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on assessment and management of suspected or confirmed CAP during the COVID-19 pandemic.1,2 It has temporarily withdrawn its pre-COVID-19 guideline on diagnosis and management of pneumonia in adults.3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


Determine disease severity (and therefore mortality risk) in patients with a working diagnosis of pneumonia using the CURB-65 score in hospital or the CRB-65 score in the community together with your clinical judgement. The score allows initiation of appropriate antibiotic therapy and confirms whether the patient can be managed in the community or needs to be admitted to hospital.

CURB-65 score[103]

Recommended by the British Thoracic Society (BTS) and the National Institute for Health and Care Excellence (NICE) in the UK for use in the hospital setting,[1][64] CURB-65 stratifies patients according to the presence or absence of five prognostic features.[ CURB-65 pneumonia severity score ] Mortality at 30 days increases with the number of criteria that are met. Always use the CURB-65 score in conjunction with your clinical judgement.[1][64] 

Scoring of the CURB-65 for CAP in hospital

  • Prognostic factors

  • Score

    • Score 3-5: high-risk; 30-day mortality >15%

      • Score of 3 or more: discuss with senior colleague at the earliest opportunity and manage as high-severity pneumonia.

      • Score of 4-5: arrange emergency assessment by a critical care specialist.

    • Score 2: moderate-risk; 30-day mortality 3% to 15% 

      • Consider for short-stay inpatient treatment or hospital-supervised outpatient treatment.

    • Score 0-1: low-risk; 30-day mortality <3% 

      • Consider for outpatient treatment.

CRB-65 score[103]

Recommended by the BTS and NICE in the UK to be used in the community setting,[1][64] CRB-65 stratifies patients according to the presence or absence of four prognostic features. Always use the CRB-65 score in conjunction with your clinical judgement.[1][64]

Scoring of the CRB-65 for CAP in the community[103]

  • Prognostic factors

  • Score

    • Score 3-4: high-risk; 30-day mortality >10%

      • Admit to hospital immediately.

    • Score 1-2: moderate-risk; 30-day mortality 1% to 10%

      • Consider hospital referral and assessment (particularly in those with a score of 2).

    • Score 0: low-risk; 30-day mortality <1%

      • Consider for treatment at home.

Pneumonia severity index (PSI)[104]

The PSI score predicts the risk of 30-day mortality; patients with a high risk are managed in hospital, and those with the highest risk are managed in the intensive care unit. The PSI stratifies patients into 5 categories based on patient age, comorbidities, physical examination, and results of laboratory testing.[ Community-acquired pneumonia severity index (PSI) for adults ] The principal limitation is the high score accorded to variables such as age and comorbidities. In the UK, the BTS and NICE consider the simplicity of the calculation of the CURB-65 score to be an advantage over PSI.[1][64]

Scoring of the PSI for CAP[104]

  • Demographics

    • Male: points = age in years

    • Female: points = age in years minus 10

    • Nursing home resident: +10 points

    • Liver disease: +20 points

    • Neoplastic disease: +30 points

    • Congestive heart failure: +10 points

    • Cerebrovascular disease: +10 points

    • Renal failure: +10 points

  • Physical examination findings

    • Altered mental status: +20 points

    • Respiratory rate ≥30 breaths/minute: +20 points

    • Systolic blood pressure <90 mmHg: +20 points

    • Temperature <35°C (<95°F) or ≥40°C (≥104°F): +15 points

    • Pulse rate ≥125 beats/minute: +10 points

  • Laboratory and radiographic findings

    • Arterial pH <7.35: +30 points

    • Urea ≥10.7 mmol/L (≥30 mg/dL): +20 points

    • Sodium <130 mmol/L (<130 mEq/L): +20 points

    • Glucose ≥13.9 mmol/L (≥250 mg/dL): +10 points

    • Haematocrit <30%: +10 points

    • PaO2 <60 mmHg (<90% O2 saturation): +10 points

    • Pleural effusion: +10 points

  • Score

    • Risk class I: 0 to 50 points: outpatients; 0.1% mortality

    • Risk class II: 51 to 70 points: outpatients; 0.6% mortality

    • Risk class III: 71-90 points: short hospital stay for observation; 2.8% mortality

    • Risk class IV: 91-130 points: hospital admission; 8.2% mortality

    • Risk class V: >130 points: hospital admission; 29.2% mortality

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