Last reviewed: 8 Apr 2021
Last updated: 04 Jun 2020

COVID-19 pandemic

During the pandemic, consider all patients with cough and fever or suggestive symptoms to have COVID-19 until proven otherwise. See our topic Coronavirus disease 2019 (COVID-19).

The National Institute for Health and Care Excellence (NICE) in the UK has issued new guidelines on assessment and management of suspected or confirmed CAP during the COVID-19 pandemic.1,2 It has temporarily withdrawn its pre-COVID-19 guideline on diagnosis and management of pneumonia in adults.3

The key changes are that the new guidance:1,2

  • Notes that the CRB-65 tool, recommended for severity assessment in its pre-COVID-19 guidance, is not validated in people with COVID-19, as it requires a blood pressure measurement, which may be ‘difficult or undesirable’ to obtain during the COVID-19 pandemic.1 It recommends using clinical judgement to assess severity and inform decisions on hospital admission during the pandemic.1
    Signs and symptoms of severe illness are:1
    • Severe shortness of breath at rest or difficulty breathing
    • Coughing up blood
    • Blue lips or face
    • Feeling cold and clammy with pale or mottled skin
    • Collapse or fainting (syncope)
    • New confusion
    • Becoming difficult to rouse
    • Little or no urine output.
  • Recommends considering a SARS-CoV2 polymerase chain reaction test in all patients with suspected moderate to severe CAP and in all patients who develop pneumonia while in hospital.2
  • Recommends oral doxycycline first line (in preference to oral amoxicillin) in all non-pregnant patients with suspected bacterial CAP treated in the community with oral amoxicillin as an alternative.1 It includes oral doxycycline as a recommended first-line option in patients with moderate or severe bacterial CAP treated in hospital who can tolerate oral medicines and whose condition is not severe enough to need intravenous antibiotics.2
    • Doxycycline has a broader spectrum of cover than amoxicillin, particularly against Mycoplasma pneumoniae and Staphylococcus aureus, which are more likely to be secondary bacterial causes of pneumonia during the COVID-19 pandemic.1


  1. National Institute for Health and Care Excellence. COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community. April 2020 [internet publication].
    Full text
  2. National Institute for Health and Care Excellence. COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital. May 2020 [internet publication].
    Full text
  3. National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. Sep 2019 [internet publication]. WITHDRAWN during COVID-19 pandemic.
    Full text



History and exam

Key diagnostic factors

  • cough with increasing sputum production
  • dyspnoea
  • pleuritic chest pain
  • rigors or night sweats
  • fever
  • abnormal auscultatory findings
  • confusion
  • risk factors

Other diagnostic factors

  • myalgia
  • malaise
  • anorexia
  • lethargy
  • worsening of pre-existing conditions
  • sore throat
  • headache
  • nausea
  • abdominal pain
  • diarrhoea

Risk factors

  • age >65 years
  • residence in a healthcare setting
  • COPD
  • exposure to cigarette smoke
  • alcohol abuse
  • poor oral hygiene
  • use of acid-reducing drugs
  • contact with children
  • diabetes mellitus
  • chronic renal disease
  • chronic liver disease
  • use of opioids

Diagnostic investigations

1st investigations to order

  • chest x-ray
  • pulse oximetry
  • arterial blood gas (ABG)
  • urea and electrolytes
  • full blood count
  • C-reactive protein (CRP)
  • liver function tests

Investigations to consider

  • blood culture
  • sputum culture (± Gram stain)
  • urinary antigen testing for legionella and pneumococcus
  • polymerase chain reaction (PCR) and/or serological tests
  • CT scan of chest
  • chest ultrasound
  • thoracocentesis and pleural fluid culture
  • computer tomographic pulmonary angiography (CTPA)
  • bronchoscopy

Treatment algorithm


Expert advisersVIEW ALL

Honorary Professor of Respiratory Sciences

University of Leicester

Respiratory Consultant

Glenfield Hospital




JB is Chair of the British Thoracic Society.


JB declares that he has no competing interests.

BMJ Best Practice would like to gratefully acknowledge the previous team of expert contributors, whose work has been retained in parts of the content:

Catia Cilloniz MSc, PhD

Post-doctoral Research

Pneumology Department

Hospital Clinic of Barcelona





Antoni Torres MD, PhD

Professor of Medicine


Pulmonary Intensive Care Unit

Respiratory Institute

Hospital Clinic of Barcelona




CC and AT are each authors of a number of references cited in this topic.

Peer reviewersVIEW ALL

Consultant Respiratory Physician and Honorary Professor of Medicine

Nottingham University Hospitals NHS Trust




WSL was chairman of the British Thoracic Society community-acquired pneumonia guidelines committee and a member of the guideline development group for the National Institute for Health and Care Excellence pneumonia guidelines. His institution has received unrestricted investigator-initiated research funding from Pfizer for a multicentre study of pneumococcal pneumonia in which he was the chief investigator, and research funding from the National Institute for Health Research for studies in pneumonia in which he was the principal investigator. He is also an author of at least one reference cited in the topic.

Section Editor, BMJ Best Practice


HDC declares that she has no competing interests.

Lead Section Editor, BMJ Best Practice


RW declares that she has no competing interests.

Comorbidities Editor, BMJ Best Practice


JC declares that she has no competing interests.

Drug Editor, BMJ Best Practice


AM declares that he has no competing interests.

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