Recommendations

1.1 Managing community-acquired pneumonia

Treatment for adults, young people and children

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

  • the severity assessment for adults, as set out in table 1 [amended 2021]

  • the severity of symptoms or signs for children and young people, based on clinical judgement

  • the risk of developing complications, for example, if the person has relevant comorbidity such as severe lung disease or immunosuppression

  • local antimicrobial resistance and surveillance data (such as flu and Mycoplasma pneumoniae infection rates)

  • recent antibiotic use

  • recent microbiological results, including colonisation with multidrug-resistant bacteria.

    At the time of publication (September 2019), no validated severity assessment tools are available for children and young people with community-acquired pneumonia, and severity of symptoms or signs should be based on clinical judgement.

1.1.2 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 guideline on sepsis).

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

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

1.1.5 This recommendation has been removed.

1.1.6 For children and young people in hospital with community-acquired pneumonia, and severe symptoms or signs or a comorbidity, consider sending a sample (for example, sputum sample) for microbiological testing.

Advice

1.1.7 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

  • 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.

Reassessment

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

1.1.9 When reassessing adults, young people and children with community-acquired pneumonia, be aware of possible non-bacterial causes, such as flu.

1.1.10 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.

1.1.11 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.

Referral and seeking specialist advice

1.1.12 Refer adults with community-acquired pneumonia to hospital if they have:

  • any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis) or

  • symptoms that are not improving as expected with antibiotics. [amended 2021]

1.1.13 Consider referring adults with community-acquired pneumonia to hospital, or seek specialist advice, if they:

  • have bacteria that are resistant to oral antibiotics or

  • cannot take oral medicines (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, if this is appropriate).

1.1.14 Consider referring children and young people with community-acquired pneumonia to hospital, or seek specialist paediatric advice on further investigation and management.

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

1.2 Choice of antibiotic

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

  • follow table 1 for adults aged 18 years and over

  • follow table 2 for children and young people under 18 years.

Table 1 Antibiotics for adults aged 18 years and over

Treatment

Antibiotic, dosage and course length

First-choice oral antibiotic if low severity (based on clinical judgement and guided by a CRB65 score 0 or a CURB65 score 0 or 1 when these scores can be calculated)

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, if 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 a CRB65 score 1 or 2, or a CURB65 score 2 when these scores can be calculated; 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 pathogens suspected)

Clarithromycin:

500 mg twice a day for 5 days

Or

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 a CRB65 score 3 or 4, or a CURB65 score 3 to 5 when these scores can be calculated; guided by microbiological results when available)

Co‑amoxiclav:

500/125 mg three times a day orally or 1.2 g three times a day intravenously for 5 days

With

Clarithromycin:

500 mg twice a day orally or intravenously for 5 days

Or

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 the past 48 hours or have 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

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

Table 2 Antibiotics for children and young people under 18 years

Treatment

Antibiotic, dosage and course length

Children under 1 month

Refer to paediatric specialist

First-choice oral antibiotic for children 1 month and over if non-severe symptoms or signs (based on clinical judgement)

Amoxicillin:

1 month to 11 months, 125 mg three times a day for 5 days

1 year to 4 years, 250 mg three times a day for 5 days

5 years 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 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

Erythromycin (in pregnancy):

8 years to 17 years, 250 mg to 500 mg four times a day for 5 days

Doxycycline:

12 years 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 month to 11 months, 0.5 ml/kg of 125/31 suspension three times a day for 5 days

1 years 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 years to 17 years, 500/125 mg three times a day for 5 days

Intravenous 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:

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

Intravenous doses:

1 month to 11 years, 7.5 mg/kg twice a day (maximum 500 mg per dose)

12 years to 17 years, 500 mg twice a day

Or

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 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.

See the committee discussions on choice of antibiotics and antibiotic course length.

Terms used in the guideline

Severe community-acquired pneumonia in children and young people

Features of severe community-acquired pneumonia in children and young people include difficulty breathing, oxygen saturation less than 90%, raised heart rate, grunting, very severe chest indrawing, inability to breastfeed or drink, lethargy and a reduced level of consciousness.

CRB65

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

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).

  • National Institute for Health and Care Excellence (NICE)