Pneumonia

NICE clinical guideline [CG191] Pneumonia in adults: diagnosis and management. Last updated: Oct 2023. NICE guideline [NG138] Pneumonia (community-acquired): antimicrobial prescribing. Published Sep 2019. NICE guideline [NG139] Pneumonia (hospital-acquired): antimicrobial prescribing. Published: Sep 2019.

Background Information

Community-acquired pneumonia: pneumonia acquired outside the hospital or without recent healthcare exposure

Hospital-acquired pneumonia: defined by pneumonia onset at least 48 hours after admission

Community-Acquired Pneumonia Guidelines

The management of pneumonia is guided by the severity score.

 

The reason why CURB65 is used in secondary care but not primary care is because one of its component is blood urea level, which is uncommonly accessible in primary care.

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

CRB65 score Risk Management Principle Recommended antibiotic
0 Low Home-based care (outpatient) 1st line: amoxicillin 500mg TDS for 5 days

2nd line:
  • Doxycycline, or
  • Clarithromycin, or
  • Erythromycin (in pregnancy)
1 or 2 Intermediate Consider home-based care using a virtual ward or community intervention team 1st line: amoxicillin  for 5 days

2nd line:
  • Doxycycline, or
  • Clarithromycin
3 or 4 High Hospital assessment 1st: co-amoxiclav (oral / IV) for 5 days 

2nd line:
  • Levofloxacin (oral / IV)

Pneumonia severity Recommended antibiotics
Low (CRB65 0)
  • Doxycycline, or
  • Clarithromycin, or
  • Erythromycin (in pregnancy)
Intermediate (CRB65 1 or 2)
  • Amoxicillin, and
  • Clarithromycin or erythromycin
High (CRB65 3 or 4)
  • Co-amoxiclav, and
  • Clarithromycin or erythromycin
 

First calculate the CURB65 score, then 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 or diastolic ≤60 1
≥65 y/o 1
 

CURB65 score Risk Management Principle Recommended antibiotic
0 or 1 Low Home-based care (outpatient) 1st line: amoxicillin 500mg TDS for 5 days

2nd line:
  • Doxycycline, or
  • Clarithromycin, or
  • Erythromycin (in pregnancy)
2 Intermediate Hospital-based care 1st line: amoxicillin  for 5 days

2nd line:
  • Doxycycline, or
  • Clarithromycin
3 or 4 or 5 High Hospital-based care and intensive care assessment 1st: co-amoxiclav (oral / IV) for 5 days 

2nd line:
  • Levofloxacin (oral / IV)

Pneumonia severity Recommended antibiotics
Low (CURB65 0 or 1)
  • Doxycycline, or
  • Clarithromycin, or
  • Erythromycin (in pregnancy)
Intermediate (CURB65 2)
  • Amoxicillin, and
  • Clarithromycin or erythromycin
High (CURB65 3 or 4 or 5)
  • Co-amoxiclav, and
  • Clarithromycin or erythromycin

Hospital-Acquired Pneumonia Guidelines

1st line: co-amoxiclav 500/125mg TDS for 5 days

2nd line:
  • Doxycycline
  • Cefalexin (but caution in penicillin allergy)
  • Co-trimoxazole

IV antibiotic options:
  • Tazocin (piperacillin with tazobactam) - usually 1st line in hospital guidelines (but not explicitly stated in NICE guideline)
  • Ceftazidime
  • Ceftriaxone
  • Cefuroxime
  • Meropenem
  • Ceftazidime with avibactam

Antibiotics to be added (i.e. dual therapy with an IV antibiotic):
  • Vancomycin
  • Teicoplanin
  • Linezolid (only if vancomycin cannot be used)
Author: Adams Lau
Reviewer:
Last edited: 31/07/25