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Pneumonia

NICE guideline [NG250] Pneumonia: diagnosis and management. Published: Sep 2025.

Community-Acquired Pneumonia

  • Community-acquired pneumonia: pneumonia acquired outside the hospital, or within 48 hours of admission (includes pneumonia that develops in a nursing home resident)
  • Hospital-acquired pneumonia: defined by pneumonia onset at least 48 hours after hospital admission, or those who presented to hospital with pneumonia but were discharged within the last 7-10 days

Calculate the CRB65 score, then use it to guide management
 
Component Score
Confusion (AMTS ≤8 / new disorientation in time, place, or person) 1
Respiratory rate ≥30 1
Blood pressure systolic <90 mmHg or diastolic ≤60 mmHg 1
≥65 y/o 1

Interpretation:
  • 0: low risk (<1% mortality risk)
  • 1 or 2: intermediate risk (1-10% mortality risk)
  • 3 or 4: high risk (>10% mortality risk)

CRB65 score-informed management:
 
CRB65 score Management Principle
0 Primary care-led service (home management with safety netting)
1 Use clinical judgement, any of the following:
  • Primary care-led service
  • Virtual ward
  • Same-day emergency care unit
  • Inpatient care
2 / 3 / 4 Refer to hospital for inpatient care

Calculate the CURB65 score, then use it to guide management
 
Component Score
Confusion (AMTS ≤8 / new disorientation in time, place, or person) 1
Blood urea >7 mmol/L 1
Respiratory rate ≥30 1
Blood pressure systolic <90 mmHg or diastolic ≤60 mmHg 1
≥65 y/o 1

Interpretation:
  • 0 or 1: low risk (<1% mortality risk)
  • 2: intermediate risk (3-15% mortality risk)
  • 3 or 4 or 5: high risk (>15% mortality risk)

CURB65 score-informed management:
 
CURB65 score Management Principle
0 / 1 Discharge to primary care-led service (home management with safety netting)
2 Use clinical judgement, one of the following:
  • Virtual ward
  • Same-day emergency care unit
  • Hospital at home service
  • Inpatient care
3 / 4 / 5 Refer to hospital for inpatient care +/- critical care referral
 

In primary care, a chest X-ray is not routinely required to diagnose CAP if the history and examination findings are typical (and given CRB65 score is low).

1st line and standard imaging: chest X-ray

The latest NICE guidelines emphasised the use of lung ultrasound for:
  • Rapid point-of-care diagnosis in a sick or deteriorating patient, or
  • Investigation for associated complications (e.g. pleural infection, parapneumonic effusion), or
  • Investigation for a possible alternative diagnosis (e.g. heart failure)

Other tests to consider:
  • Baseline CRP on admission
  • Sputum sample for microbiological testing (if not, nasopharyngeal swab for respiratory screen)
  • Blood cultures
  • Pneumococcal urinary antigen test (to support use of narrow-spectrum antibiotic)
  • Legionella urinary antigen test (if there are risk factors)
 

NICE recommends NOT to routinely offer microbiological tests in low-severity CAP, but only consider in moderate or high-severity CAP.

Standard course: oral antibiotics for 5 days

  • Give IV antibiotics or a prolonged course of antibiotics as per clinical judgement

Choice of antibiotics is based on the severity of disease (NICE noted that they often, but not always match the mortality risk score. Emphasis is put on using clinical judgement.
 
Severity of disease 1st line Penicillin allergy
Low
  • Amoxicillin 500mg TDS
  • Doxycycline, or
  • Clarithromycin, or
  • Erythromycin (in pregnancy)
Moderate
  • Amoxicillin 500mg TDS
  • Doxycycline, or
  • Clarithromycin
High
  • Co-amoxiclav, and
  • Clarithromycin / erythromycin (in pregnancy)
  • Levofloxacin
 
If an atypical pathogen is suspected, add one of the following to amoxicillin:
  • 1st line: macrolide (clarithromycin preferred) (erythromycin preferred in pregnancy)
  • 2nd line: doxycycline
  • 3rd line: levofloxacin 

NICE also recommends considering IV hydrocortisone (alternative: dexamethasone) for 4-7 days or until discharge, in addition to antibiotics in high-severity CAP

 

Choice of antibiotics in CAP is now guided by clinical judgement of disease severity, as opposed to previous guidelines that recommended based on CRB65 / CURB65 risk category.

If the patient is not improving with antibiotics, consider non-bacterial causes of pneumonia, such as influenza.

The MHRA statement on fluoroquinolones (updated in Jan 2024) emphasises that fluoroquinolone antibiotics must only be prescribed when other commonly recommended antibiotics are inappropriate.

This restriction follows concerns over serious, disabling, long-lasting, and potentially irreversible side effects, including tendonitis, tendon rupture, muscle pain and weakness, joint pain, peripheral neuropathy, and psychiatric symptoms.

For those managed in hospital, consider measuring CRP or procalcitonin 3/4 days after starting treatment if there is a clinical concern about treatment failure:
  • High levels of CRP or procalcitonin or levels that do not significantly improve with treatment are associated with treatment failure

Explain to patients to expect the following recovery timeline (but rate of improvement will vary with the severity of the pneumonia):
  • 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: they will feel back to normal

Routine follow-up chest X-ray is NOT recommended

Follow-up chest X-ray at 6 weeks following discharge should be considered if:
  • Risk factors for lung cancer, or
  • Underlying respiratory disease, or
  • Persisting or deteriorating symptoms, or
  • Unexplained weight loss

 

In clinical practice, it is very common to perform a routine follow-up chest X-ray in all patients who had a pneumonia.

Hospital-Acquired Pneumonia (HAP) Guidelines

Key difference from CAP is that the causative agent is usually different, therefore different antibiotics are recommended.

  • Community-acquired pneumonia: pneumonia acquired outside the hospital, or within 48 hours of admission (includes pneumonia that develops in a nursing home resident)
  • Hospital-acquired pneumonia: defined by pneumonia onset at least 48 hours after hospital admission, or those who presented to hospital with pneumonia but were discharged within the last 7-10 days

Antibiotic choice should always be based on specialist microbiological advice and local resistance data, when available.
 

1st line: oral antibiotics

Choice of antibiotics:
  • 1st line: co-amoxiclav 500/125mg TDS for 5 days
  • 2nd line options:
    • Doxycycline
    • Cefalexin
    • Co-trimoxazole (off-label)
    • Levofloxacin (only if switching from IV levofloxacin)

 

The MHRA statement on fluoroquinolones (updated in Jan 2024) emphasises that fluoroquinolone antibiotics must only be prescribed when other commonly recommended antibiotics are inappropriate.

This restriction follows concerns over serious, disabling, long-lasting, and potentially irreversible side effects, including tendonitis, tendon rupture, muscle pain and weakness, joint pain, peripheral neuropathy, and psychiatric symptoms.

1st line: IV antibiotics

Choice of antibiotics:
  • Tazocin (piperacillin with tazobactam) - usually 1st line in hospital guidelines (but not explicitly stated in NICE guideline)
  • Ceftazidime
  • Ceftriaxone
  • Cefuroxime
  • Meropenem
  • Ceftazidime with avibactam
  • Levofloxacin

 

The MHRA statement on fluoroquinolones (updated in Jan 2024) emphasises that fluoroquinolone antibiotics must only be prescribed when other commonly recommended antibiotics are inappropriate.

This restriction follows concerns over serious, disabling, long-lasting, and potentially irreversible side effects, including tendonitis, tendon rupture, muscle pain and weakness, joint pain, peripheral neuropathy, and psychiatric symptoms.

Offer IV dual antibiotic therapy (one of the following + a 1st line antibiotic)
  • Vancomycin
  • Teicoplanin
  • Linezolid (only if vancomycin cannot be used)

References

Author: Adams Lau
Reviewer:
Last edited: 16/09/25