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Penicillin V as first-line treatment of pneumonia in primary care: a registry-based study

Olof Cronberg¹, Mia Tyrstrup², Anders Beckman²

¹Växjöhälsan Primary Healthcare Centre, Växjö, Sweden; Department of Research and Development, Region Kronoberg, Växjö, Sweden; Department of Clinical Sciences, Family Medicine and Community Medicine, Lund University, Malmö, Sweden.

Clinical Microbiology and Infection : the Official Publication of the European Society of Clinical Microbiology and Infectious Diseases

|August 25, 2025

Insights

Penicillin V (PcV) and amoxicillin showed similar risks for hospitalization or death in pneumonia patients. However, amoxicillin led to fewer antibiotic switches compared to Penicillin V in primary care settings.

Area of Science:

Infectious Diseases
Pharmacology
Public Health

Background:

Penicillin V (PcV) is a recommended first-line treatment for community-acquired pneumonia in Scandinavia.
Limited data exist to support the recommendation of Penicillin V for pneumonia treatment.

Purpose of the Study:

To compare the efficacy of Penicillin V and amoxicillin in treating pneumonia.
To evaluate the risk of treatment failures, including hospitalization and antibiotic switch, in patients treated with Penicillin V versus amoxicillin.

Main Methods:

Retrospective study using Swedish healthcare registry data from 2018-2021.
Included 34,306 primary care pneumonia cases in individuals over 5 years old.
Analyzed hospitalization for lower respiratory tract infections (LRTI) or all-cause mortality and antibiotic switch using logistic regression and propensity score matching.

Main Results:

No significant difference in hospitalization for LRTI or all-cause mortality between Penicillin V and amoxicillin groups (aOR 1.07, 95% CI: 0.87-1.32).
Amoxicillin group had a lower rate of antibiotic switch compared to the Penicillin V group (aOR 0.58, 95% CI: 0.50-0.67).
Propensity score matching confirmed these findings.

Conclusions:

Penicillin V and amoxicillin demonstrate comparable safety profiles regarding severe outcomes in primary care pneumonia treatment.
Penicillin V can be considered an alternative treatment option in primary care, especially where resistance patterns align with Sweden's.
The higher rate of antibiotic switch with Penicillin V warrants consideration in clinical decision-making.

Read full analysis

Abstract

Objectives:

Penicillin V (PcV) is considered the first-line treatment for community-acquired pneumonia in Scandinavian countries, although data supporting this recommendation are scarce. Thus, this study aimed to compare PcV and amoxicillin regarding the risk of treatment failures in children aged >5 years and adults treated for pneumonia in primary care.

Methods:

In this retrospective study of healthcare registry data from four regions in Sweden with 2.3 million inhabitants, we included 34 306 primary care cases of pneumonia from February 12, 2018 to December 3, 2021. Adjusted odds ratios (aORs) and 95% CIs for treatment failure days 1 to 28 (primary composite endpoint: hospitalization for lower respiratory tract infections [LRTI] or all-cause mortality; and secondary endpoint: antibiotic switch) were calculated using logistic regression analysis. A propensity score matched analysis was conducted.

Results:

PcV was prescribed in 19 761 cases, amoxicillin in 2363 cases, doxycycline in 9830 cases, and other antibiotics in 2352 cases. Hospitalization for LRTI or all-cause mortality occurred in 4.9% of cases treated with amoxicillin vs. 3.8% of cases treated with PcV (aOR, 1.07; 95% CI, 0.87-1.32). Antibiotic switch occurred in 8.9% of cases treated with amoxicillin vs. 14% of cases treated with PcV (aOR, 0.58; 95% CI, 0.50-0.67). The corresponding ORs of the propensity score match analysis were 1.13 (95% CI, 0.86-1.49) for hospitalization for LRTI or all-cause mortality and 0.55 (95% CI, 0.45-0.65) for antibiotic switch.

Conclusions:

This study showed no difference in risks of hospitalization for LRTI or all-cause mortality between PcV and amoxicillin for pneumonia in primary care.

Keywords:

Amoxicillin Antibiotic switch Antibiotics Doxycycline Hospitalization Mortality Penicillin V Pneumonia Primary care Treatment failure

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