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Pneumonia

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What is covered

This NICE Pathway covers assessing and managing community-acquired pneumonia and hospital-acquired pneumonia. However, it does not provide recommendations on areas of care where best practice is already established, such as diagnosis using chest X-ray. It does not cover bronchiectasis complicated by pneumonia, or patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end-of-life care.
For recommendations on managing pneumonia in adults during the COVID-19 pandemic see the NICE COVID-19 rapid guidelines on managing suspected or confirmed pneumonia in adults in the community and antibiotics for pneumonia in adults in hospital. Where the new recommendations cover existing recommendations in this NICE Pathway, follow the rapid guideline recommendations during the pandemic.

Updates

Updates to this NICE Pathway

9 October 2020 Amended the cefuroxime dosage in the table on antibiotics for adults with hospital-acquired pneumonia to give the full range of options for flexibility.
1 May 2020 Pathway updated to remove NICE guideline CG191, which has been withdrawn during the COVID-19 pandemic.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to microbiological tests.
16 September 2019 Pneumonia (community-acquired): antimicrobial prescribing (NICE guideline NG138) and pneumonia (hospital-acquired): antimicrobial prescribing (NICE guideline NG139) added.
23 August 2016 Extracorporeal carbon dioxide removal for acute respiratory failure (NICE interventional procedures guidance 564) added to severe acute respiratory failure and monitoring in hospital.
18 January 2016 Pneumonia in adults (NICE quality standard 110) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to microbiological tests.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on assessing and managing community- and hospital-acquired pneumonia in an interactive flowchart

What is covered

This NICE Pathway covers assessing and managing community-acquired pneumonia and hospital-acquired pneumonia. However, it does not provide recommendations on areas of care where best practice is already established, such as diagnosis using chest X-ray. It does not cover bronchiectasis complicated by pneumonia, or patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end-of-life care.
For recommendations on managing pneumonia in adults during the COVID-19 pandemic see the NICE COVID-19 rapid guidelines on managing suspected or confirmed pneumonia in adults in the community and antibiotics for pneumonia in adults in hospital. Where the new recommendations cover existing recommendations in this NICE Pathway, follow the rapid guideline recommendations during the pandemic.

Updates

Updates to this NICE Pathway

9 October 2020 Amended the cefuroxime dosage in the table on antibiotics for adults with hospital-acquired pneumonia to give the full range of options for flexibility.
1 May 2020 Pathway updated to remove NICE guideline CG191, which has been withdrawn during the COVID-19 pandemic.
18 February 2020 SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (NICE diagnostics guidance 20) added to microbiological tests.
16 September 2019 Pneumonia (community-acquired): antimicrobial prescribing (NICE guideline NG138) and pneumonia (hospital-acquired): antimicrobial prescribing (NICE guideline NG139) added.
23 August 2016 Extracorporeal carbon dioxide removal for acute respiratory failure (NICE interventional procedures guidance 564) added to severe acute respiratory failure and monitoring in hospital.
18 January 2016 Pneumonia in adults (NICE quality standard 110) added.
6 October 2015 Procalcitonin testing for diagnosing and monitoring sepsis (NICE diagnostics guidance 18) added to microbiological tests.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Pneumonia (hospital-acquired): antimicrobial prescribing (2019 updated 2020) NICE guideline NG139
Extracorporeal membrane carbon dioxide removal for acute respiratory failure (2016) NICE interventional procedures guidance 564
SepsiTest assay for rapidly identifying bloodstream bacteria and fungi (2016, updated 2020) NICE diagnostics guidance 20
Antimicrobial prescribing: Ceftazidime/avibactam (2017) NICE evidence summary ES16
Fungitell for antifungal treatment stratification (2017) NICE medtech innovation briefing 118
Alere Afinion CRP for C-reactive protein testing in primary care (2016) NICE medtech innovation briefing 81
QuikRead go for C-reactive protein testing in primary care (2016) NICE medtech innovation briefing 78

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Antibiotics for children and young people under 18 years with hospital-acquired pneumonia

Antibiotic
Dosage and course length
Choice for children under 1 month
Antibiotic choice based on local resistance data and specialist microbiological advice
First choice oral antibiotic for children aged 1 month and over if non-severe symptoms or signs and not at higher risk of resistance (guided by microbiological results when available)
Co-amoxiclav
1 month to 11 months, 0.5 ml/kg of 125/31 suspension three times a day for 5 days, then review
1 year to 5 years, 10 ml of 125/31 suspension (or 5 ml of 250/62 suspension) three times a day, or 0.5 ml/kg of 125/31 suspension three times a day for 5 days, then review
6 years to 11 years, 10 ml of 250/62 suspension three times a day or 0.3 ml/kg of 250/62 suspension three times a day for 5 days, then review
12 years to 17 years, 500/125 mg three times a day for 5 days, then review
Alternative oral antibiotics for children aged 1 month and over if non-severe symptoms or signs and not at higher risk of resistance, for penicillin allergy or if co-amoxiclav unsuitable (other options may be suitable based on specialist microbiological advice and local resistance data)
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days, then review
8 kg to 11 kg, 62.5 mg twice a day for 5 days, then review
12 kg to 19 kg, 125 mg twice a day for 5 days, then review
20 kg to 29 kg, 187.5 mg twice a day for 5 days, then review
30 kg to 40 kg, 250 mg twice a day for 5 days, then review
12 years to 17 years, 500 mg twice a day for 5 days, then review
First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis), or at higher risk of resistance (antibiotic choice should be based on specialist microbiological advice and local resistance data)
Options include:
Piperacillin with tazobactam
1 month to 11 years, 90 mg/kg three or four times a day (maximum 4.5 g per dose four times a day)
12 years to 17 years, 4.5 g 3 times a day (increased to 4.5 g four times a day if severe infection)
Ceftazidime
1 month to 17 years, 25 mg/kg three times a day (50 mg/kg three times a day if severe infection; maximum 6 g per day)
Ceftriaxone
1 month to 11 years (up to 50 kg), 50 mg/kg to 80 mg/kg once a day (use dose at higher end of range if severe infection; maximum 4 g per day)
9 years to 11 years (50 kg and above), 2 g once a day
12 years to 17 years, 2 g once a day
Antibiotics to be added if suspected or confirmed MRSA infection (dual therapy with a first-choice IV antibiotic)
Teicoplanin
1 month, initially 16 mg/kg for 1 dose, then 8 mg/kg once daily, subsequent dose to be given 24 hours after initial dose (doses given by IV infusion)
2 months to 11 years, initially 10 mg/kg every 12 hours intravenously for 3 doses, then 6 mg/kg to 10 mg/kg once daily intravenously
12 years to 17 years, initially 6 mg/kg every 12 hours intravenously for 3 doses, then 6 mg/kg once daily intravenously
(see BNF for children for information on monitoring)
Vancomycin
1 month to 11 years, 10 mg/kg to 15 mg/kg four times a day intravenously, adjusted according to serum-vancomycin concentration
12 years to 17 years, 15 mg/kg to 20 mg/kg two or three times a day intravenously, adjusted according to serum-vancomycin concentration (a loading dose of 25 mg/kg to 30 mg/kg can be used in seriously ill people); maximum 2 g per dose
Linezolid (if vancomycin cannot be used; off-label use; specialist advice only)
3 months to 11 years, 10 mg/kg three times a day orally or intravenously (maximum 600 mg per dose)
12 years to 17 years, 600 mg twice a day orally or intravenously
(see BNF for children for information on monitoring)
See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.
Higher risk of resistance includes symptoms or signs starting more than 5 days after hospital admission, relevant comorbidity such as severe lung disease or immunosuppression, recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before current admission.
Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics for a total of 5 days, then review.
For off-label use, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's good practice in prescribing and managing medicines and devices for further information.

Antibiotics for children and young people under 18 years with community-acquired pneumonia

Antibiotic
Dosage and course length
Children under 1 month
Refer to paediatric specialist.
First-choice oral antibiotic for children aged 1 month and over if non-severe symptoms or signs (based on clinical judgement)
Amoxicillin
1 to 11 months, 125 mg three times a day for 5 days
1 to 4 years, 250 mg three times a day for 5 days
5 to 17 years, 500 mg three times a day for 5 days (higher doses can be used for all ages; see BNF for children)
Alternative oral antibiotics if non-severe symptoms or signs (based on clinical judgement), for penicillin allergy or if amoxicillin unsuitable (for example, atypical pathogens suspected)
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days
8 to 11 kg, 62.5 mg twice a day for 5 days
12 to 19 kg, 125 mg twice a day for 5 days
20 to 29 kg, 187.5 mg twice a day for 5 days
30 to 40 kg, 250 mg twice a day for 5 days
12 to 17 years:
250 mg to 500 mg twice a day for 5 days
Erythromycin (in pregnancy)
8 to 17 years, 250 mg to 500 mg four times a day for 5 days
Doxycycline
12 to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)
(see BNF for children for use of doxycycline in children under 12)
First-choice antibiotic(s) if severe symptoms or signs (based on clinical judgement; guided by microbiological results when available)
Co-amoxiclav
Oral doses:
1 to 11 months, 0.5 ml/kg of 125/31 suspension three times a day for 5 days
1 to 5 years, 10 ml of 125/31 suspension three times a day or 0.5 ml/kg of 125/31 suspension three times a day for 5 days (or 5 ml of 250/62 suspension)
6 years to 11 years, 10 ml of 250/62 suspension three times a day or 0.3 ml/kg of 250/62 suspension three times a day for 5 days
12 to 17 years, 500/125 mg three times a day for 5 days
IV doses:
1 month to 2 months, 30 mg/kg twice a day
3 months to 17 years, 30 mg/kg three times a day (maximum 1.2 g per dose three times a day)
With (if atypical pathogen suspected):
Clarithromycin or
Oral doses:
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days
8 kg to 11 kg, 62.5 mg twice a day for 5 days
12 kg to 19 kg, 125 mg twice a day for 5 days
20 kg to 29 kg, 187.5 mg twice a day for 5 days
30 kg to 40 kg, 250 mg twice a day for 5 days
12 years to 17 years:
250 mg to 500 mg twice a day for 5 days
IV doses:
1 month to 11 years, 7.5 mg/kg twice a day (maximum 500 mg per dose)
12 to 17 years, 500 mg twice a day
Erythromycin (in pregnancy)
8 years to 17 years, 250 mg to 500 mg four times a day orally for 5 days
Alternative antibiotics if severe symptoms or signs (based on clinical judgement), for penicillin allergy (guided by microbiological results when available)
Consult local microbiologist
See the BNF for children for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
The age bands apply to children of average size and, in practice, the prescriber will use the age bands in conjunction with other factors such as the severity of the condition being treated and the child's size in relation to the average size of children of the same age.
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.
Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable (fever in past 48 hours or more than 1 sign of clinical instability [systolic blood pressure less than 90 mmHg, heart rate more than 100/minute, respiratory rate less than 24/minute, arterial oxygen saturation less than 90% or PaO2 under 60 mmHg in room air]).
Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years and is more common in school-aged children.

Antibiotics for adults aged 18 years and over with hospital-acquired pneumonia

Antibiotic
Dosage and course length
First-choice oral antibiotic if non-severe symptoms or signs, and not at higher risk of resistance (guided by microbiological results when available)
Co-amoxiclav
500/125 mg three times a day for 5 days then review
Alternative oral antibiotics if non-severe symptoms or signs, and not at higher risk of resistance, for penicillin allergy or if co-amoxiclav unsuitable (based on specialist microbiological advice and local resistance data)
Options include:
Doxycycline
200 mg on first day, then 100 mg once a day for 4 days (5-day course) then review
Cefalexin (caution in penicillin allergy)
500 mg twice or three times a day (can be increased to 1 g to 1.5 g three or four times a day) for 5 days then review
Co-trimoxazole (off-label use)
960 mg twice a day for 5 days then review (see BNF for information on monitoring)
Levofloxacin (only if switching from IV levofloxacin with specialist advice; off-label use; consider safety issues)
500 mg once or twice a day for 5 days then review
First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance (based on specialist microbiological advice and local resistance data)
Options include:
Piperacillin with tazobactam
4.5 g three times a day (increased to 4.5 g four times a day if severe infection)
Ceftazidime
2 g three times a day
Ceftriaxone
2 g once a day
Cefuroxime
750 mg three times a day (increased to 750 mg four times a day or 1.5 g three or four times a day if severe infection)
Meropenem
0.5 g to 1 g three times a day
Ceftazidime with avibactam
2/0.5 g three times a day
Levofloxacin (off-label use; consider safety issues)
500 mg once or twice a day (use higher dosage if severe infection)
Antibiotics to be added if suspected or confirmed MRSA infection (dual therapy with a first-choice IV antibiotic)
Vancomycin
15 mg/kg to 20 mg/kg two or three times a day intravenously, adjusted according to serum-vancomycin concentration (a loading dose of 25 mg/kg to 30 mg/kg can be used in seriously ill people); maximum 2 g per dose (see BNF for information on monitoring)
Teicoplanin
Initially 6 mg/kg every 12 hours for 3 doses, then 6 mg/kg once a day intravenously (see BNF for information on monitoring)
Linezolid (if vancomycin cannot be used; specialist advice only)
600 mg twice a day orally or intravenously
See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
Higher risk of resistance includes symptoms or signs starting more than 5 days after hospital admission, relevant comorbidity such as severe lung disease or immunosuppression, recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before current admission.
Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics for a total of 5 days, then review.
For off-label use, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's good practice in prescribing and managing medicines and devices for further information.
See Medicines and Healthcare products Regulatory Agency (MHRA) advice for restrictions and precautions for using fluoroquinolone antibiotics because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

Antibiotics for adults aged 18 years and over with community-acquired pneumonia

Antibiotic
Dosage and course length
First-choice oral antibiotic if low severity (based on clinical judgement and guided by CRB65 score 0, or CURB65 score 0 or 1)
Amoxicillin
500 mg three times a day (higher doses can be used; see the BNF) for 5 days
Alternative oral antibiotics if low severity, for penicillin allergy or if amoxicillin unsuitable (for example, atypical pathogens suspected)
Doxycycline
200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)
Clarithromycin
500 mg twice a day for 5 days
Erythromycin (in pregnancy)
500 mg four times a day for 5 days
First-choice oral antibiotics if moderate severity (based on clinical judgement and guided by CRB65 score 1 or 2, or CURB65 score 2; guided by microbiological results when available)
Amoxicillin
500 mg three times a day (higher doses can be used; see the BNF) for 5 days
With (if atypical pathogen suspected)
Clarithromycin or
500 mg twice a day for 5 days
Erythromycin (in pregnancy)
500 mg four times a day for 5 days
Alternative oral antibiotics if moderate severity, for penicillin allergy (guided by microbiological results when available)
Doxycycline
200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)
Clarithromycin
500 mg twice a day for 5 days
First-choice antibiotics if high severity (based on clinical judgement and guided by CRB65 score 3 or 4, or CURB65 score 3 to 5; guided by microbiological results when available)
Co-amoxiclav with:
500/125 mg three times a day orally or 1.2 g three times a day intravenously for 5 days
Clarithromycin or
500 mg twice a day orally or intravenously for 5 days
Erythromycin (in pregnancy)
500 mg four times a day orally for 5 days
Alternative antibiotic if high severity, for penicillin allergy (guided by microbiological results when available; consult a local microbiologist if fluoroquinolone not appropriate)
Levofloxacin (consider safety issues)
500 mg twice a day orally or intravenously for 5 days
See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, pregnancy and breastfeeding, and administering intravenous (or, where appropriate, intramuscular) antibiotics.
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.
Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course is needed or the person is not clinically stable, for example, if they have had a fever in past 48 hours or more than 1 sign of clinical instability (systolic blood pressure less than 90 mmHg, heart rate more than 100/minute, respiratory rate more than 24/minute, arterial oxygen saturation less than 90% or partial pressure of oxygen of more than 60 mmHg in room air).
For fluoroquinolone antibiotics, see Medicines and Healthcare products Regulatory Agency (MHRA) advice for restrictions and precautions because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).
Consider adding a macrolide to amoxicillin if atypical pathogens are suspected, and review when microbiological results are available. Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years.
CRB65: confusion, respiratory rate 30/minute or more, blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less), age 65 or more.
CRB65 is used in primary care to assess 30 day mortality risk in adults with pneumonia. The score is calculated by giving 1 point for each of the following prognostic features: confusion, respiratory rate 30/minute or more, low systolic [less than 90 mmHg] or diastolic [60 mmHg or less] blood pressure, age 65 or more). Risk of death is stratified as follows:
  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1% to 10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).
CURB65: confusion, urea more than 7 mmol/litre, respiratory rate 30/minute or more, blood pressure (systolic less than 90 mmHg or diastolic 60 mmHg or less), age 65 or more.
CURB65 is used in hospital to assess 30 day mortality risk in adults with pneumonia. The score is calculated by giving 1 point for each of the following prognostic features: (confusion, urea more than 7 mmol/litre, respiratory rate 30/minute or more, low systolic [less than 90 mmHg] or diastolic [60 mmHg or less] blood pressure, age 65 or more). Risk of death is stratified as follows:
  • 0 or 1: low risk (less than 3% mortality risk)
  • 2: intermediate risk (3% to 15% mortality risk)
  • 3 to 5: high risk (more than 15% mortality risk).
Adults with score of 1 and particularly 2 are at increased risk of death (should be considered for hospital referral) and people with a score of 3 or more are at high risk of death (require urgent hospital admission).
NICE has published interventional procedures guidance on the following procedures with special arrangements for consent, audit and clinical governance:
Start antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and certainly within 4 hours (within 1 hour if the person has suspected sepsis and meets any of the high risk criteria for this – see the NICE Pathway on sepsis).
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

Glossary

(diagnosis based on symptoms and signs of lower respiratory tract infection in a patient who, in the opinion of the GP and in the absence of a chest X-ray, is likely to have community-acquired pneumonia; this might be because of the presence of focal chest signs, illness severity or other features)
(pneumonia that is acquired outside hospital: pneumonia that develops in a nursing home resident is included in this definition; when managed in hospital the diagnosis is usually confirmed by chest X-ray)
(includes symptoms or signs of pneumonia starting more than 5 days after hospital admission, relevant comorbidity such as severe lung disease or immunosuppression, recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with health and social care settings before current admission)
(pneumonia that develops 48 hours or more after hospital admission and that was not incubating at hospital admission: when managed in hospital, the diagnosis is usually confirmed by chest X-ray; for the purpose of this guidance, pneumonia that develops in hospital after intubation (ventilator-associated pneumonia) is excluded from this definition)
(intravenous)
(an acute illness (present for 21 days or less), usually with cough as the main symptom, and with at least 1 other lower respiratory tract symptom (such as fever, sputum production, breathlessness, wheeze or chest discomfort or pain) and no alternative explanation (such as sinusitis or asthma); pneumonia, acute bronchitis and exacerbation of chronic obstructive airways disease are included in this definition)
(the percentage likelihood of death occurring in a patient in the next 30 days)
(methicillin-resistant Staphylococcus aureus)
(a medicine with an existing UK marketing authorisation that is used outside the terms of its marketing authorisation, for example, by indication, dose, route or patient population)
(includes difficulty breathing, oxygen saturation < 90%, raised heart rate, grunting, very severe chest indrawing, inability to breastfeed or drink, lethargy and a reduced level of consciousness)

Paths in this pathway

Pathway created: December 2014 Last updated: November 2020

© NICE 2020. All rights reserved. Subject to Notice of rights.

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