SNAP Trial Findings Favor Penicillin Over Antistaphylococcal Penicillins for Susceptible Staph Bacteremia

Benzylpenicillin is as effective as, and safer than, the antistaphylococcal penicillins cloxacillin or flucloxacillin in treating penicillin-susceptible Staphylococcus aureus (PSSA), according to findings of the global Staphylococcus aureus Network Adaptive Platform (SNAP) trial.¹

Although the rise of penicillinase-producing S aureus prompted development and widespread use of the antistaphylococcal semisynthetic penicillins, the investigators point out that PSSA is reemerging internationally—responsible for up to 25% of all clinical S aureus isolates in some areas—and that treatment with penicillin has fewer associated adverse effects such as phlebitis, hepatotoxicity, and nephrotoxicity.

"Although antistaphylococcal penicillins should no longer be considered the standard of care for adults with PSSA bacteremia, whether benzylpenicillin or cefazolin should be preferred is a question that remains unanswered," the investigators indicated.

To ascertain whether benzylpenicillin is noninferior to flucloxacillin or cloxacillin for S aureus bacteremia that has laboratory-confirmed penicillin susceptibility, they followed 90-day outcomes of 493 patients with PSSA bacteremia in the platform trial of over 2600 adult patients assigned to siloed groups based on antibiotic susceptibility of their PSSA, methicillin-susceptible S aureus (MSSA), or methicillin-resistant S aureus isolates.

The primary outcome was all-cause mortality at 90 days. Determining a 90-day mortality rate of 15% in the control group, a noninferiority margin of adjusted OR less than 1.20 translated to an absolute difference of 2.5% in 90-day mortality. Superiority was defined as an adjusted OR of less than 1.0.

The recommended standard dosing of benzylpenicillin was 1.8 g (3 million units) intravenously every 4 hours or 2.4 g (4 million units) every 6 hours, at the discretion of the treating clinician. The semisynthetic penicillin regimens were flucloxacillin 2 g intravenously every 6 hours or cloxacillin 2 g every 4 hours; each adjusted for renal dysfunction, critical illness, and continuous infusion. Duration of treatment was a minimum of 14 days for uncomplicated bacteremia and between 28 and 42 days for complicated bacteremia.

The SNAP investigators reported that 21 of 152 patients (14%) in the benzylpenicillin group and 26 of 121 patients (22%) in the flucloxacillin or cloxacillin group met the primary outcome of death at 90 days (adjusted OR, 0.67; 95% CI, 0.35-1.28; posterior probability of benzylpenicillin noninferiority of 96.1% and superiority of 88.9%).

The issue of safety was prominent in this assessment, with acute renal injury occurring in 17 of 153 patients (11%) in the benzylpenicillin group compared with 27 of 124 patients (22%) receiving flucloxacillin or cloxacillin. This portion of the platform trial, in addition to the comparison of cefazolin to semisynthetic penicillins for MSSA, was discontinued early in response to that safety signal.

In accompanying commentary, Annette Westgeest, PhD, of the Department of Infectious Diseases at Leiden University Medical Center in the Netherlands, and Vance Fowler Jr, MD, MHS, of the Division of Infectious Diseases in the Department of Medicine at Duke University School of Medicine in Durham, North Carolina, welcomed these first published results from the SNAP trial, characterizing them as key contributions to the field.²

"First, it shows that benzylpenicillin is likely to be at least noninferior to flucloxacillin or cloxacillin in terms of 90-day mortality and is probably less nephrotoxic. Second, the results support the use of a combination of automated screening and confirmatory modern phenotypic penicillin-susceptibility testing to guide treatment decisions involving benzylpenicillin," Westgeest and Fowler indicated.²

References

1. Staphylococcus aureus Network Adaptive Platform (SNAP) Trial Group. Benzylpenicillin versus flucloxacillin or cloxacillin for the treatment of penicillin-susceptible Staphylococcus aureus bacteremia (SNAP): an international, multicentre, open-label, non-inferiority randomised controlled trial. Lancet. 2026;408(10550):141-152. doi:10.1016/S0140-6736(26)00761-0

2. Westgeest AC, Fowler VG JR. Treating penicillin-susceptible Staphylococcus aureus bacteraemia: confusing the issue with facts. Lancet. 2026;408(10550):99-101. doi:10.1016/S0140-6736(26)00857-3