Recommendations

Guidance

1.1 Managing hospital-acquired pneumonia
1.2 Choice of antibiotic
Terms used in the guideline

Recommendations

For recommendations on identifying and treating hospital-acquired bacterial pneumonia secondary to COVID-19, see our rapid guideline on managing acute COVID-19.

1.1 Managing hospital-acquired pneumonia

Treatment for adults, young people and children

1.1.1 For adults, young people and children with symptoms or signs of pneumonia starting within 48 hours of hospital admission, follow the NICE guideline on community-acquired pneumonia.

1.1.2 Offer an antibiotic(s) for adults, young people and children with hospital-acquired pneumonia. When choosing an antibiotic(s) (see the recommendations on choice of antibiotic), take account of:

the severity of symptoms or signs (at the time of publication, in September 2019, no validated severity assessment tools are available for hospital-acquired pneumonia, and severity of symptoms or signs should be based on clinical judgement)
the number of days in hospital before onset of symptoms
the risk of developing complications, for example, if the person has a relevant comorbidity such as severe lung disease or immunosuppression
local hospital and ward-based antimicrobial resistance data
recent antibiotic use
recent microbiological results, including colonisation with multidrug-resistant bacteria
recent contact with a health or social care setting before current admission
the risk of adverse effects with broad-spectrum antibiotics, such as Clostridium difficile infection.

1.1.3 Start antibiotic treatment as soon as possible after establishing a diagnosis of hospital-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 guideline on sepsis).

1.1.4 Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.1.5 If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

1.1.6 Send a sample (for example, sputum sample, nasopharyngeal swab or tracheal aspirate) for microbiological testing.

Reassessment and specialist advice

1.1.7 When microbiological results are available:

review the choice of antibiotic(s) and
change the antibiotic(s) according to results, using a narrower-spectrum antibiotic, if appropriate.

1.1.8 Reassess adults, young people and children with hospital-acquired pneumonia if symptoms do not improve as expected or worsen rapidly or significantly.

1.1.9 Seek specialist advice from a microbiologist for adults, young people and children with hospital-acquired pneumonia if they have:

symptoms that are not improving as expected with antibiotics or
multidrug-resistant bacteria.

1.1.10 Follow the NICE guideline on care of dying adults in the last days of life when caring for adults with hospital-acquired pneumonia who are approaching their end of life.

See the evidence and committee discussions on antibiotic prescribing strategies and choice of antibiotics.

1.2 Choice of antibiotic

1.2.1 When prescribing an antibiotic(s) for hospital-acquired pneumonia:

follow table 1 for adults aged 18 years and over
follow table 2 for children and young people under 18 years.

1.2.2 Consider following the NICE guideline on community-acquired pneumonia for choice of antibiotic for adults, young people and children with symptoms or signs of pneumonia starting within days 3 to 5 of hospital admission who are not at higher risk of resistance. Higher risk of resistance includes 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.

**Table 1 Antibiotics for adults aged 18 years and over**
Treatment	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 intravenous 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) [amended October 2020] 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 meticillin-resistant *Staphylococcus aureus* infection (dual therapy with a first-choice intravenous 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 BNF for information on monitoring)

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).

**Table 2 Antibiotics for children and young people under 18 years**
Treatment	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 antibiotic 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 three 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 meticillin-resistant *Staphylococcus aureus* infection (dual therapy with a first-choice intravenous 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 intravenous 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 (see BNF for children for information on monitoring) 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.

See the evidence and committee discussions on choice of antibiotic and antibiotic course length, dosage and route of administration.

Terms used in the guideline

Hospital-acquired pneumonia

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 guideline, pneumonia that develops in hospital after intubation (ventilator-associated pneumonia) is excluded from this definition.