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on assessment and management of suspected or confirmed CAP during the COVID-19 pandemic.1,2 It has temporarily withdrawn its pre-COVID-19 guideline on diagnosis and management of pneumonia in adults.3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

References

  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

Recommendations

Urgent

Think 'Could this be sepsis?' whenever an acutely unwell person presents with likely infection, even if their temperature is normal. Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.[66][67][68]

  • Remember that sepsis represents the severe, life-threatening end of infection.[69]

  • Pneumonia is one of the main sources of infection in sepsis.[70]

  • It is important to make an early, accurate diagnosis of infection and use antibiotics appropriately.

Urgent: in hospital

Stratify patients with pneumonia confirmed by chest x-ray according to mortality risk and disease severity using the CURB-65 score and your clinical judgement.[ CURB-65 pneumonia severity score ] Use the score to help inform your management plan.

  • Score of 3-5: high-severity.

    • Score of 3 or more: discuss with a senior colleague at the earliest opportunity and manage as high-severity pneumonia.[1][64]

    • Score of 4 or 5: arrange emergency assessment by a critical care specialist.[1] 

  • Score of 2: manage as moderate-severity pneumonia.

  • Score of 0 or 1: manage as low-severity pneumonia.

Give empirical antibiotics immediately to all patients with CAP confirmed by chest x-ray. Patients should receive antibiotics within 4 hours of presentation to hospital.[1][105]

  • High-severity CAP: give broad-spectrum intravenous antibiotics – refer to your local protocol.

  • Moderate- and low-severity CAP: give oral antibiotics (or intravenous if oral therapy is contraindicated) – refer to your local protocol.

Give empirical antibiotics to patients with life-threatening disease based on a presumptive clinical diagnosis, then order an immediate chest x-ray to confirm the diagnosis.[1]

  • Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.[66][67][68]

Assess oxygen requirements. Prescribe oxygen if oxygen saturation <94% and maintain at target range.[1] In patients at risk of hypercapnia prescribe oxygen if oxygen saturation <88%.[1]

  • Target oxygen saturation range of:

    • 94% to 96% in acutely ill patients who are not at risk of hypercapnia[72] 

    • 88% to 92% in patients at risk of hypercapnia.[71] 

Measure and record observations at least twice daily and more frequently (e.g., every hour) in those admitted to a critical care unit to inform your management plan.[1]

Review all patients with high-severity CAP (high risk of death) at least every 12 hours until improvement.[1] This should be done by a senior colleague and the medical team.[1]

Urgent: in the community

Stratify patients according to mortality risk and disease severity using the CRB-65 score (see our Diagnosis – recommendations section for more information) and your clinical judgement.[1] 

  • Score of 3 or more (high-severity): admit patient to hospital immediately.[1][64]

  • Score of 1 or 2 (moderate-severity): refer to hospital. These patients are at increased risk of death, particularly those with a score of 2.[1][64]

  • Score of 0 (low-severity): treat most patients at home.[1][64]

Consider treatment at home for patients with a CRB-65 score of 0 (low-severity), or a CRB-65 score of 1 or 2 (medium-severity) if they wish to be treated at home and they meet all of the following criteria:[1][64]

  • They are able to take oral medication safely and reliably

  • Their social circumstances make them suitable for treatment at home

  • They do not have unstable comorbidities.

Take a cautious approach when deciding whether it is safe to treat any patient with moderate-severity CAP (CRB-65 score of 1 or 2) in the community.

Give empirical antibiotics prior to hospital transfer (usually by blue-light ambulance in the UK) to patients with suspected CAP considered to be life-threatening.[1] Follow your local protocol.

Consider giving antibiotics prior to hospital transfer (usually by blue-light ambulance in the UK) to patients with suspected CAP where there are likely to be delays of over 6 hours to hospital admission and treatment.[1] Follow your local protocol.

Key Recommendations

Risk assessment and management of CAP in the first 4 hours: hospital settingRisk assessment and management of CAP in the first 4 hours: hospital setting[Figure caption and citation for the preceding image starts]: Risk assessment and management of CAP in the first 4 hours: hospital settingAdapted from Lim WS, et al. Thorax. 2009 Oct;64(suppl 3):iii1-55 [Citation ends].

Risk assessment and management of CAP in the first 4 hours: community settingRisk assessment and management of CAP in the first 4 hours: community setting. *Consider social circumstances, unstable comorbidities, ability to take oral treatment safely and reliably, and patient’s wishes when deciding whether to treat patients at home. **The majority of patients with moderate-severity CAP should be referred to hospital. However, you should consider social circumstances, ability to take oral treatment safely, unstable comorbidities, and patient’s wishes when deciding on home treatment [Figure caption and citation for the preceding image starts]: Risk assessment and management of CAP in the first 4 hours: community setting. *Consider social circumstances, unstable comorbidities, ability to take oral treatment safely and reliably, and patient’s wishes when deciding whether to treat patients at home. **The majority of patients with moderate-severity CAP should be referred to hospital. However, you should consider social circumstances, ability to take oral treatment safely, unstable comorbidities, and patient’s wishes when deciding on home treatment Adapted from Lim WS, et al. Thorax. 2009 Oct;64(suppl 3):iii1-55 [Citation ends].

Supportive care

Give intravenous fluids to patients with volume depletion.[1]

Arrange for patients with CURB-65 scores of 4 and 5 and an indication for intensive care unit (ICU) admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[ CURB-65 pneumonia severity score ][1] 

  • Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.

Do not routinely give non-invasive ventilation (NIV) or continuous positive airways pressure (CPAP) support in patients with respiratory failure due to CAP.[1]

  • If indicated, you should conduct a trial of non-invasive support only in a critical care area where immediate expertise is available to allow a rapid transition to invasive ventilation.[1]

Give simple analgesia (e.g., paracetamol) as appropriate (e.g., for pleuritic pain).[1]

Other treatments

Do not give corticosteroids routinely to patients with CAP of any severity.[1][64]

  • Discuss with a senior colleague patients with comorbidities for which corticosteroids are indicated.[64]

Failure to improve

Discuss with a senior colleague any patient who does not improve as expected.[1]

  • Consider repeat chest x-ray, C-reactive protein, white cell count, and further specimens for microbiology in patients who are not progressing satisfactorily after 3 days of treatment.[1]

  • Consider referral to a respiratory physician.[1]

Prognosis

For hospitalised patients, mortality rate ranges from 5% to 15%, but increases to between 20% and 50% in patients requiring admission to the ICU.[6][106] Patients treated in the community generally have a good prognosis.[1]

Full recommendations

Determine disease severity in patients with a working diagnosis of CAP as severe pneumonia is associated with a high risk of complications and death.[65]

  • Stratify patients into those with low-, moderate- or high-severity disease (see below).[1][64] 

  • Early identification of severity allows initiation of appropriate antibiotic therapy, as well as confirming whether the patient can be managed in the community or needs to be admitted to hospital where assisted ventilation in an intensive care setting may be necessary.[1][64] 

Practical tip

Think ‘Could this be sepsis?’ whenever an acutely unwell person presents with likely infection, even if their temperature is normal. Follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigation and treatment of all patients with suspected sepsis, or those at risk, within 1 hour.[66][67][68]

  • Remember that sepsis represents the severe, life-threatening end of infection.[69] 

  • Pneumonia is one of the main sources of infection in sepsis.[70] 

  • It is important to make an early, accurate diagnosis of infection and use antibiotics appropriately.

Use your clinical judgement in conjunction with a scoring system:[1][64]

Your clinical judgement is key when assessing severity in CAP using a scoring system.

  • For example, consider a young person with a normal blood pressure and urea level, but a low oxygen saturation despite supplemental oxygen. This person could potentially have severe pneumonia, but you could miss this if you only use a scoring system in your assessment.[65] 

  • You should use mortality prediction tools such as CURB-65 and CRB-65 to supplement, rather than replace, clinical judgement when assessing severity in CAP.

Consult with a senior colleague regarding the decision to start antibiotics at the earliest opportunity.[1]

In hospital

Assess severity using the CURB-65 score and your clinical judgement to identify patients with suspected CAP at high risk of death so that you can prioritise immediate treatment and consider whether the patient should be admitted.[1][64] 

Assess severity regularly in all patients with CAP following hospital admission.[1]

  • An early opportunity for this is by a senior colleague and the medical team during the ward round following admission.[1]

CURB-65 score: hospital setting 

Score 1 point for each feature present:

  • Confusion*

  • Urea >7 mmol/L (>19.6 mg/dL) 

  • Respiratory rate ≥30/minute

  • Blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg)

  • Age ≥65 years.

  • *Use the Abbreviated Mental Test to assess for confusion. Abbreviated Mental Test Score external link opens in a new window

    • Each question scores 1 mark, with a total possible score of 10 marks.

    • A score of 8 or less has been used to define mental confusion in the CURB-65 severity score.[64]

Use the Abbreviated Mental Test to assess for confusion. Each question scores 1 mark, with a total possible score of 10 marks. A score of 8 or less has been used to define mental confusion in the CURB-65 severity score.

Discuss patients with a CURB-65 score of 3 or more with a senior colleague at the earliest opportunity and manage as high-severity pneumonia (see below).[1][64]

Arrange emergency assessment of patients with a CURB-65 score of 4 or 5 by a critical care specialist.[1]

Risk assessment and management of CAP in the first 4 hours: hospital settingRisk assessment and management of CAP in the first 4 hours: hospital setting[Figure caption and citation for the preceding image starts]: Risk assessment and management of CAP in the first 4 hours: hospital settingAdapted from Lim WS, et al. Thorax. 2009 Oct;64(suppl 3):iii1-55 [Citation ends].

Follow your local protocol when prescribing antibiotics. The recommendations given here are based on British Thoracic Society (BTS) guidelines.[1] See our Management in hospital section below for more detail on antibiotic regimens.

CURB-65 is an accurate prognostic tool for predicting mortality in patients with CAP, and it is recommended by the British Thoracic Society (BTS) and the National Institute for Health and Care Excellence (NICE) alongside clinical judgement.[1][64]

  • It was developed from three prospective studies in the UK, New Zealand, and the Netherlands that included more than 1000 patients with CAP.[103] 

  • Validation studies have been carried out in several countries (including more than 3000 patients in total). They have shown increasing mortality with increasing CURB-65 scores, ranging from 0% to 1.1% (CURB-65 score = 0) to 17% to 60% (CURB-65 score = 5),[107][108][109][110] and increasing need for mechanical ventilation with increasing CURB-65 scores, ranging from 0% (CURB-65 score = 0) to 11% (CURB-65 score = 5).[110] 

    • In a study comparing CURB-65 to the pneumonia severity index (PSI), CURB-65 showed equal sensitivity and higher specificity (74.6% CURB-65 vs. 52.2% PSI) in predicting mortality due to CAP.[107]

    • Another study suggests that PSI may be more accurate than CURB-65 (and CRB-65) in predicting 30-day mortality in patients with CAP.[111] 

  • Despite emerging evidence for some benefits of PSI, both NICE and the BTS consider the simplicity of the calculation of the CURB-65 score to be an advantage over PSI.[1][64]

In the community

Assess severity using the CRB-65 score together with your clinical judgement to decide whether to treat patients with suspected CAP at home or refer to hospital for assessment or hospital admission.[1][64]

CRB-65 score: community setting

Score 1 point for each feature present:

  • Confusion*

  • Respiratory rate ≥30/minute

  • Blood pressure (systolic <90 mmHg or diastolic ≤60 mmHg)

  • Age ≥65 years.

*Use the Abbreviated Mental Test to assess for confusion. Abbreviated Mental Test Score external link opens in a new window

  • Each question scores 1 mark, with a total possible score of 10 marks.

  • A score of 8 or less has been used to define mental confusion in the CRB-65 severity score.[64]

Risk assessment and management of CAP: community settingRisk assessment and management of CAP in the first 4 hours: community setting. *Consider social circumstances, unstable comorbidities, ability to take oral treatment safely and reliably, and patient’s wishes when deciding whether to treat patients at home. **The majority of patients with moderate-severity CAP should be referred to hospital. However, you should consider social circumstances, ability to take oral treatment safely, unstable comorbidities, and patient’s wishes when deciding on home treatment [Figure caption and citation for the preceding image starts]: Risk assessment and management of CAP in the first 4 hours: community setting. *Consider social circumstances, unstable comorbidities, ability to take oral treatment safely and reliably, and patient’s wishes when deciding whether to treat patients at home. **The majority of patients with moderate-severity CAP should be referred to hospital. However, you should consider social circumstances, ability to take oral treatment safely, unstable comorbidities, and patient’s wishes when deciding on home treatment Adapted from Lim WS, et al. Thorax. 2009 Oct;64(suppl 3):iii1-55 [Citation ends].

Follow your local protocol when prescribing antibiotics. The recommendations given here are based on BTS and NICE guidelines.[1][105] See our Management in the community section below for more detail on antibiotic regimens.

Antibiotics

Give empirical antibiotics to all patients with CAP confirmed by chest x-ray immediately after diagnosis and within 4 hours of presentation to hospital.[1][105] 

  • Aim to give antibiotics to all patients with confirmed CAP before they leave the initial assessment area.[1] 

  • Give empirical antibiotics to patients with life-threatening disease based on a presumptive clinical diagnosis of CAP, then order an immediate chest x-ray to confirm the diagnosis.[1]

    • For these patients, follow your local protocol (e.g., Sepsis Six or Surviving Sepsis Campaign 1-hour care bundle) for investigating and treating all patients with suspected sepsis, or those at risk, within 1 hour.[66][67][68]

    • Pneumonia is one of the main sources of infection in sepsis.[70] 

    • It is important to make an early, accurate diagnosis of infection and use antibiotics appropriately.

Consult with a senior colleague about your decision to start antibiotics at the earliest opportunity.[1]

  • Clearly document the indication for prescribing antibiotics in the medical notes.[1]

De-escalate treatment as soon as appropriate, including switching from intravenous to oral antibiotic therapy.[1] When making this decision consider response to treatment (see practical tip), change in disease severity, and contraindications to oral administration such as:[1] 

  • Patient is unable to swallow (e.g., impaired swallowing reflex, impaired consciousness)

  • Gastrointestinal malabsorption for functional or anatomical reasons.

Review route of administration initially on the ward round following admission and then daily thereafter.[1] 

Practical tip

Pointers to clinical improvement

The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[1]

  • Pulse rate <100 beats/minute

  • Resolution of tachypnoea

  • Clinically hydrated and taking oral fluids

  • Resolution of fever for >24 hours

  • Resolution of hypotension

  • Absence of hypoxia

  • Improving white cell count

  • Non-bacteraemic infection

  • No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection

  • No concerns over gastrointestinal absorption.

Consider narrowing the spectrum of antibiotics or switching to pathogen-targeted antibiotics once a causative pathogen is identified.[1]

Empirical antibiotics

Treat the majority of patients empirically as the causative pathogen is only rarely identified at the initial assessment.[1] 

Prescribe an appropriate antibiotic regimen according to your local protocol to help reduce the development of antibiotic resistance and Clostridium difficile infection.[1] To aid antibiotic stewardship, the British Thoracic Society (BTS) recommends:[1]

  • Give empirical broad-spectrum intravenous antibiotics only to patients with high-severity CAP, and de-escalate to narrow-spectrum antibiotics as soon as clinically appropriate, based on the results of early microbiological investigations.[1] 

    • This group comprises approximately one third of all patients admitted to hospital with confirmed CAP.[1] 

  • Give empirical antibiotics to all other patients and switch to pathogen-targeted antibiotics as soon as specific pathogens are identified.

  • Consult with a microbiologist about appropriate antibiotic therapy.[1]

Consult local antibiotic protocols to determine the most appropriate choice based on local pathogen prevalence and antibiotic resistance patterns.

Consider whether a correct diagnosis of CAP has been made if a patient does not respond to initial empirical antibiotics.[1] 

  • Consider clinical and radiographic review to look for secondary diagnoses or complications of CAP such as pleural effusion/empyema, lung abscess, or worsening pneumonic shadowing.[1] 

  • Consider changing initial empirical antibiotics but first consider compliance with and adequate absorption of an oral regimen.[1] 

The following recommendations are based on guidelines from the BTS and the National Institute for Health and Care Excellence (NICE).[1][105] 

High-severity CAP (CURB-65 score: 3 or more)

Always manage patients with high-severity CAP in hospital.[1]

Give empirical broad-spectrum intravenous antibiotics immediately after diagnosis and within 4 hours of presentation to hospital.[1][105] 

The BTS CAP care bundle study was carried out in 2013 in 16 UK hospital trusts.

  • The CAP care bundle consisted of four elements:

    • A chest x-ray obtained within 4 hours of hospital admission in all adults with suspected CAP

    • Oxygen assessment and prescription in keeping with the BTS oxygen guideline[89] 

    • Severity assessment supported by the CURB-65 score

    • Timely and targeted antibiotics given according to CAP severity within 4 hours of admission.

  • The study compared patients with CAP receiving the CAP care bundle with those receiving standard care. Analysis of data from 2118 adults (median age 75.3 years) showed that significantly more patients in the CAP care bundle group received antibiotics within 4 hours of admission (adjusted odds ratio [OR] 1.52, 95% CI 1.08 to 2.14, P = 0.016) and that 30-day inpatient mortality was lower in this group (8.8% vs. 13.6%; adjusted odds ratio [OR] 0.59, 95% CI 0.37 to 0.95, P = 0.03).[71] 

Give a broad-spectrum beta-lactamase-resistant penicillin (e.g., amoxicillin/clavulanate) plus a macrolide (e.g., clarithromycin).[1]

  • The BTS guideline recommends adding a fluoroquinolone to the existing empirical regimen (i.e., triple therapy) if the patient does not respond, or if legionella pneumonia is strongly suspected.[1] However, in practice there are concerns about the risk of using a macrolide and fluoroquinolone together as they can both prolong the QT interval. Some clinicians therefore replace the macrolide in the original empirical regimen with a fluoroquinolone instead (i.e., dual therapy). Consider the safety issues associated with fluoroquinolone use. Consult with a microbiologist and senior colleague before treating these patients.

  • More recent (2019) guidelines from NICE on antimicrobial prescribing in adults also recommend amoxicillin/clavulanate plus clarithromycin (or erythromycin) as first-line in people with high-severity CAP. These recommendations are based mainly on expert opinion as the evidence is limited.[105]

For patients who are allergic to penicillin, give a second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) plus a macrolide (e.g., clarithromycin).[1] 

  • A small number of patients are allergic to both penicillins and cephalosporins; consult an infectious disease consultant for selection of appropriate antibiotics in these patients.

  • NICE guidelines on antimicrobial prescribing in adults recommend levofloxacin (after considering safety issues associated with fluoroquinolone use) as an alternative antibiotic for patients with high-severity CAP who are allergic to penicillin.[105]

Review the need for intravenous antibiotics initially during the ward round following admission and then every day thereafter.[1] 

Switch to oral antibiotics as soon as clinical improvement occurs (see practical tip above for pointers to clinical improvement), and as long as there are no contraindications to oral administration such as:[1] 

  • Patient is unable to swallow (e.g., impaired swallowing reflex, impaired consciousness)

  • Gastrointestinal malabsorption for functional or anatomical reasons.

Give antibiotic therapy for 5 days. NICE recommends:[105] 

  • Prescribing the shortest course that is likely to be effective to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects[105]

  • Stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable. This should be based on your clinical judgement and the following criteria:[105][112]

    • Fever in the past 48 hours, or more than one sign of clinical instability:

      • Systolic blood pressure <90 mmHg

      • Heart rate >100/minute

      • Respiratory rate >24/minute

      • Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.

In some people, longer courses might be needed due to individual circumstances. In the UK, some hospitals require consultation with the microbiology team if considering extending the duration of antibiotic treatment beyond 5 days in high-severity CAP. Follow your local protocol.

  • NICE guidelines do not provide an upper limit on antibiotic course length. This will be determined in individual circumstances, based on time taken to reach clinical stability.[105]

Moderate-severity CAP (CURB-65 score: 2)

Give antibiotics as soon as possible after diagnosis and within 4 hours of presentation to hospital.[1][105]

Consider patients with moderate-severity CAP for short-stay inpatient treatment or hospital-supervised outpatient treatment.[1]

The BTS CAP care bundle study was carried out in 2013 in 16 UK hospital trusts.

  • The CAP care bundle consisted of four elements:

    • A chest x-ray obtained within 4 hours of hospital admission in all adults with suspected CAP.

    • Oxygen assessment and prescription in keeping with the BTS oxygen guideline[89]

    • Severity assessment supported by the CURB-65 score

    • Timely and targeted antibiotics given according to CAP severity within 4 hours of admission.

  • The study compared patients with CAP receiving the CAP care bundle with those receiving standard care. Analysis of data from 2118 adults (median age 75.3 years) showed that significantly more patients in the CAP care bundle group received antibiotics ≤4 hours after admission (adjusted OR 1.52, 95% CI 1.08 to 2.14, P = 0.016) and that 30-day inpatient mortality was lower in this group (8.8% vs. 13.6%; adjusted OR 0.59, 95% CI 0.37 to 0.95, P = 0.03).[71]

Most patients with moderate-severity CAP can be treated with dual oral antibiotic therapy. The preferred choice is amoxicillin plus a macrolide (e.g., clarithromycin).[1]

  • NICE guidelines on antimicrobial prescribing in adults recommend monotherapy with amoxicillin in people with moderate-severity CAP, with the addition of clarithromycin (or erythromycin) only if an atypical pathogen is suspected. These recommendations are based mainly on expert opinion as the evidence is limited.[105]

Consider monotherapy with a macrolide for patients who have been treated in the community and who have not responded to an adequate course of amoxicillin prior to hospital admission.[1]

  • Deciding whether the course of amoxicillin was adequate is tricky and involves clinical judgement. Consult a senior clinician before prescribing monotherapy within the first 24 hours of admission.[1]

If oral antibiotics are contraindicated (e.g., patient is unable to swallow or has gastrointestinal malabsorption for functional or anatomical reasons), give intravenous amoxicillin or benzylpenicillin, plus clarithromycin.[1]

For patients who are allergic to penicillin or macrolides, consider oral doxycycline.[1] Alternative choices include oral levofloxacin or moxifloxacin (after considering safety issues associated with fluoroquinolone use).[1]

  • NICE guidelines on antimicrobial prescribing in adults with CAP recommend doxycycline or clarithromycin in people who are allergic to penicillin.[105] 

For patients who are allergic to penicillin in whom oral antibiotics are contraindicated, give a second-generation cephalosporin (e.g., cefuroxime) or a third-generation cephalosporin (e.g., cefotaxime or ceftriaxone) plus clarithromycin, or intravenous levofloxacin as monotherapy.[1]

If the patient does not respond to a combination of amoxicillin plus clarithromycin consider changing treatment to doxycycline or a fluoroquinolone with effective pneumococcal cover.[1]

In November 2018, the European Medicines Agency (EMA) completed a review of serious, disabling, and potentially irreversible adverse effects associated with systemic and inhaled fluoroquinolone antibiotics. These adverse effects include tendonitis, tendon rupture, arthralgia, neuropathies, and other musculoskeletal or nervous system effects.

  • As a consequence of this review, the EMA now recommends that fluoroquinolone antibiotics be restricted for use in serious, life-threatening bacterial infections only. Furthermore, they recommend that fluoroquinolones should not be used for mild to moderate infections unless other appropriate antibiotics for the specific infection cannot be used, and should not be used in non-severe, non-bacterial, or self-limiting infections. Patients who are older, have renal impairment, or have had a solid organ transplant, and those being treated with a corticosteroid are at a higher risk of tendon damage. Co-administration of a fluoroquinolone and a corticosteroid should be avoided.[113] The UK-based Medicines and Healthcare products Regulatory Agency (MHRA) supports these recommendations.[114] 

  • For this reason, fluoroquinolones should only be considered in moderate-severity CAP when it is considered inappropriate to use other antibiotics that are commonly recommended for the treatment of CAP. Consult with a microbiologist about whether a fluoroquinolone is an appropriate option for your patient. 

Review the need for intravenous antibiotics initially on the ward round following admission and then every day thereafter.[1]

  • Switch to oral antibiotics as soon as clinical improvement occurs (see practical tip), and as long as there are no contraindications to oral administration such as:[1]

    • Patient is unable to swallow (e.g., impaired swallowing reflex, impaired consciousness)

    • Gastrointestinal malabsorption for functional or anatomical reasons.

Practical tip

Pointers to clinical improvement

The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[1]

  • Pulse rate <100 beats/minute

  • Resolution of tachypnoea

  • Clinically hydrated and taking oral fluids

  • Resolution of fever for >24 hours

  • Resolution of hypotension

  • Absence of hypoxia

  • Improving white cell count

  • Non-bacteraemic infection

  • No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection

  • No concerns over gastrointestinal absorption.

Give antibiotic therapy for 5 days. NICE recommends:[105]

  • Prescribing the shortest course that is likely to be effective to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects

  • Stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable. This should be based on your clinical judgement and the following criteria:[1][112]

    • Fever in past 48 hours, or more than one sign of clinical instability:

      • Systolic blood pressure <90 mmHg

      • Heart rate >100/minute

      • Respiratory rate >24/minute

      • Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.

In some people, longer courses might be needed due to individual circumstances. In the UK, some hospitals require consultation with the microbiology team if considering extending the duration of antibiotic treatment beyond 5 days in moderate-severity CAP. Follow your local protocol.

  • NICE guidelines do not provide an upper limit on antibiotic course length. This will be determined in individual circumstances, based on time taken to reach clinical stability.[105]

Low-severity CAP (CURB-65 score: 0-1)

Give antibiotics as soon as possible and within 4 hours of presentation to hospital.[1][105]

The BTS CAP care bundle study was carried out in 2013 in 16 UK hospital trusts.

  • The CAP care bundle consisted of four elements:

    • A chest x-ray obtained within 4 hours of hospital admission in all adults with suspected CAP 

    • Oxygen assessment and prescription in keeping with the BTS oxygen guideline[89] 

    • Severity assessment supported by the CURB-65 score

    • Timely and targeted antibiotics given according to CAP severity within 4 hours of admission.

  • The study compared patients with CAP receiving the CAP care bundle with those receiving standard care. Analysis of data from 2118 adults (median age 75.3 years) showed that significantly more patients in the CAP care bundle group received antibiotics ≤4 hours after admission (adjusted OR 1.52, 95% CI 1.08 to 2.14, P = 0.016) and that 30-day inpatient mortality was lower in this group (8.8% vs. 13.6%; adjusted OR 0.59, 95% CI 0.37 to 0.95, P = 0.03).[71]

Most patients with low-severity CAP who are managed in hospital can be treated with oral antibiotics.[1] The preferred choice is amoxicillin.[1] Consider a macrolide (e.g., clarithromycin) or a tetracycline (e.g., doxycycline) for patients who are allergic to penicillin.[1] 

  • NICE recommends clarithromycin (or erythromycin) or doxycycline as alternatives to amoxicillin for patients allergic to penicillin and for patients in whom amoxicillin is unsuitable (e.g., if atypical pneumonia is suspected). NICE recommendations are based mainly on expert opinion as the evidence is limited.[105] 

If the oral route is contraindicated (e.g., impaired swallowing reflex, impaired consciousness, gastrointestinal malabsorption), consider intravenous amoxicillin, benzylpenicillin, or clarithromycin.[1]

  • Review the need for intravenous antibiotics initially during the ward round following admission and then every day after.[1] 

  • Switch to oral antibiotics as soon as clinical improvement occurs (see practical tip), and as long as there are no contraindications to oral administration.[1][105]

Practical tip

Pointers to clinical improvement

The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[1] 

  • Pulse rate <100 beats/minute

  • Resolution of tachypnoea

  • Clinically hydrated and taking oral fluids

  • Resolution of fever for >24 hours

  • Resolution of hypotension

  • Absence of hypoxia

  • Improving white cell count

  • Non-bacteraemic infection

  • No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection

  • No concerns over gastrointestinal absorption.

If the patient does not respond to amoxicillin monotherapy, consider switching to, or adding, a macrolide (e.g., clarithromycin).[1]

Give antibiotic therapy for 5 days. NICE recommends:[105]

  • Prescribing the shortest course that is likely to be effective to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects

  • Stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable. This should be based on your clinical judgement and the following criteria:[105][112]

    • Fever in past 48 hours, or more than one sign of clinical instability:

      • Systolic blood pressure <90 mmHg

      • Heart rate >100/minute

      • Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.

Pathogen-targeted antibiotic treatment

Switch from empirical antibiotics to pathogen-targeted antibiotics as soon as specific pathogens are identified (unless there are legitimate concerns about dual-pathogen infection).[1] 

  • Consult with a microbiologist about appropriate antibiotic therapy.[1]

  • Only about one third to one quarter of patients with CAP admitted to hospital will have their pneumonia defined microbiologically.[1] Among these patients: 

    • Around 14% have an atypical pathogen, of which:[21]

      • 7% have Mycoplasma pneumoniae

      • 4% have Chlamydophila pneumoniae

      • 3% have Legionella pneumophila

    • Those with infections due to organisms such as Mycoplasma, Chlamydophila, and Coxiella burnetii will be diagnosed late in the illness on the basis of seroconversion, reducing the opportunity for early targeted therapy.[1] Among patients managed in the community, very few will be microbiologically defined.[1] 

Consider switching treatment once the results of sensitivity testing are available or following consultation with a microbiologist, intensivist, or respiratory physician.[1] 

BTS recommendations for pathogen-targeted antibiotics[1]

Pathogen

Preferred antibiotic

Alternative antibiotic

Mycoplasma pneumoniae

Chlamydophila pneumoniae

Clarithromycin (orally or intravenously)

Doxycycline (orally) or a fluoroquinolone (orally or intravenously)

Legionella species

Fluoroquinolone (orally or intravenously)

Clarithromycin (orally or intravenously) or azithromycin (in countries where it is used for managing pneumonia)

Streptococcus pneumoniae

Amoxicillin (orally) or benzylpenicillin (intravenously)

Clarithromycin (orally) or cefuroxime or cefotaxime or ceftriaxone (intravenously)

Chlamydia psittaci

Coxiella burnetii

Doxycycline (orally)

Clarithromycin (orally or intravenously)

Haemophilus influenzae

Non-beta-lactamase-producing: amoxicillin (orally or intravenously)

Beta-lactamase-producing: amoxicillin/clavulanate (orally or intravenously)

Cefuroxime or cefotaxime or ceftriaxone (intravenously) or a fluoroquinolone (orally or intravenously)

Gram-negative enteric bacilli

Cefuroxime or cefotaxime or ceftriaxone (intravenously)

Fluoroquinolone (intravenously) or imipenem/cilastatin (intravenously) or meropenem (intravenously)

Pseudomonas aeruginosa

Ceftazidime (intravenously)

plus

Gentamicin or tobramycin (dose monitoring required) 

Ciprofloxacin (intravenously) or piperacillin/tazobactam (intravenously)

plus

Gentamicin or tobramycin (dose monitoring required) 

Staphylococcus aureus: non-MRSA

Flucloxacillin (intravenously)

with or without

Rifampicin (orally or intravenously) 

Staphylococcus aureus: MRSA

Vancomycin (intravenously; dose monitoring required) or linezolid (intravenously) or teicoplanin (intravenously)

with or without

Rifampicin (orally or intravenously) 

Supportive care

Provide supportive care for patients treated in hospital. This may include the following measures.[1]

Oxygen

Assess oxygen saturation in all patients by pulse oximetry (preferably while breathing air).

  • Give oxygen if oxygen saturation <94% and maintain at target range.[1] In patients at risk of CO2 retention give oxygen if oxygen saturation <88%. Early oxygen assessment is associated with improved prognosis.[71]

  • BTS guidelines recommend a target oxygen saturation range of:[71] 

    • 94% to 98% in age >16 years

    • 88% to 92% in patients at risk of hypercapnia.

    However, latest evidence suggests that liberal use of supplemental oxygen (target SpO2 >96%) in acutely ill adults is associated with higher mortality than more conservative oxygen therapy.[72] A reasonable approach is to aim for a target oxygen saturation of 94% to 96% in acutely ill patients who are not at risk of hypercapnia.

    Too much supplemental oxygen increases mortality.

    Latest evidence supports a 96% upper limit for target oxygen saturation in non-hypercapnic acutely ill adults.

    • Guidelines differ in their recommendations on target oxygen saturation in acutely unwell adults who are receiving supplemental oxygen. The 2017 BTS guideline recommends a target SpO2 range of 94% to 98% for patients not at risk of hypercapnia,[89] whereas the 2015 Thoracic Society of Australia and New Zealand guideline recommends 92% to 96%.[115]

    • A 2018 systematic review including meta-analysis of data from 25 randomised controlled trials found that, in adults with acute illness, liberal oxygen therapy (broadly equivalent to a target saturation >96%) is associated with higher mortality than conservative oxygen therapy (broadly equivalent to a target saturation ≤96%).[72] In-hospital mortality was 11 per 1000 higher for the liberal oxygen therapy group versus the conservative therapy group (95% CI, 2-22 per 1000 more). Mortality at 30 days was also higher in the group who had received liberal oxygen (RR 1.14, 95% CI 1.01 to 1.29). The trials included adults with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had had emergency surgery. The review excluded studies limited to people with chronic respiratory illness or psychiatric illness, or to patients on extracorporeal life support, receiving hyperbaric oxygen therapy, or having elective surgery.

    • An upper SpO2 limit of 96% is therefore reasonable when administering supplemental oxygen to medical patients with acute illness who are not at risk of hypercapnia. However, a higher target may be appropriate for some specific conditions (e.g., pneumothorax, carbon monoxide poisoning, cluster headache, and sickle cell crisis).[116]

  • Measure arterial blood gases in those with SpO2 <94%, those with a risk of hypercapnic ventilatory failure (CO2 retention), and all patients with high-severity CAP.[1]

Practical tip

Always record the inspired oxygen concentration clearly as this is essential for interpreting blood gas results.

Standard intensive care unit (ICU) supportive care

Arrange for patients with CURB-65 scores of 4 and 5 and an indication for ICU admission to be transferred to ICU and managed by ICU specialists together with respiratory physicians.[1] 

  • Patients with respiratory failure despite appropriate oxygen therapy require urgent airway management and possible intubation.

Do not routinely give non-invasive ventilation (NIV) or continuous positive airways pressure (CPAP) support in patients with respiratory failure due to CAP.[1] 

  • If indicated, you should conduct a trial of non-invasive support only in a critical care area where immediate expertise is available to allow a rapid transition to invasive ventilation.[1]

Vasopressors

Start vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure level ≥65 mmHg.[117]

Intravenous fluids

Assess all patients for volume depletion and give intravenous fluids if required.[1] 

Venous thromboembolism (VTE) prophylaxis

Consider prophylaxis for VTE with a low molecular weight heparin for all patients who are not fully mobile.[1] 

Nutritional support

Arrange nutritional support (whether enteral, parenteral, or via nasogastric feeding) for patients with severe CAP who require a prolonged hospital stay.[1] 

Airway clearance

Do not treat people with uncomplicated pneumonia with traditional airway clearance techniques routinely. If needed, offer these patients advice regarding expectoration of sputum.[1]

Consider airway clearance techniques if the patient has difficulty expectorating sputum or if they have a pre-existing lung condition.[1]

Analgesia

Give simple analgesia (e.g., paracetamol) as appropriate (e.g., for pleuritic pain).[1] 

Practical tip

Encourage patients with uncomplicated CAP (i.e., not complicated by the presence of parapneumonic effusion, empyema, abscess, pneumothorax, necrotising pneumonia, or bronchopleural fistula), whose medical condition allows them to, to sit out of bed. Initially aim for at least 20 minutes in the first 24 hours, and then increase mobility each subsequent day of hospitalisation. 

Other treatments

Corticosteroids

Do not give corticosteroids routinely to patients with CAP of any severity.[1][64]

  • Discuss with a senior colleague patients with comorbidities for which corticosteroids are indicated.[64]

Latest evidence suggests corticosteroids given as an adjunct to antibiotic treatment improve outcomes in adults with CAP but increases the risk of hyperglycaemia. The recommendation from NICE not to give corticosteroids routinely remains valid until further evidence is available.

  • A Cochrane review including 17 studies evaluated the safety and efficacy of corticosteroids given as an adjunct to antibiotic treatment for adults and children with pneumonia (CAP, hospital-acquired pneumonia, and ventilator-associated pneumonia). The intervention included oral prednisolone in 3 trials and intravenous dexamethasone, hydrocortisone, or methylprednisolone in 13 trials. The findings suggest that corticosteroids significantly reduced mortality and morbidity in patients with high-severity CAP. They also reduced morbidity, although not mortality, in patients with moderate- or low-severity CAP. Hyperglycaemia was the most common adverse event in adults treated with corticosteroids; however, the authors concluded that overall the benefits outweigh the harms.[118] 

  • Two systematic reviews (published before the Cochrane review) also looked at the safety and efficacy of adjunctive glucocorticoids for patients with CAP.[119][120] They showed no significant difference in all-cause mortality and reported significant reductions in length of ICU stay,[119] length of hospital stay,[119][120] and length of time to clinical stability in the corticosteroid groups.[119][120] One of the reviews reported an increased risk of hyperglycaemia in patients treated with corticosteroids.[120] 

  • NICE is due to review this area when the results of two ongoing trials have been published. For now, the recommendation not to give corticosteroids routinely remains valid.[64] 

Monitoring

Measure observations initially at least twice daily, and more frequently (e.g., every hour) in those admitted to a critical care unit (high-dependency unit or ICU).[1] Monitor:

  • Pulse

  • Blood pressure

  • Respiratory rate

  • Temperature

  • Oxygen saturation (with a recording of the inspired oxygen saturation at the same time)

  • Mental status.

Consider measuring a baseline C-reactive protein concentration in patients with CAP on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.[1][64] 

Review all patients with high-severity CAP at least every 12 hours until clinical improvement occurs.[1] This should be done by a senior colleague and the medical team.[1] 

Practical tip

Pointers to clinical improvement

The following clinical features should prompt you to consider switching from intravenous to oral antibiotic therapy:[1] 

  • Pulse rate <100 beats/minute

  • Resolution of tachypnoea

  • Clinically hydrated and taking oral fluids

  • Resolution of fever for >24 hours

  • Resolution of hypotension

  • Absence of hypoxia

  • Improving white cell count

  • Non-bacteraemic infection

  • No microbiological evidence of legionella, staphylococcal, or gram-negative enteric bacilli infection

  • No concerns over gastrointestinal absorption.

Assess severity regularly in all patients with CAP following hospital admission.[1] An early opportunity for this is the ward round following admission by a senior colleague and medical team.[1]

For more information on complications related to CAP see our separate Complications section.

Failure to improve

Discuss with a senior colleague any patient who does not improve as expected.[1] 

  • Consider repeat chest x-ray, C-reactive protein, white cell count, and further specimens for microbiology in patients not progressing satisfactorily after 3 days of treatment.[1] 

  • Consider referral to a respiratory physician.[1]

Practical tip

The main reasons why patients do not improve as expected include:[1] 

  • Incorrect diagnosis or complicating condition (e.g., pulmonary embolism, bronchial carcinoma, bronchiectasis)

  • Unexpected pathogen or pathogens not covered by antibiotic choice (e.g., ‘atypical’ pathogens, pathogens resistant to commonly used antibiotics such as ampicillin-resistant Haemophilus influenzae)

  • Antibiotic ineffective or causing allergic reaction (e.g., poor absorption of oral antibiotic, inadequate dose, antibiotic hypersensitivity)

  • Impaired local (e.g., bronchiectasis, endobronchial obstruction, aspiration) or systemic (e.g., HIV infection, myeloma) defenses

  • Local (e.g., parapneumonic effusion, empyema, lung abscess) or distant (e.g., metastatic infection, septicaemia, phlebitis at intravenous cannula site) complications of CAP

  • Overwhelming infection

  • Improvement expected too soon (e.g., in older patients).

Discharge from hospital

Do not routinely discharge patients if they have had 2* or more of the following findings present in the past 24 hours:[64]

  • Temperature >37.5°C (>99.5°F)

  • Heart rate >100/minute

  • Respiratory rate ≥24/minute

  • Systolic blood pressure ≤90 mmHg

  • Oxygen saturation <90% on room air

  • Inability to maintain oral intake

  • Abnormal mental status.

(*The BTS recommends basing your decision to discharge patients with CAP on 1 or more of the findings listed [unless they represent the usual baseline status for that patient] and uses a temperature threshold of 37.8°C [100.04°F]. See +Debate below.[1])

Consider delaying discharge of patients with CAP if their temperature is higher than 37.5°C (99.5°F).[64]

The BTS considers a temperature >37.8°C (>100.04°F), rather than the >37.5°C (>99.5°F) threshold recommended by NICE, as a finding that should prompt you to consider delaying discharge in a patient with CAP.[1] 

  • The >37.5°C (>99.5°F) threshold that is recommended by NICE[64] is based on the conclusions of a prospective cohort study that looked at the value of simple clinical variables for predicting short-term outcomes in patients with pneumonia.[121]

  • It found a cut-off of 37.5°C (99.5°F) to be strongly associated with 30-day mortality risk. 

  • For this reason we have based our recommendation on NICE guidance.

At discharge or at follow-up, offer patients access to information about CAP, such as a patient information leaflet.[1] 

Arrange a follow-up visit at around 6 weeks either with the patient’s general practitioner or in a hospital clinic.[1] 

Follow-up after discharge

Request a repeat chest x-ray during recovery after about 6 weeks for patients (regardless of whether they have been admitted to hospital):[1]

  • With persisting symptoms or physical signs

  • Who are at higher risk of underlying malignancy (especially smokers and those aged >50 years).

Consider bronchoscopy during recovery in patients with persisting signs, symptoms, and radiological abnormalitiesat around 6 weeks after completing treatment.[1] 

  • Consider a chest and upper abdomen CT scan in these patients prior to bronchoscopy.[98] 

Use the CRB-65 mortality risk tool and your clinical judgement to determine which patients are suitable for management in the community (see our section above on Risk stratification).

Consider treatment at home for patients with a CRB-65 score of 0 (low-severity) or a CRB-65 score of 1 or 2 (medium-severity) if they wish to be treated at home and they meet all of the following criteria:[1][64]

  • They are able to take oral medication safely and reliably

  • Their social circumstances make them suitable for treatment at home

  • They do not have unstable comorbidities.

Take a cautious approach, however, when deciding whether it is safe to treat any patient with moderate-severity CAP (CRB-65 score of 1 or 2) in the community. These patients are at increased risk of death, particularly those with a CRB-65 score of 2. You should refer the majority for management in hospital.[1][64]

  • If you decide to treat the patient in the community, follow the same treatment recommendations given below for patients with suspected CAP presenting in the community (low-severity).

Refer any patients presenting in the community with a CRB-65 score of 3 or more for immediate hospital admission (usually by blue-light ambulance in the UK).[1][64]

Antibiotics

The following recommendations are based on guidelines from the British Thoracic Society (BTS) and the National Institute for Health and Care Excellence (NICE).[1] [105]

Giving antibiotics prior to hospital transfer
High-severity CAP (CRB-65 score 3 or 4)

Give empirical antibiotics prior to hospital transfer (usually by blue-light ambulance in the UK) to patients with suspected CAP considered to be life-threatening.[1] Follow your local protocol.

  • The first-line choice is intravenous benzylpenicillin or oral amoxicillin. Clarithromycin is an alternative for people who are allergic to penicillin.[1] 

    • More recent (2019) guidelines from NICE on antimicrobial prescribing in adults recommend amoxicillin/clavulanate plus clarithromycin (or erythromycin) first-line in people with high-severity CAP. These recommendations are based mainly on expert opinion as the evidence is limited.[105] 

Consider giving antibiotics prior to hospital transfer to patients with suspected high-severity CAP where there are likely to be delays of over 6 hours to hospital admission and treatment.[1] 

  • Pre-admission antibiotics can negatively influence the results of subsequent microbiological investigations, but this is not seen as a reason for withholding antibiotics if a general practitioner considers it indicated.[1] 

Moderate-severity CAP (CRB-65 score 1 or 2) and low-severity CAP (CRB-65 score 0)

Do not give antibiotics to patients with moderate-severity CAP or low-severity CAP prior to hospital referral.[1] 

Empirical antibiotics for home treatment

Give empirical oral antibiotics to patients treated in the community.

  • The first-line option is amoxicillin.[1][105] 

  • Alternative options for patients who are allergic to penicillin are a macrolide (e.g., clarithromycin) or a tetracycline (e.g., doxycycline).[1] 

    • NICE recommends clarithromycin (or erythromycin) or doxycycline as alternatives to amoxicillin for patients allergic to penicillin and for patients in whom amoxicillin is unsuitable (e.g., if atypical pneumonia is suspected). NICE recommendations are based mainly on expert opinion as the evidence is limited.[105] 

Consider adding or switching to a macrolide if the patient does not respond to amoxicillin.[1] 

  • Consider whether a correct diagnosis of CAP has been made if a patient does not respond to initial empirical antibiotics.[1] 

    • Consider clinical and radiographic review to look for secondary diagnoses or complications of CAP such as pleural effusion/empyema, lung abscess, or worsening pneumonic shadowing.[1] 

    • Consider changing initial empirical antibiotics but first consider compliance with and adequate absorption of an oral regimen.[1] 

Give antibiotic therapy for 5 days. NICE recommends:[105] 

  • Prescribing the shortest course that is likely to be effective to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects

  • Stopping treatment after 5 days unless microbiological results suggest a longer course or the patient is not clinically stable. This should be based on your clinical judgement and the following criteria:[105][112]

    • Fever in past 48 hours, or more than one sign of clinical instability:

      • Systolic blood pressure <90 mmHg

      • Heart rate >100/minute

      • Respiratory rate >24/minute

      • Arterial oxygen saturation <90% or PaO2 <60 mmHg in room air.

General management

Advise patients to rest, to drink plenty of fluids, and not to smoke.[1] 

Failure to respond

Advise patients (and their carers) to seek medical advice if:[105] 

  • Symptoms worsen rapidly or significantly

  • Symptoms do not start to improve within 3 days

  • The person becomes systemically very unwell.

Around 10% of patients managed in the community do not respond to antibiotic therapy and require hospitalisation.[122]

Admit urgently to hospital any patient on antibiotic treatment with features of moderate- or high-severity infection.[1] 

Order a chest x-ray during recovery after about 6 weeks for patients (regardless of whether patients have been admitted to hospital):[1] 

  • With persisting symptoms or physical signs

  • Who are at higher risk of underlying malignancy (especially people who smoke and those aged >50 years).

Consider bronchoscopy during recovery in patients with persisting signs, symptoms, and radiological abnormalities at around 6 weeks after completing treatment.[1] 

  • Consider a chest and upper abdomen CT scan in these patients prior to bronchoscopy.[98]

For patients admitted to hospital, mortality rate ranges from 5% to 15%, but increases to 20% to 50% in patients requiring admission to the intensive care unit (ICU).[6][106] 

  • Risk factors associated with increased 30-day mortality include bacteraemia, admission to the ICU, comorbidities (especially neurological disease), and infection with a potentially multidrug-resistant pathogen (e.g., Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae).[36][123][124][125]

Patients treated in the community generally have a good prognosis.[1]

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