tonsillitis may be caused by beta-lactamase producing bacteria in the tonsillar tissue. A prospective randomized clinical study13 comparing the efficacy of penicillin-V potassium with amoxicillin plus clavulanate potassium (Augmentin) in the treatment of acute episodes of recurrent streptococcal tonsillitis was conducted. Twenty children were included in each group. Surface tonsillar cultures were obtained before therapy, 10 days after termination of therapy, and then once every two months for up to one year. beta-Lactamase producing aerobic and anaerobic bacteria were present in 34 of the 40 (85%) tonsillar cultures prior to treatment. Group A beta-haemolytic streptococci were eradicated in 14 of 20 (70%) patients treated with penicillin and in all those treated with amoxicillin/clavulanate potassium. In a one-year follow-up, 11 of the 19 patients treated with penicillin and two of the 18 treated with amoxycillin/clavulanate potassium had recurrent streptococcal tonsillitis (P less than 0.005). This study demonstrates the efficacy of amoxycillin/clavulanate potassium in the therapy of acute episodes of recurrent tonsillitis and prevention of recurrent infection.
• Otitis media (middle ear infection)
  Amoxicillin-clavulanate is superior to penicillin V in the treatment of otitis media.
  
  Prospective, double-blind, randomized study12 compared the effect of 2 different antimicrobial agents in the treatment of secretory otitis media. 360 children (aged 1-10 years) with secretory otitis media of at least 3 months' duration were evenly distributed among 4 treatment groups: penicillin V for 14 and 28 days, and amoxicillin and clavulanate potassium in combination for 14 and 28 days. Criteria for improvement was a change in tympanometric findings to type C1 or type A. The success rates were in favor of amoxicillin-clavulanate treatment for 28 days (rates for respective 14- and 28-day groups: penicillin V, 23% and 19%; amoxicillin-clavulanate, 31% and 44%). Antimicrobial therapy was more efficient in unilateral vs bilateral disease. Amoxicillin-clavulanate provides superior improvement to penicillin V.

• Streptococcal pharyngitis
  Once-daily amoxicillin is at least as effective as twice-daily penicillin V for the treatment of streptococcal pharyngitis in children10
  
  Randomised non-inferiority trial10 was conducted to test the non-inferiority of once-daily oral amoxicillin to the recommended twice-daily oral penicillin V in streptococcal pharyngitis. 353 children with positive throat swabs for GABHS were randomised to amoxicillin 1500 mg once-daily (n=177) or penicillin V (n=176) 500mg twice-daily for 10 days. Eradication of GABHS was determined with follow-up throat cultures on days 3-6, 12-16 and 26-36. Treatment failures (including relapses) occurred at each visit in 5.8%, 12.7% and 10.7% of amoxicillin recipients and 6.2%, 11.9% and 11.3% of penicillin V recipients respectively. No significant differences in resolution of symptoms were noted between treatment groups. In this adequately-powered study, once-daily oral amoxicillin is not inferior to twice-daily penicillin V for the treatment and eradication of GABHS in children with pharyngitis.

• Streptococcal pharyngitis/tonsillitis
  Azithromycin (10 or 20 mg/kg/day one daily for 3 days) is as safe and effective as penicillin V (4 times daily for 10 days) in the treatment of children with streptococcal pharyngitis/tonsillitis. However, azithromycin once daily 10 mg/kg for 3 days has lower levels of bacteriologic eradication than penicillin V 100,000 IU/kg/day for 10 days in the theatment of streptococcal pharyngitis15.
  
  The efficacy and safety of azithromycin and penicillin V in the treatment of acute streptococcal pharyngitis/tonsillitis in paediatric patients were compared in a double-blind, double-dummy prospective study11. A satisfactory clinical response (cure or improvement) was recorded in 99% of the 10 mg/kg azithromycin group, 100% of the 20 mg/kg azithromycin group, and 97% of the penicillin V group at the end of therapy (day 12-14). At the follow-up evaluation (day 28-30), relapse rates in patients cured or improved at the end of therapy were 6%, 5%, and 2%, respectively. Bacteriological eradication rates at the end of therapy were 98% in both azithromycin groups and 92% in patients who received penicillin V; pathogen recurrence was recorded at follow-up in 4% of the 20 mg/kg azithromycin group and in 6% of both the 10 mg/kg azithromycin and penicillin V groups. Treatment-related adverse events, the majority of mild to moderate severity, occurred in 13% of patients in the 20 mg/kg azithromycin group, 9% in the 10 mg/kg azithromycin group, and 5% in the penicillin V group.
• Lyme disease
  Azithromycin appears to be as effective as penicillin V for the treatment of early Lyme disease and it seems to clear the erythema migrans more promptly.
  
  In a randomized multicenter therapeutic trial9, 32 patients with erythema migrans received oral azithromycin 500 mg once daily and 33 patients received phenoxymethylpenicillin (penicillin V) 1 million U three times daily for 10 days. Four weeks after initiation of therapy, 20 (62%) patients given azithromycin and 17 (51%) patients given penicillin V were completely free of all signs and symptoms and did not develop new ones subsequently (no significant difference). Three months after initiation of therapy, the corresponding figures were 25 (78%) azithromycin and 28 (85%) penicillin V recipients (no significant difference). There were only minor sequelae such as arthralgia, headache, fatigue, stiff neck and dysesthesia. Azithromycin led to a significantly faster resolution of the erythema migrans than penicillin V. Usually mild to moderate side effects occurred in 12 patients given azithromycin and five patients given penicillin V.

• Streptococcal pharyngitis/tonsillitis
  Clarithromycin extended-release (ER) 500 mg once daily for 5 days is equally effective as penicillin V 500 mg three times daily for 10 days in the treatment of adolescents and adults with streptococcal tonsillopharyngitis.
  
  Multicenter, double-blind, randomized study14 compared a short-course of clarithromycin with a standard course of penicillin V in patients with tonsillopharyngitis caused by Streptococcus pyogenes. A total of 539 patients, aged 12-75 years, were randomized to receive either clarithromycin extended-release (ER) 500 mg once daily for 5 days or penicillin V 500 mg three times daily for 10 days. Bacteriological and clinical assessments were conducted at each study visit (visit 1: study day 1; visit 2: study day 3; visit 3: study days 8-12; visit 4: study days 13-20; and visit 5: study days 40-50). At the test-of-cure visit (visit 3 for clarithromycin ER patients and visit 4 for penicillin V patients) in per-protocol patients, 5 days of clarithromycin ER was comparable to 10 days of penicillin V in eradicating S. pyogenes (89% (157/177) vs 90% (139/154) respectively). Bacterial eradication was sustained in both treatment groups at the follow-up visit (88% (135/153) vs 91% (112/123) respectively). Clinical cure was achieved in > or = 94% of patients in each treatment group. The most commonly reported drug-related adverse events (< or = 3% in either treatment group) were abdominal pain, diarrhea, dyspepsia and nausea.
• Streptococcal pharyngitis/tonsillitis
  Five days' treatment with clarithromycin is superior to 10 days of penicillin in eradicating group A beta-hemolytic streptococcus (GABHS).
  
  The safety and efficacy of clarithromycin and penicillin V were compared in a randomized, investigator-blind study16. Children 6 months to 12 years of age received 5 days of clarithromycin suspension 7.5 mg/kg twice daily (n = 268) or 10 days of penicillin V suspension 13.3 mg/kg three times daily (n = 260). Patients were evaluated for signs and symptoms of pharyngitis, and throat swabs for culture were obtained prior to therapy, at the end of therapy, and at follow-up. Clarithromycin and penicillin V produced comparable rates of clinical success (cure + improvement) at the posttreatment (97% and 94%) and follow-up (81% and 82%) evaluations. The GABHS eradication rate, however, was significantly higher with clarithromycin (94% vs 78%).

• Lyme disease (erythema migrans)
  Cefuroxime axetil and phenoxymethyl penicillin are equally effective in the treatment of children with erythema migrans. Side effects occur more frequently with cefuroxime axetil.
  
  The clinical study4 compared the efficacy and drug-related adverse effects of cefuroxime axetil or phenoxymethyl penicillin in the treatment of children with erythema migrans. Forty-six patients received cefuroxime axetil (group C) and 44, phenoxymethyl penicillin (group P). The clinical course during the post-treatment period revealed no significant differences between the two groups: the duration of erythema migrans (7.1 +/- 7.5 days in group C, 10.6 +/- 19.3 days in group P) and the appearance of minor manifestations of Lyme borreliosis (8.8% in group C, 9.1% in group P) were comparable; no major manifestations were recorded. Twelve months after antibiotic treatment all patients were free of symptoms. The patients treated with cefuroxime axetil had more drug-related adverse effects than did those treated with phenoxymethyl penicillin (26.1% versus 6.8%). "Herxheimer's reaction" at the beginning of treatment was identified more often in group C than in group P.
• Streptococcal pharyngitis
  Cefuroxime axetil is at least as effective as penicillin V in the treatment of streptococcal pharyngitis and may be more effective in preventing the carrier state6-8.
  
  The German Society for Pediatric Infectious Diseases (DGPI) undertook a large study of culture-proven tonsillopharyngitis involving several agents and included a 1 year follow-up to establish the effect on complications. In one arm of this study, cefuroxime 250 mg bid was compared with 50,000 IU penicillin V given in three divided doses. Cefuroxime axetil was more effective than oral penicillin V in eradicating group A beta-haemolytic streptococci (GABHS) at the assessment 2-4 days post-treatment (441/490 (90%) patients versus 1196/1422 (84%) patients). Clinically, the two agents were equivalent in efficacy, and carriage rates were similar (11.1% and 13.8%, respectively) in patients receiving cefuroxime axetil and penicillin V, 7-8 weeks post-treatment. One case of glomerular nephritis occurred in a patient given penicillin V. There were no post-streptococcal complications confirmed for patients treated with cefuroxime axetil. The findings confirm the previously reported efficacy of short-course (4-5 day) treatments with cefuroxime axetil and indicate that short-course treatment is comparable to the standard oral penicillin V regimen in preventing post-streptococcal sequelae.
• Recurrent Streptococcal pharyngitis
  Cefuroxime axetil is more effective than penicillin V for the treatment of recurrent tonsillopharyngitis.
  
  Comparative, randomized, investigator-blind, multicentre trial5 studied the efficacy of cefuroxime axetil compared with penicillin V for recurrent tonsillopharyngitis (group A beta-haemolytic streptococci). A total of 236 children (aged 3-12 years with a history of at least 1 episode of tonsillopharyngitis requiring antibiotic therapy during the previous 3 months) with culture-proven tonsillitis received either cefuroxime axetil suspension or penicillin V syrup. Cefuroxime axetil treatment gave a significantly higher bacteriological eradication rate and improvement in signs and symptoms rate than penicillin V. At day 2-5 post treatment the eradication rates were 99/114 (87%) for cefuroxime axetil vs 61/109 (56%) for penicillin V. The clinical cure (resolution of signs and symptoms) rates were 98/114 (86%) and 73/109 (67%) respectively. Up to 21-28 days post-treatment, 9/114 (8%) cefuroxime axetil patients and 37/109 (34%) penicillin V patients were treatment failures or had recurrence/reinfection of streptococcal tonsillopharyngitis. More than 90% of the patients who experienced bacteriological treatment failure at either the first or second follow-up had the same serotype isolated pre- and post-treatment. During the study period, 21/114 (18%) patients in the cefuroxime axetil group and 50/109 (46%) patients in the penicillin V group received additional antibiotics. No serious adverse events were noted and the mild adverse events were equally distributed among the patients in the 2 study groups: 15% for cefuroxime axetil and 14% for penicillin V.

• Streptococcal pharyngitis
  Cefaclor is more effective than penicillin V in staphylococcal infections in children.
  
  Prospective randomized study18 compared the effectiveness of penicillin V (50,000 to 100,000 IU/kg/day in three divided doses) and Cefaclor (20 to 40 mg/kg/day in three divided doses), each given for ten consecutive days. Cefaclor was given to 56 patients and penicillin V to 61 (children mean age 5.7 years). Reevaluation with a repeat bacteriologic study was performed in all patients at the end of the treatment period, or earlier in the event of new clinical manifestations, and towards D40. Among patients given penicillin V, bacteriologic failure rate at completion of therapy was 19.6%, clinical failure rate on D10 was 8%, and recurrence rate on D40 was 16.5%. Cefaclor exhibited greater bacteriologic and clinical effectiveness, with 3.4% bacteriologic failures on D10, 1.7% clinical failures on D10, 8.9% clinical recurrences between D10 and D40, and an overall 10.6% rate of failure or recurrence.

• Streptococcal pharyngitis
  Cefadroxil and penicillin V are similarly effective in the treatment of streptococcal pharyngitis in children.
  
  The efficacy of cefadroxil, an orally administered broad spectrum cephalosporin, was compared with that of penicillin V in several studies comprising more than 550 children with group A beta-haemolytic streptococcal (GABHS) pharyngitis19. Both drugs alleviated clinical signs and symptoms and eradicated GABHS from the upper respiratory tract within 18 to 24 hours of the initiation of therapy. Approximately 8% of the patients treated with either cefadroxil or penicillin V had strains of GABHS isolated from 1 of their follow-up throat cultures which were considered bacteriological treatment failures. Compliance was greater than 90% with all of the regimens used, but was significantly better with cefadroxil given as a 30 mg/kg dose once daily than with penicillin V given 3 times daily. There were no serious adverse reactions with either drug.

• Otitis, Sinusitis
  Ciprofloxacin is more effective than penicillin V in the treatment of otitis and sinusitis.
  
  80 adult patients suffering from otitis media, sinusitis (maxillaris or frontalis) or peritonsillitis were treated with 500 mg ciprofloxacin 2 times daily (n = 40) or with 2 g penicillin V 3 times daily (n = 40)17. The patients were randomly allocated. Three groups of patients resulted, clinically and bacteriologically evaluable, or only clinically evaluable because the isolated strains were resistant to ciprofloxacin or penicillin V or because no strains were isolated. Ciprofloxacin was superior to penicillin V; there were fewer resistant strains (one compared to 11), and the eradication rate (57% compared to 43%) as well as the clinical efficacy (60% compared to 48%) of ciprofloxacin were better than those of penicillin V--even in a daily dose of 6.0 g. Both treatments were well tolerated; side effects were neither reported nor found.

• Orofacial infections
  Penicillin and clindamycin are both efffective in the treatment of orofacial infections.
  
  The efficacy of clindamycin and phenoxymethylpenicillin in the treatment of orofacial infections was compared in a randomised study3 in 60 patients: 30 patients received clindamycin 150 mg every 6 h for seven days, and 30 received phenoxymethylpenicillin (penicillin V) 1 g every 12 h for seven days. All patients but one in each group responded satisfactorily to treatment. Although the clindamycin group had a shorter duration of pain, swelling and fever, the differences between the groups were not statistically significant. Of the 60 microbiological specimens 23 yielded only anaerobic bacteria, 34 both anaerobic and aerobic bacteria, two aerobic bacteria only and one no growth. In the penicillin group one case of severe diarrhoea occurred, and six patients in the clindamycin group had moderate to severe gastrointestinal discomfort, including one case of Clostridium difficile associated diarrhoea. This difference was however not statistically significant. The results support the continued use of penicillin for treatment of orofacial infections, with clindamycin serving as an effective alternative.

• Penicillin VK (Pen-Vee K) Medical Facts

• 1. Lewis MA, Carmichael F, MacFarlane TW, Milligan SG. A randomised trial of co-amoxiclav (Augmentin) versus penicillin V in the treatment of acute dentoalveolar abscess. Br Dent J. 1993 Sep 11;175(5):169-74. PubMed
• 2. Dykhuizen RS, Golder D, Reid TM, Gould IM. Phenoxymethyl penicillin versus co-amoxiclav in the treatment of acute streptococcal pharyngitis, and the role of beta-lactamase activity in saliva. J Antimicrob Chemother. 1996 Jan;37(1):133-8. PubMed
• 3. von Konow L, Kondell PA, Nord CE, Heimdahl A. Clindamycin versus phenoxymethylpenicillin in the treatment of acute orofacial infections. Eur J Clin Microbiol Infect Dis. 1992 Dec;11(12):1129-35. PubMed
• 4. Arnez M, Radsel-Medvescek A, Pleterski-Rigler D, Ruzic'-Sabljic' E, Strle F. Comparison of cefuroxime axetil and phenoxymethyl penicillin for the treatment of children with solitary erythema migrans. Wien Klin Wochenschr. 1999 Dec 10;111(22-23):916-22. PubMed
• 5. Holm S, Henning C, Grahn E, Lomberg H, Staley H. Is penicillin the appropriate treatment for recurrent tonsillopharyngitis? Results from a comparative randomized blind study of cefuroxime axetil and phenoxymethylpenicillin in children. The Swedish Study Group. Scand J Infect Dis. 1995;27(3):221-8. PubMed
• 6. Gooch WM 3rd, Swenson E, Higbee MD, Cocchetto DM, Evans EC. Cefuroxime axetil and penicillin V compared in the treatment of group A beta-hemolytic streptococcal pharyngitis. Clin Ther. 1987;9(6):670-7. PubMed
• 7. Scholz H. Streptococcal-A tonsillopharyngitis: a 5-day course of cefuroxime axetil versus a 10-day course of penicillin V. results depending on the children's age. Chemotherapy. 2004 Apr;50(1):51-4. PubMed
• 8. Adam D, Scholz H, Helmerking M. Comparison of short-course (5 day) cefuroxime axetil with a standard 10 day oral penicillin V regimen in the treatment of tonsillopharyngitis. J Antimicrob Chemother. 2000 Feb;45 Suppl:23-30. PubMed
• 9. Weber K, Wilske B, Preac-Mursic V, Thurmayr R. Azithromycin versus penicillin V for the treatment of early Lyme borreliosis. Infection. 1993 Nov-Dec;21(6):367-72. PubMed
• 10. Lennon DR Fracp, Farrell E Mhsc, Martin DR Phd, Stewart JM Msc. Once-daily Amoxicillin versus Twice-daily Penicillin V in Group A {beta}-Hemolytic Streprococcus Pharyngitis. Arch Dis Child. 2008 Mar 12 PubMed
• 11. O'Doherty B. Azithromycin versus penicillin V in the treatment of paediatric patients with acute streptococcal pharyngitis/tonsillitis. Paediatric Azithromycin Study Group. Eur J Clin Microbiol Infect Dis. 1996 Sep;15(9):718-24. PubMed
• 12. Thomsen J, Sederberg-Olsen J, Balle V, Hartzen S. Antibiotic treatment of children with secretory otitis media. Amoxicillin-clavulanate is superior to penicillin V in a double-blind randomized study. Arch Otolaryngol Head Neck Surg. 1997 Jul;123(7):695-9. PubMed
• 13. Brook I. Treatment of patients with acute recurrent tonsillitis due to group A beta-haemolytic streptococci: a prospective randomized study comparing penicillin and amoxycillin/clavulanate potassium. J Antimicrob Chemother. 1989 Aug;24(2):227-33. PubMed
• 14. Takker U, Dzyublyk O, Busman T, Notario G. Comparison of 5 days of extended-release clarithromycin versus 10 days of penicillin V for the treatment of streptococcal pharyngitis/tonsillitis: results of a multicenter, double-blind, randomized study in adolescent and adult patients. Curr Med Res Opin. 2003;19(5):421-9. PubMed
• 15. Schaad UB, Kellerhals P, Altwegg M; Swiss Pharyngitis Study Group. Azithromycin versus penicillin V for treatment of acute group A streptococcal pharyngitis. Pediatr Infect Dis J. 2002 Apr;21(4):304-8. PubMed
• 16. McCarty J, Hedrick JA, Gooch WM. Abstract Clarithromycin suspension vs penicillin V suspension in children with streptococcal pharyngitis. Adv Ther. 2000 Jan-Feb;17(1):14-26. PubMed
• 17. Falser N, Mittermayer H, Weuta H. Antibacterial treatment of otitis and sinusitis with ciprofloxacin and penicillin V--a comparison. Infection. 1988;16 Suppl 1:S51-4. PubMed
• 18. Cohen R, de La Rocque F, Boucherat M, Lecompte MD, Bouhanna A, Wollner A, Ponet D, Elbez A, Richoux F, Brami A, et al. Cefaclor versus penicillin V in staphylococcal infections in children. Ann Pediatr (Paris). 1991 Apr;38(4):289-95. PubMed
• 19. Gerber MA. A comparison of cefadroxil and penicillin V in the treatment of streptococcal pharyngitis in children. Drugs. 1986;32 Suppl 3:29-32. PubMed

Published: March 31, 2008
Last updated: January 09, 2010