Recommendations

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[1]

  • 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[2].

Table 1 Antibiotics for adults aged 18 years and over

Antibiotic 1

Dosage and course length 2

First-choice oral antibiotic for non‑severe symptoms or signs and not at higher risk of resistance 3 (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 resistance 3 , 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 resistance 3 . Review IV antibiotics by 48 hours and consider switching to oral antibiotics as above for a total of 5 days then review 4

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.

Abbreviations: BNF, British national formulary; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus.

Table 2 Antibiotics for children and young people under 18 years

Antibiotic 1

Dosage and course length 2

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 resistance 3 (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 antibiotic if non-severe symptoms or signs and not at higher risk of resistance 3 , 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 resistance 3 . Review IV antibiotics by 48 hours and consider switching to oral antibiotics as above for a total of 5 days then review 4

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.

Abbreviations: BNFC, British national formulary for children; IV, intravenous; MRSA, methicillin-resistant Staphylococcus aureus.

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



[1] At the time of publication (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.

[2] 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.

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