1 Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

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.

Terms used in this guideline

Clinical diagnosis of community-acquired pneumonia

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.

Community-acquired pneumonia

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.

Dual antibiotic therapy

Treatment with 2 different antibiotics at the same time.

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.

Lower respiratory tract infection

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.

Mortality risk

The percentage likelihood of death occurring in a patient in the next 30 days.

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.

1.1 Presentation with lower respiratory tract infection

1.1.1 For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C‑reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. Use the results of the C‑reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:

  • Do not routinely offer antibiotic therapy if the C‑reactive protein concentration is less than 20 mg/litre.

  • Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C‑reactive protein concentration is between 20 mg/litre and 100 mg/litre.

  • Offer antibiotic therapy if the C‑reactive protein concentration is greater than 100 mg/litre.

1.2 Community-acquired pneumonia

Severity assessment in primary care

1.2.1 When a clinical diagnosis of community-acquired pneumonia is made in primary care, determine whether patients are at low, intermediate or high risk of death using the CRB65 score (see box 1).

Box 1 CRB65 score for mortality risk assessment in primary care[a]

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).

[a] Lim 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

[b] For guidance on delirium, see the NICE guideline on delirium.

1.2.2 Use clinical judgement in conjunction with the CRB65 score to inform decisions about whether patients need hospital assessment as follows:

  • consider home‑based care for patients with a CRB65 score of 0

  • consider hospital assessment for all other patients, particularly those with a CRB65 score of 2 or more.

Severity assessment in hospital

1.2.3 When a diagnosis of community-acquired pneumonia is made at presentation to hospital, determine whether patients are at low, intermediate or high risk of death using the CURB65 score (see box 2).

Box 2 CURB65 score for mortality risk assessment in hospital[a]

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).

[a] Lim 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

[b] For guidance on delirium, see the NICE guideline on delirium.

1.2.4 Use clinical judgement in conjunction with the CURB65 score to guide the management of community‑acquired pneumonia, as follows:

  • consider home‑based care for patients with a CURB65 score of 0 or 1

  • consider hospital‑based care for patients with a CURB65 score of 2 or more

  • consider intensive care assessment for patients with a CURB65 score of 3 or more.

1.2.5 Stratify patients presenting with community‑acquired pneumonia into those with low‑, moderate‑ or high‑severity disease. The grade of severity will usually correspond to the risk of death.

Microbiological tests

1.2.6 Do not routinely offer microbiological tests to patients with low‑severity community‑acquired pneumonia.

1.2.7 For patients with moderate‑ or high‑severity community‑acquired pneumonia:

  • take blood and sputum cultures and

  • consider pneumococcal and legionella urinary antigen tests.

Timely diagnosis and treatment

1.2.8 Put in place processes to allow diagnosis (including X‑rays) and treatment of community‑acquired pneumonia within 4 hours of presentation to hospital.

1.2.9 Offer antibiotic therapy as soon as possible after diagnosis, and certainly within 4 hours to all patients with community‑acquired pneumonia who are admitted to hospital.

Antibiotic therapy

Low-severity community-acquired pneumonia

1.2.10 Offer a 5‑day course of a single antibiotic to patients with low‑severity community‑acquired pneumonia.

1.2.11 Consider amoxicillin in preference to a macrolide or a tetracycline for patients with low‑severity community‑acquired pneumonia. Consider a macrolide or a tetracycline for patients who are allergic to penicillin.

1.2.12 Consider extending the course of the antibiotic for longer than 5 days as a possible management strategy for patients with low‑severity community‑acquired pneumonia whose symptoms do not improve as expected after 3 days.

1.2.13 Explain to patients with low‑severity community‑acquired pneumonia treated in the community, and when appropriate their families or carers, that they should seek further medical advice if their symptoms do not begin to improve within 3 days of starting the antibiotic, or earlier if their symptoms are worsening.

1.2.14 Do not routinely offer patients with low‑severity community‑acquired pneumonia:

  • a fluoroquinolone

  • dual antibiotic therapy.

Moderate- and high-severity community-acquired pneumonia

1.2.15 Consider a 7‑ to 10‑day course of antibiotic therapy for patients with moderate‑ or high‑severity community‑acquired pneumonia.

1.2.16 Consider dual antibiotic therapy with amoxicillin and a macrolide for patients with moderate‑severity community‑acquired pneumonia.

1.2.17 Consider dual antibiotic therapy with a beta‑lactamase stable beta‑lactam[1] and a macrolide for patients with high‑severity community‑acquired pneumonia.

Glucocorticoid treatment

1.2.18 Do not routinely offer a glucocorticoid to patients with community‑acquired pneumonia unless they have other conditions for which glucocorticoid treatment is indicated.

Monitoring in hospital

1.2.19 Consider measuring a baseline C‑reactive protein concentration in patients with community‑acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Safe discharge from hospital

1.2.20 Do not routinely discharge patients with community‑acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:

  • temperature higher than 37.5°C

  • respiratory rate 24 breaths per minute or more

  • heart rate over 100 beats per minute

  • systolic blood pressure 90 mmHg or less

  • oxygen saturation under 90% on room air

  • abnormal mental status

  • inability to eat without assistance.

1.2.21 Consider delaying discharge for patients with community‑acquired pneumonia if their temperature is higher than 37.5°C.

Patient information

1.2.22 Explain to patients with community‑acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia, and most people can expect that by:

  • 1 week: fever should have resolved

  • 4 weeks: chest pain and sputum production should have substantially reduced

  • 6 weeks: cough and breathlessness should have substantially reduced

  • 3 months: most symptoms should have resolved but fatigue may still be present

  • 6 months: most people will feel back to normal.

1.2.23 Advise patients with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.

1.3 Hospital-acquired pneumonia

Antibiotic therapy

1.3.1 Offer antibiotic therapy as soon as possible after diagnosis, and certainly within 4 hours, to patients with hospital-acquired pneumonia.

1.3.2 Choose antibiotic therapy in accordance with local hospital policy (which should take into account knowledge of local microbial pathogens) and clinical circumstances for patients with hospital‑acquired pneumonia.

1.3.3 Consider a 5‑ to 10‑day course of antibiotic therapy for patients with hospital‑acquired pneumonia.

More information

You can also see this guideline in the NICE Pathway on pneumonia.

To find out what NICE has said on topics related to this guideline, see our web page on infections.

See also the guideline committee's discussion and the evidence reviews (in the full guideline), and information about how the guideline was developed, including details of the committee.



[1] Available beta-lactamase stable beta‑lactams include: co‑amoxiclav, cefotaxime, ceftaroline fosamil, ceftriaxone, cefuroxime and piperacillin with tazobactam.

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