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Pneumonia

About

What is covered

This NICE Pathway covers the diagnosis and management of 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. This NICE Pathway 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.

Updates

Updates to this NICE Pathway

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.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to microbiological tests.
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 diagnosing and managing community- and hospital-acquired pneumonia in an interactive flowchart

What is covered

This NICE Pathway covers the diagnosis and management of 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. This NICE Pathway 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.

Updates

Updates to this NICE Pathway

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.
9 February 2016 Tests for rapidly identifying bloodstream bacteria and fungi (LightCycler SeptiFast Test MGRADE, SepsiTest and IRIDICA BAC BSI assay) (NICE diagnostics guidance 20) added to microbiological tests.
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 in adults: diagnosis and management (2014 updated 2019) NICE guideline CG191
Extracorporeal membrane carbon dioxide removal for acute respiratory failure (2016) NICE interventional procedures guidance 564
Pneumonia in adults (2016) NICE quality standard 110
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

Mortality risk assessment in primary care using CRB65 score

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice for pneumonia in adults and should be read in full.

Quality statement

Adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.

Rationale

Assessing mortality risk using the CRB65 score in primary care informs clinical judgement and supports decision-making about whether care can be managed in the community or if hospital assessment is needed. This ensures that treatment is based on the severity of the infection and will improve treatment outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.
Data source: Local data collection.
Process
Proportion of community-acquired pneumonia diagnoses of adults in primary care at which the adult has a mortality risk assessment using the CRB65 score.
Numerator – the number in the denominator at which the adult has a mortality risk assessment using the CRB65 score.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in primary care.
Data source: Local data collection.
Outcome
Mortality.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services) ensure that adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.
Healthcare professionals (such as GPs and nurse practitioners) carry out a mortality risk assessment using the CRB65 score when an adult is diagnosed with community-acquired pneumonia in primary care. Details of the risk assessment should be shared if the adult is referred to hospital or outpatient care.
Commissioners (NHS England area teams and clinical commissioning groups) commission services in which adults have a mortality risk assessment using the CRB65 score when they are diagnosed with community-acquired pneumonia in primary care.

What the quality statement means for patients, service users and carers

Adults diagnosed with community-acquired pneumonia by their GP have a first assessment to find out how serious the pneumonia is. This includes a ‘CRB65 score’, which uses the person’s age, symptoms and blood pressure to help decide the how serious the risks are for that person and whether they need to go to hospital.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendations 1.2.1 and 1.2.2

Definitions of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]
Mortality risk assessment in primary care
When a clinical diagnosis of community-acquired pneumonia is made in primary care, the healthcare professional should assess whether the person is at low, intermediate or high risk of death by calculating the CRB65 score at the initial assessment (box 1).
Box 1 CRB65 score for mortality risk assessment in primary carea
CRB65 score is calculated by giving 1 point for each of the following prognostic features:
  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)b
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.
Patients are stratified for risk of death as follows:
  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1–10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).
aLim WS, van der Eerden MM, Laing R et al. (2003) Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82.
bFor guidance on delirium, see the NICE guideline on delirium.
[Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.1]

Equality and diversity considerations

It is important to be aware of dementia when assessing confusion, and to adapt the assessment approach to meet individual needs.
Healthcare professionals should be aware of the needs of adults at the end of life and agree the approach for managing pneumonia in the context of the person’s overall care plan.

Antibiotic therapy for diagnosed low-severity community-acquired pneumonia

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice for pneumonia in adults and should be read in full.

Quality statement

Adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.

Rationale

Pneumonia is usually caused by bacteria and should be treated with antibiotic therapy. A 5-day course of a single antibiotic is usually an effective treatment for diagnosed low-severity community-acquired pneumonia unless symptoms do not improve. Prescribing a 5-day course will ensure that antibiotic therapy is not given for longer than necessary, and will contribute to effective antimicrobial stewardship. Healthcare professionals should give people advice on seeking further help if their symptoms do not show signs of improving after 3 days of antibiotic therapy.

Quality measures

Process
Proportion of adults with low-severity community-acquired pneumonia who receive a 5-day maximum course of a single antibiotic.
Numerator – the number in the denominator who are prescribed a 5-day maximum course of a single antibiotic.
Denominator – the number of adults with low-severity community-acquired pneumonia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services and secondary care services) ensure that adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.
Healthcare professionals (such as GPs, hospital clinicians and nurse practitioners) prescribe a 5-day course of a single antibiotic to adults with low-severity community-acquired pneumonia and give advice on seeking further help if symptoms do not show signs of improving.
Commissioners (NHS England and clinical commissioning groups) ensure that adults with low-severity community-acquired pneumonia are prescribed a 5-day course of a single antibiotic.

What the quality statement means for patients, service users and carers

Adults with mild community-acquired pneumonia (also called low severity) are prescribed a 5-day course of an antibiotic.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendation 1.2.10 (key priority for implementation)

Definition of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.

Chest X-ray and diagnosis within 4 hours of hospital presentation

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice for pneumonia in adults and should be read in full.

Quality statement

Adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation.

Rationale

When community-acquired pneumonia is suspected in adults, it is important that a clinical assessment sequence is carried out. If the person presents at hospital, assessment should include performing and reviewing a chest X-ray, to help make a timely diagnosis in line with the 4-hour patient processing targets in A&E departments. This will ensure that treatment is given to adults with pneumonia as quickly as possible and that those who do not have community-acquired pneumonia are not given inappropriate antibiotic treatment.

Quality measures

Structure
Evidence of local arrangements and processes to ensure that adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.
Data source: Local data collection.
Process
a) Proportion of diagnoses of community-acquired pneumonia in adults in hospital at which the adult has a chest X-ray within 4 hours of presentation at hospital.
Numerator – the number in the denominator for which a chest X-ray was carried out within 4 hours of presentation at hospital.
Denominator – the number of diagnoses of community-acquired pneumonia in adults.
Data source: Local data collection.
b) Proportion of diagnoses of community-acquired pneumonia in adults in hospital which are made within 4 hours of presentation at hospital.
Numerator – the number in the denominator for which a diagnosis was made within 4 hours of presentation at hospital.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in hospital.
Data source: Local data collection.
Outcome
Inappropriate antibiotic use.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.
Healthcare professionals (such as hospital doctors and nurse practitioners) arrange a chest X-ray for adults with suspected community-acquired pneumonia in hospital, and confirm or rule out a diagnosis of community-acquired pneumonia within 4 hours of presentation at hospital.
Commissioners (clinical commissioning groups) commission services in which adults with suspected community-acquired pneumonia in hospital have a chest X-ray and receive a diagnosis within 4 hours of presentation at hospital.

What the quality statement means for patients, service users and carers

Adults with suspected pneumonia who go to hospital have a chest X-ray and are diagnosed within 4 hours of presentation at hospital.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendation 1.2.8 (key priority for implementation)

Definition of terms used in this quality statement

Suspected community-acquired pneumonia
Community-acquired pneumonia is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. It is suspected in adults who have symptoms and signs of lower respiratory tract infection, and diagnosed in adults who, in the opinion of the doctor and in the absence of a chest X-ray, are likely to have community-acquired pneumonia. Symptoms and signs include, but are not limited to, one or more of the following: fever, shortness of breath, cough, pleuritic chest pain, increased respiratory rate or work of breathing, and localised crepitations heard on auscultation of the person’s chest.
Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]

Equality and diversity considerations

Adults with pneumonia or their carers who have difficulty speaking or understanding English should have access to an interpreter or advocate if needed to ensure that they understand the diagnosis.

Mortality risk assessment in hospital using CURB65 score

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice for pneumonia in adults and should be read in full.

Quality statement

Adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.

Rationale

Assessing mortality risk using the CURB65 score in hospital informs clinical judgement and supports decision-making about how the infection is treated, whether the person should receive home- or hospital-based care, the choice of microbiological tests and the choice of antibiotic. This will ensure that treatment is based on the severity of the infection and will improve treatment outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.
Data source: Local data collection.
Process
Proportion of diagnoses of community-acquired pneumonia in adults in hospital at which the adult has a mortality risk assessment using the CURB65 score.
Numerator – the number in the denominator at which the adult has a mortality risk assessment using the CURB65 score.
Denominator – the number of diagnoses of community-acquired pneumonia in adults in hospital.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care and ambulatory care services) ensure that adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.
Healthcare professionals (such as hospital doctors and nurse practitioners) carry out a mortality risk assessment using the CURB65 score when adults are diagnosed with community-acquired pneumonia in hospital.
Commissioners (clinical commissioning groups) commission services in which adults have a mortality risk assessment using the CURB65 score when they are diagnosed with community-acquired pneumonia in hospital.

What the quality statement means for patients, service users and carers

Adults diagnosed with community-acquired pneumonia in hospital have an assessment to find out how serious the pneumonia is. This includes a CURB65 score, which uses the person’s age, symptoms, blood pressure and a blood test to help decide how serious the risks are for that person, whether they need to stay in hospital and what treatment they should have.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendations 1.2.3 and 1.2.4

Definitions of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]
Mortality risk assessment in hospital
When a diagnosis of community-acquired pneumonia is made at presentation to hospital, the healthcare professional should assess whether the person is at low, intermediate or high risk of death by calculating the CURB65 score (box 2).
Box 2 CURB65 score for mortality risk assessment in hospitala
CURB65 score is calculated by giving 1 point for each of the following prognostic features:
  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time)b
  • raised blood urea nitrogen (over 7 mmol/litre)
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.
Patients are stratified for risk of death as follows:
  • 0 or 1: low risk (less than 3% mortality risk)
  • 2: intermediate risk (3–15% mortality risk)
  • 3 to 5: high risk (more than 15% mortality risk).
aLim WS, van der Eerden MM, Laing R et al. (2003) Defining community-acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82.
bFor guidance on delirium, see the NICE guideline on delirium.
[Pneumonia in adults (2014) NICE guideline CG191, recommendation 1.2.3]

Equality and diversity considerations

It is important to be aware of dementia when assessing confusion and to adapt the assessment approach to meet individual needs.
Healthcare professionals should be aware of the needs of people at the end of life and agree the approach for managing pneumonia in the context of their overall care plan.

Antibiotic therapy within 4 hours in hospital

This quality statement is taken from the pneumonia in adults quality standard. The quality standard defines clinical best practice for pneumonia in adults and should be read in full.

Quality statement

Adults with community-acquired pneumonia who are admitted to hospital start antibiotic therapy within 4 hours of presentation.

Rationale

Starting appropriate antibiotic therapy as soon as possible (and within 4 hours of presentation) is important for treating adults with community-acquired pneumonia who are admitted to hospital. Evidence shows that early treatment is associated with improved clinical outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with community-acquired pneumonia who are admitted to hospital start antibiotic therapy within 4 hours of presentation.
Data source: Local data collection.
Process
Proportion of hospital admissions of community-acquired pneumonia in adults at which antibiotic therapy is started within 4 hours of presentation.
Numerator – the number in the denominator at which antibiotic therapy is started within 4 hours of presentation.
Denominator – the number of hospital admissions of community-acquired pneumonia in adults.
Data source: Local data collection.
Outcome
Mortality.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services) ensure that adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.
Healthcare professionals (hospital clinicians) ensure adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.
Commissioners (clinical commissioning groups) commission services in which adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic therapy within 4 hours of presentation.

What the quality statement means for patients, service users and carers

Adults who are admitted to hospital and diagnosed with community-acquired pneumonia start antibiotic treatment within 4 hours of being seen.

Source guidance

Pneumonia in adults: diagnosis and management (2014) NICE guideline CG191, recommendations 1.2.8 (key priority for implementation) and 1.2.9

Definition of terms used in this quality statement

Community-acquired pneumonia
Pneumonia that is acquired outside hospital. Pneumonia that develops in a person living in a nursing or residential home is included in this definition. Pneumonia that develops in people who are immunocompromised, and terminal pneumonia associated with another disease are not included.
[Pneumonia in adults (2014) NICE guideline CG191 and expert opinion]

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

Antibiotic1
Dosage and course length2
Children under 1 month
Antibiotic choice based on local resistance data and specialist microbiological advice
Children aged 1 month and over
First-choice oral antibiotic if non-severe symptoms or signs and not at higher risk of resistance3 (guided by microbiological results when available)
Co-amoxiclav
1 month to 11 months, 0.5 ml/kg of 125/31 suspension 3 times a day for 5 days then review4
1 year to 5 years, 10 ml of 125/31 suspension5 3 times a day or 0.5 ml/kg of 125/31 suspension 3 times a day for 5 days then review4
6 years to 11 years, 10 ml of 250/62 suspension 3 times a day or 0.3 ml/kg of 250/62 suspension 3 times a day for 5 days then review4
12 years to 17 years, 500/125 mg 3 times a day for 5 days then review4
Alternative oral antibiotics if non-severe symptoms or signs and not at higher risk of resistance3, for penicillin allergy or if co-amoxiclav unsuitable
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days then review4
8 kg to 11 kg, 62.5 mg twice a day for 5 days then review4
12 kg to 19 kg, 125 mg twice a day for 5 days then review4
20 kg to 29 kg, 187.5 mg twice a day for 5 days then review4
30 kg to 40 kg, 250 mg twice a day for 5 days then review4
12 years to 17 years, 500 mg twice a day for 5 days then review4
Other options may be suitable based on specialist microbiological advice and local resistance data.
First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance3. Review IV antibiotics by 48 hours and consider switching to oral antibiotics as above for a total of 5 days then review4
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 3 or 4 times a day (maximum 4.5 g per dose 4 times a day)
12 years to 17 years, 4.5 g 3 times a day (increased to 4.5 g 4 times a day if severe infection)
Ceftazidime
1 month to 17 years, 25 mg/kg 3 times a day (50 mg/kg 3 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 the IV antibiotic chosen from the list above)
Teicoplanin6,7
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 IV for 3 doses, then 6 mg/kg to 10 mg/kg once daily IV
12 years to 17 years, initially 6 mg/kg every 12 hours IV for 3 doses, then 6 mg/kg once daily IV
Vancomycin6,7
1 month to 11 years, 10 mg/kg to 15 mg/kg 4 times a day IV, adjusted according to serum-vancomycin concentration
12 years to 17 years, 15 mg/kg to 20 mg/kg 2 or 3 times a day IV, 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
Linezolid6,8 (if vancomycin cannot be used; specialist advice only)
3 months to 11 years, 10 mg/kg 3 times a day orally or IV (maximum 600 mg per dose)
12 years to 17 years, 600 mg twice a day orally or IV
1 See 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.
2 Oral doses are for immediate-release medicines. 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.
3 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.
4 Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable.
5 Or 5 ml of 250/62 suspension.
6 See BNF for children for information on monitoring of patient parameters.
7 See BNF for children for information on therapeutic drug monitoring.
8 Not licensed in children and young people under 18 years, so use would be off label. 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

Antibiotic1
Dosage and course length2
Children under 1 month
Refer to paediatric specialist.
Children aged 1 month and over
First-choice oral antibiotic if non-severe symptoms or signs (based on clinical judgement)3
Amoxicillin
1 to 11 months, 125 mg 3 times a day for 5 days4
1 to 4 years, 250 mg 3 times a day for 5 days4
5 to 17 years, 500 mg 3 times a day for 5 days4 (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 suspected5)3
Clarithromycin
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days4
8 to 11 kg, 62.5 mg twice a day for 5 days4
12 to 19 kg, 125 mg twice a day for 5 days4
20 to 29 kg, 187.5 mg twice a day for 5 days4
30 to 40 kg, 250 mg twice a day for 5 days4
12 to 17 years:
250 mg to 500 mg twice a day for 5 days4
Erythromycin (in pregnancy)
8 to 17 years, 250 mg to 500 mg 4 times a day for 5 days4
Doxycycline6
12 to 17 years, 200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)4
First-choice antibiotic(s) if severe symptoms or signs (based on clinical judgement); guided by microbiological results when available3
Co-amoxiclav
Oral doses:
1 to 11 months, 0.5 ml/kg of 125/31 suspension 3 times a day for 5 days4
1 to 5 years, 10 ml of 125/31 suspension 3 times a day or 0.5 ml/kg of 125/31 suspension 3 times a day for 5 days4,7
6 to 11 years, 10 ml of 250/62 suspension 3 times a day or 0.3 ml/kg of 250/62 suspension 3 times a day for 5 days4
12 to 17 years, 500/125 mg 3 times a day for 5 days4
IV doses8:
1 to 2 months, 30 mg/kg 2 times a day4
3 months to 17 years, 30 mg/kg 3 times a day (maximum 1.2 g per dose 3 times a day) 4
with (if atypical pathogen suspected5):
Clarithromycin or
Oral doses: see above for clarithromycin; for 5 days4
IV doses8:
1 month to 11 years, 7.5 mg/kg twice a day (maximum 500 mg per dose)4
12 to 17 years, 500 mg twice a day4
Erythromycin (in pregnancy)
See oral dose above for erythromycin; for 5 days4
Alternative antibiotics if severe symptoms or signs (based on clinical judgement), for penicillin allergy; guided by microbiological results when available3
Consult local microbiologist
1 See 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.
2 Oral doses are for immediate-release medicines. 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.
3 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
4 Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course length is needed or the person is not clinically stable.
5 Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years and is more common in school-aged children.
6 See BNF for children for use of doxycycline in children under 12.
7 Or 5 ml of 250/62 suspension.
8 Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.

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

Antibiotic1
Dosage and course length2
First-choice oral antibiotic for non-severe symptoms or signs and not at higher risk of resistance3 (guided by microbiological results when available)
Co-amoxiclav
500/125 mg 3 times a day for 5 days then review4
Alternative oral antibiotics for non-severe symptoms or signs and not at higher risk of resistance3, if penicillin allergy or if co-amoxiclav unsuitable
Antibiotic choice should be 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 review4
Cefalexin (caution in penicillin allergy)
500 mg twice or 3 times a day (can be increased to 1 g to 1.5 g 3 or 4 times a day) for 5 days then review4
Co-trimoxazole5,6
960 mg twice a day for 5 days then review4
Levofloxacin6 (only if switching from IV levofloxacin with specialist advice; consider safety issues7)
500 mg once or twice a day for 5 days then review4
First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance3. Review IV antibiotics by 48 hours and consider switching to oral antibiotics as above for a total of 5 days then review4
Antibiotic choice should be based on specialist microbiological advice and local resistance data. Options include:
Piperacillin with tazobactam
4.5 g 3 times a day (increased to 4.5 g 4 times a day if severe infection)
Ceftazidime
2 g 3 times a day
Ceftriaxone
2 g once a day
Cefuroxime
750 mg 3 or 4 times a day (increased to 1.5 g 3 or 4 times a day if severe infection)
Meropenem
0.5 g to 1 g 3 times a day
Ceftazidime with avibactam
2/0.5 g 3 times a day
Levofloxacin6 (consider safety issues7)
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 an IV antibiotic listed above)
Vancomycin5,8
15 mg/kg to 20 mg/kg 2 or 3 times a day IV, 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
Teicoplanin5,8
Initially 6 mg/kg every 12 hours for 3 doses, then 6 mg/kg once a day
Linezolid5 (if vancomycin cannot be used; specialist advice only)
600 mg twice a day orally or IV
1 See 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.
2 Oral doses are for immediate-release medicines.
3 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.
4 Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable.
5 See BNF for information on monitoring of patient parameters.
6 Not licensed for hospital-acquired pneumonia, so use would be off label. 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.
7 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).
8 See BNF for information on therapeutic drug monitoring.

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

Antibiotic1
Dosage and course length2
First-choice oral antibiotic if low severity (based on clinical judgement and guided by CRB65 score 0, or CURB65 score 0 or 1)3
Amoxicillin
500 mg 3 times a day (higher doses can be used – see BNF) for 5 days4
Alternative oral antibiotics if low severity, for penicillin allergy or if amoxicillin unsuitable (for example, atypical pathogens suspected5)3
Doxycycline
200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)4
Clarithromycin
500 mg twice a day for 5 days4
Erythromycin (in pregnancy)
500 mg 4 times a day for 5 days4
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 available3
Amoxicillin with (if atypical pathogens suspected5):
500 mg 3 times a day (higher doses can be used – see BNF) for 5 days4
Clarithromycin6 or
500 mg twice a day for 5 days4
Erythromycin6 (in pregnancy)
500 mg 4 times a day for 5 days4
Alternative oral antibiotics if moderate severity, for penicillin allergy; guided by microbiological results when available3
Doxycycline
200 mg on first day, then 100 mg once a day for 4 days (5-day course in total)4
Clarithromycin
500 mg twice a day for 5 days4
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 available3
Co-amoxiclav with:
500/125 mg 3 times a day orally or 1.2 g 3 times a day IV7 for 5 days4
Clarithromycin or
500 mg twice a day orally or IV7 for 5 days4
Erythromycin (in pregnancy)
500 mg 4 times a day orally for 5 days4
Alternative antibiotic if high severity, for penicillin allergy; guided by microbiological results when available3
Levofloxacin8 (consider safety issues)
500 mg twice a day orally or IV7 for 5 days5
Consult local microbiologist if fluoroquinolone not appropriate.
1 See 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.
2 Oral doses are for immediate-release medicines.
3 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.
4 Stop antibiotic treatment after 5 days unless microbiological results suggest a longer course 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 <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).
5 Mycoplasma pneumoniae infection occurs in outbreaks approximately every 4 years.
6 Consider adding a macrolide to amoxicillin if atypical pathogens suspected. Review when microbiological results available.
7 Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics if possible.
8 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).
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, low systolic [<90 mmHg] or diastolic [≤60 mmHg] blood pressure, age ≥65). Risk of death is stratified as follows:
  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1–10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).
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 >7 mmol/l, respiratory rate ≥30/minute, low systolic [<90 mmHg] or diastolic [≤60 mmHg] blood pressure, age ≥65). Risk of death is stratified as follows:
  • 0 or 1: low risk (less than 3% mortality risk)
  • 2: intermediate risk (3–15% 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:

Severity assessment

A judgement by the managing clinician as to the likelihood of adverse outcomes in a patient. This is based on a combination of clinical understanding and knowledge in addition to a mortality risk score. The difference between categories of severity and mortality risk can be important. Typically the mortality risk score will match the severity assessment. However, there may be situations where the mortality score does not accurately predict mortality risk and clinical judgement is needed. An example might be a patient with a low mortality risk score who has an unusually low oxygen level, who would be considered to have a severe illness.
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.
Give advice to adults, young people and children with community-acquired pneumonia about:
  • possible adverse effects of the antibiotic(s)
  • how long symptoms are likely to last (see also providing information)
  • seeking medical help (if the person is receiving treatment in the community) if:
    • symptoms worsen rapidly or significantly or
    • symptoms do not start to improve within 3 days or
    • the person becomes systemically very unwell.
NICE has written information for the public on antimicrobial prescribing for community-acquired pneumonia.
Reassess adults, young people and children with community-acquired pneumonia if symptoms or signs do not improve as expected or worsen rapidly or significantly.
When reassessing adults, young people and children with community-acquired pneumonia, be aware of possible non-bacterial causes, such as flu.
If a sample has been sent for microbiological testing:
  • review the choice of antibiotic(s) when results are available and
  • consider changing the antibiotic(s) according to results, using a narrower-spectrum antibiotic, if appropriate.
Send a sample (for example, a sputum sample) for microbiological testing if symptoms or signs have not improved following antibiotic treatment, and this has not been done already.

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: September 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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