1

4 NATIONAL INSTITUTE FOR HEALTH AND CARE

5 EXCELLENCE

6 Guideline
7 Pneumonia: diagnosis and management
8 (update)
9 Draft for consultation, April 2025
10

This guideline covers diagnosing, assessing, and treating community-

acquired and hospital-acquired pneumonia, including bacterial pneumonia
secondary to COVID-19, in babies over 1 month (corrected gestational
age), children, young people and adults. It aims to optimise antibiotic use
and reduce antibiotic resistance.

It does not cover ventilator associated pneumonia or COVID-19

pneumonia. For recommendations on managing suspected or confirmed
COVID-19 pneumonia, see NICE's guideline on managing COVID-19.

For bacterial infection in healthy babies up to and including 28 days

(corrected gestational age), see NICE’s guideline on neonatal infection:
antibiotics for prevention and treatment.

This guideline will update NICE guideline CG191 (published December

2014). It will also incorporate recommendations from NG138 and NG139
(published September 2019).

1
Who is it for?
• Healthcare professionals
• People who have suspected or confirmed pneumonia (except ventilator-
associated and COVID-19 pneumonia), their families and carers

What does it include?

• the recommendations
• recommendations for research
• rationale and impact sections that explain why the committee made the
2025 recommendations and how they might affect practice
• the guideline context.

Information about how the guideline was developed is on the guideline’s

webpage. This includes the evidence reviews, the scope, details of the
committee and any declarations of interest.

New and updated recommendations

We have reviewed the evidence on the diagnosis, assessment and
treatment of community-acquired and hospital-acquired pneumonia. You
are invited to comment on the new and updated recommendations. These
are marked as [2025].

You are also invited to comment on recommendations that we propose to

delete from the 2014 guideline.

We have not reviewed the evidence for the recommendations shaded in

grey, and cannot accept comments on them. In some cases, we have
made minor wording changes for clarification.

See update information for a full explanation of what is being updated.

Full details of the evidence and the committee’s discussion on the 2025
recommendations are in the evidence reviews. Evidence for the 2014
recommendations is in the full version of CG191. Evidence for the 2019

2
 recommendations about community-acquired pneumonia is on the
webpage for NG138. Evidence for the 2019 recommendations about
hospital-acquired pneumonia is on the webpage for NG139.

3
 1 Contents
2 Recommendations ........................................................................................... 5
3 First contact with NHS services, remote or in-person................................... 5
4 Assessing community-acquired pneumonia ................................................. 6
5 Assessment tools hospital-acquired pneumonia ........................................ 10
6 Investigations in hospital .............................................................................. 8
7 Starting and reviewing antibiotics ............................................................... 13
8 Antibiotic treatment for community-acquired pneumonia ............................ 13
9 Antibiotic treatment for hospital-acquired pneumonia................................. 20
10 Corticosteroid treatment in hospital ............................................................ 27
11 Non-invasive respiratory support ................................................................ 28
12 Information about treatment and recovery for community-acquired
13 pneumonia.................................................................................................. 29
14 Reassessment............................................................................................ 31
15 Follow-up chest X-rays ............................................................................... 32
16 Terms used in this guideline ....................................................................... 33
17 Recommendations for research ..................................................................... 35
18 Rationale and impact ..................................................................................... 37
19 Context .......................................................................................................... 51
20 Finding more information and committee details ............................................ 52
21 Update information......................................................................................... 53
22

4
1 Recommendations

People have the right to be involved in discussions and make informed

decisions about their care, as described in NICE's information on making
decisions about your care.

Making decisions using NICE guidelines explains how we use words to

show the strength (or certainty) of our recommendations, and has
information about prescribing medicines (including off-label use),
professional guidelines, standards and laws (including on consent and
mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people

delivering care:

• Patient experience in adult NHS services

• Babies, children and young people's experience of healthcare
• Service user experience in adult mental health
• People's experience in adult social care services
• Shared decision making
• Medicines adherence
• Medicines optimisation
• Multimorbidity
• Transition from children’s to adults’ services
2 If sepsis is suspected, assess and manage the person in line with NICE’s
3 guideline on sepsis: recognition, diagnosis and early management.

4 For babies or children under 5 with fever with no obvious cause, see NICE’s
5 guideline on fever in under 5s: assessment and initial management for
6 recommendations about diagnosing pneumonia.

7 1.1 First contact with NHS services, remote or in-person

8 1.1.1 For people aged 16 and over presenting with suspected lower
9 respiratory tract infection, see NICE’s guideline on suspected

5
 1 respiratory infection in over 16s: assessment at first presentation
2 and initial management. [2014, amended 2023]

3 1.2 Assessing community-acquired pneumonia

4 Assessment of adults in primary care and deciding place of care

5 1.2.1 If a clinical diagnosis of community-acquired pneumonia has been
6 made, determine whether adults are at low, intermediate or high
7 risk of death using the CRB65 scoring system (see box 1). [2014]

8 1.2.2 Use clinical judgement together with the CRB65 score (see box 1)
9 to stratify adults with community-acquired pneumonia into those
10 with low-, moderate- or high-severity disease. The disease severity
11 will usually correspond to the risk of death. [2014]

Box 1 CRB65 score for mortality risk assessment in primary care

CRB65 score is calculated by giving 1 point for each of the following

prognostic features:

• confusion (abbreviated Mental Test score 8 or less, or new disorientation

in person, place or time). For guidance on delirium, see NICE’s guideline
on delirium.
• raised respiratory rate (30 breaths per minute or more)
• low blood pressure (diastolic 60 mmHg or less, or systolic less than
90 mmHg)
• age 65 years or more.

Adults are stratified for risk of death (within 30 days) as follows:

• 0: low risk (less than 1% mortality risk)

• 1 or 2: intermediate risk (1 to 10% mortality risk)
• 3 or 4: high risk (more than 10% mortality risk).

12 1.2.3 Use clinical judgement together with the CRB65 score (bearing in
13 mind this can be affected by other factors, for example,
6
 1 comorbidities or pregnancy) to inform shared decisions about place
2 of care. Consider:

3 • referral to hospital for adults with a CRB65 score of 2 or more

4 • GP-led care, referral to hospital or hospital at home service or
5 same day emergency care (SDEC) unit for adults with a CRB65
6 score of 1
7 • GP-led care with safety netting advice for adults with a CRB65
8 score of 0. [2025]

9 1.2.4 Refer adults to hospital if they have any symptoms or signs

10 suggesting a more serious illness or condition (for example,
11 cardiorespiratory failure or sepsis). [2019, amended 2021]

12 1.2.5 Consider referring adults with community-acquired pneumonia to

13 hospital, or seek specialist advice, if they cannot take oral
14 medicines (exploring locally available options for giving intravenous
15 antibiotics at home or in the community, rather than in hospital, if
16 this is appropriate). [2019]

17 Children and young people presenting to primary care

18 1.2.6 Consider referring children and young people with community-
19 acquired pneumonia to hospital or seek specialist paediatric advice
20 on further investigation and management. [2019]

21 Assessment of adults in hospital and deciding place of care

22 1.2.7 If a clinical diagnosis of community-acquired pneumonia has been
23 made in hospital, determine whether adults are at low, intermediate
24 or high risk of death using the CURB65 scoring system (see box 2).
25 [2014]

26 1.2.8 Use clinical judgement together with the CURB65 score (see box 2)
27 to stratify adults with community-acquired pneumonia into those
28 with low-, moderate- or high-severity disease. The disease severity
29 will usually correspond to the risk of death. [2014]
7
 Box 2 CURB65 score for mortality risk assessment in hospital

CURB65 score is calculated by giving 1 point for each of the following

prognostic features:

• confusion (abbreviated Mental Test score 8 or less, or new disorientation in

person, place or time). For guidance on delirium, see NICE’s guideline on
delirium
• raised blood urea nitrogen (over 7 mmol/litre)
• raised respiratory rate (30 breaths per minute or more)
• low blood pressure (diastolic 60 mmHg or less, or systolic less than
90 mmHg)
• age 65 years or more.

Adults are stratified for risk of death as follows:

• 0 or 1: low risk (less than 3% mortality risk)

• 2: intermediate risk (3 to 15% mortality risk)
• 3 to 5: high risk (more than 15% mortality risk).

1 1.2.9 Use clinical judgement together with the CURB65 score (bearing in
2 mind this can be affected by other factors, for example,
3 comorbidities or pregnancy) to inform shared decisions about place
4 of care. Consider:

5 • inpatient care for adults with a CURB65 score of 3 or more, with

6 referral to critical care services where appropriate
7 • inpatient care or hospital at home service or same day
8 emergency care (SDEC) unit for adults with a CURB65 score of
9 2
10 • discharge home, GP-led care with safety netting advice for
11 adults with a CURB65 score of 0 or 1. [2025]

8
 1 1.2.10 Consider early discharge to a hospital at home service for adults on
2 an inpatient ward whose clinical condition is improving but require
3 ongoing monitoring or treatment. [2025]

4 Shared decision-making regarding place of care

5 1.2.11 When considering referral to a hospital at home service or same
6 day emergency care (SDEC) unit, make a shared decision with the
7 person (and their family or carers, where appropriate) about the
8 most appropriate place of care, taking into account:

9 • the person’s preferences

10 • clinical risks, including any comorbidities or frailty
11 • the safety and suitability of their home environment
12 • their support network. [2025]

For a short explanation of why the committee made the 2025

recommendations and how they might affect practice, see the rationale and
impact section on hospital at home.

Full details of the evidence and the committee’s discussion are in evidence
review B: hospital at home.

13 Prediction tools for under 18s in primary care

14 NICE has made a recommendation for research on prediction tools for under
15 18s in primary care.

For a short explanation of why the committee made no recommendations,

see the rationale and impact section on prediction tools for under 18s in
primary care.

Full details of the evidence and the committee’s discussion are in evidence
review J: prediction tools for babies, children and young people.

9
 1 1.3 Assessment tools for hospital-acquired pneumonia
2 NICE has made a recommendation for research on assessment tools for
3 hospital-acquired pneumonia.

For a short explanation of why the committee made no recommendations,

see the rationale and impact section on assessment tools for hospital-
acquired pneumonia.

Full details of the evidence and the committee’s discussion are in evidence
review K: early warning scores for hospital-acquired pneumonia.

4 1.4 Investigations in hospital

5 Imaging
6 1.4.1 Put in place processes to allow diagnosis (including chest X-ray)
7 and treatment of community-acquired pneumonia in adults within 4
8 hours of presentation to hospital. [2014]

9 1.4.2 Be aware that lung ultrasound can be used in the diagnosis of

10 pneumonia in hospital, for example:

11 • for rapid point-of-care diagnosis in a sick or deteriorating person

12 • where there is a possible alternative diagnosis, for example,
13 heart failure
14 • for investigating associated complications such as pleural
15 disease. [2025]

For a short explanation of why the committee made the 2025

recommendation and how it might affect practice, see the rationale and
impact section on lung ultrasound.

Full details of the evidence and the committee’s discussion are in evidence
review A: lung ultrasound.

10
 1 C-reactive protein for adults with community-acquired pneumonia
2 on admission
3 1.4.3 Consider measuring a baseline C-reactive protein (CRP) in adults
4 with community-acquired pneumonia on admission to hospital.
5 [2025]

For a short explanation of why the committee made this recommendation

and how it might affect practice, see the rationale and impact section on
biomarkers.

Full details of the evidence and the committee’s discussion are in evidence
review H: biomarkers.

6 Microbiological tests
7 1.4.4 For people with hospital-acquired pneumonia, send a sample (for
8 example, sputum sample, nasopharyngeal swab or tracheal
9 aspirate) for microbiological testing. [2025]

10 1.4.5 Do not routinely offer microbiological tests to adults with low-

11 severity community-acquired pneumonia or children with non-
12 severe community-acquired pneumonia. [2025]

13 1.4.6 For adults with moderate- or high-severity community-acquired

14 pneumonia, consider:

15 • blood cultures if there are additional clinical indications such as

16 suspected sepsis (see NICE’s guideline on sepsis)
17 • sputum cultures, taking into account the person’s history of
18 antibiotic treatment, their clinical trajectory, the presence of any
19 comorbidities, any recent hospitalisation and the likelihood of
20 getting a good quality sputum sample
21 • pneumococcal urinary antigen tests to support de-escalation to a
22 narrower spectrum antibiotic

11
 1 • legionella urinary antigen tests if the person has risk factors for
2 legionella infection. [2025]

3 1.4.7 For children and young people with severe community-acquired

4 pneumonia:

5 • consider blood cultures if there are additional clinical indications

6 such as suspected sepsis (see NICE’s guideline on sepsis) and
7 • consider sputum cultures, if possible and age appropriate, taking
8 into account their history of antibiotic treatment, their clinical
9 trajectory, the presence of any comorbidities, any recent
10 hospitalisation and the likelihood of getting a good quality
11 sputum sample
12 • do not routinely use urinary antigen tests. [2025]

For a short explanation of why the committee made the 2025

recommendations and how they might affect practice, see the rationale and
impact section on microbiological tests.

Full details of the evidence and the committee’s discussion are in evidence
review C: microbiological tests.

12
 1 1.5 Starting and reviewing antibiotics
2 1.5.1 Start antibiotic treatment as soon as possible after establishing a
3 diagnosis of pneumonia, and within 4 hours (if the person has
4 suspected sepsis, see NICE’s guideline on sepsis). [2019]

5 1.5.2 Give oral antibiotics first line if the person can take oral medicines,
6 and the severity of their condition does not require intravenous
7 antibiotics. [2019]

8 1.5.3 If intravenous antibiotics are given, review by 48 hours and, if

9 possible, consider switching to oral antibiotics to complete the
10 course. [2019]

11 1.5.4 If a sample has been sent for microbiological testing:

12 • review the choice of antibiotic(s) when results are available and

13 • consider changing the antibiotic(s) according to results, using a
14 narrower-spectrum antibiotic, if appropriate. [2019]

15 1.6 Antibiotic treatment for community-acquired

16 pneumonia

17 Factors to take into account when offering antibiotics

18 1.6.1 Offer an antibiotic(s) for people with community-acquired
19 pneumonia. When choosing an antibiotic, take account of:

20 • the assessment of disease severity for adults, based on clinical

21 judgement together with the CRB65 score (see box 1) or
22 CURB65 score (see box 2)
23 • the severity of symptoms or signs for children and young people,
24 based on clinical judgement
25 • the risk of developing complications, for example, if the person
26 has relevant comorbidity such as severe lung disease or
27 immunosuppression

13
 1 • local antimicrobial resistance and surveillance data (such as
2 influenza and Mycoplasma pneumoniae infection rates)
3 • recent antibiotic use
4 • recent microbiological results, including colonisation with
5 multidrug-resistant bacteria. [2019]

6 Choice, dosage and duration of antibiotic

7 1.6.2 When prescribing an antibiotic(s) for community-acquired
8 pneumonia, see the following tables for antibiotic choice, dosage
9 and course length:

10 • table 1 for adults [2019]

11 • table 2 for children and young people. [2025].

12 1.6.3 For adults with community-acquired pneumonia, stop antibiotic

13 treatment after 5 days unless:

14 • microbiological results suggest a longer course is needed or

15 • the person is not clinically stable, for example, if they have had a
16 fever in the past 48 hours or have more than 1 of the following
17 signs of clinical instability:
18 − systolic blood pressure less than 90 mmHg
19 − heart rate more than 100 beats per minute
20 − respiratory rate more than 24 breaths per minute
21 − arterial oxygen saturation less than 90% or partial pressure of
22 oxygen of more than 60 mmHg in room air. [2019]
23
24 1.6.4 Offer a 3-day course of antibiotics for babies and children aged 3
25 months (corrected gestational age) to 11 years with non-severe
26 community-acquired pneumonia without complications or

14
 1 underlying disease. See recommendations 1.10.2 to 1.10.4 for
2 information and advice for parents and carers. [2025]

3 1.6.5 Consider extending use of antibiotics beyond 3 days for babies and
4 children aged 3 months (corrected gestational age) to 11 years if
5 they are not clinically stable, for example, if they are in respiratory
6 distress, or their oxygen saturation levels have not improved as
7 expected. [2025]

8 1.6.6 For all children and young people with community-acquired

9 pneumonia, stop antibiotic treatment after 5 days unless
10 microbiological results suggest a longer course is needed or the
11 child or young person is not clinically stable. [2019, amended
12 February 2025]

For a short explanation of why the committee made the 2025

recommendations and how they might affect practice, see the rationale and
impact section on antibiotic duration for children.

Full details of the evidence and the committee’s discussion are in evidence
review D: antibiotic duration.

13 Table 1 Antibiotics for treating community-acquired pneumonia in adults

Treatment based on disease Antibiotic, dosage and course length

severity and suitability
Low-severity disease: first-line Amoxicillin:
oral antibiotic 500 mg three times a day (higher doses can
be used; see the BNF) for 5 days
Low-severity disease: Doxycycline:
alternative oral antibiotics for 200 mg on first day, then 100 mg once a day
penicillin allergy or if for 4 days (5-day course in total)
amoxicillin unsuitable (for
example, if atypical pathogens
suspected) Clarithromycin:
500 mg twice a day for 5 days

Erythromycin (in pregnancy):

500 mg four times a day for 5 days

15
Moderate-severity disease: Amoxicillin:
first-line oral antibiotics 500 mg three times a day (higher doses can
be used; see the BNF) for 5 days

With (if atypical pathogens suspected)

Clarithromycin:
500 mg twice a day for 5 days

Or

Erythromycin (in pregnancy):

500 mg four times a day for 5 days
Moderate-severity disease: Doxycycline:
alternative oral antibiotics for 200 mg on first day, then 100 mg once a day
penicillin allergy for 4 days (5-day course in total)

Clarithromycin:
500 mg twice a day for 5 days
High-severity disease: first-line Co-amoxiclav:
antibiotics 500/125 mg three times a day orally or 1.2 g
three times a day intravenously for 5 days

With

Clarithromycin:
500 mg twice a day orally or intravenously for
5 days

Or

Erythromycin (in pregnancy):

500 mg four times a day orally for 5 days
High-severity disease: Levofloxacin:
alternative antibiotic for 500 mg twice a day orally or intravenously for
penicillin allergy 5 days

(consult a local microbiologist if See the MHRA January 2024 advice on

fluoroquinolone not appropriate) restrictions and precautions for using
fluoroquinolone antibiotics because of the risk
of disabling and potentially long-lasting or
irreversible side effects
Notes for table 1
See the BNF for appropriate use and dosing in specific populations, for
example, hepatic impairment, renal impairment, pregnancy and

16
 breastfeeding, and administering intravenous (or, where appropriate,
intramuscular) antibiotics.

1 Table 2 Antibiotics for treating community-acquired pneumonia in

2 babies, children and young people

Treatment based on Antibiotic, dosage and course length

severity of symptoms or
signs and suitability
Non-severe symptoms or Amoxicillin:
signs: first-line oral 1 month to 2 months, 125 mg three times a day for
antibiotic 5 days
3 months to 11 months, 125 mg three times a day
for 3 days
1 year to 4 years, 250 mg three times a day for
3 days
5 years to 11 years, 500 mg three times a day for
3 days
12 years to 17 years, 500 mg three times a day for
5 days
(higher doses can be used for all ages; see BNF for
children)
Non-severe symptoms or Clarithromycin:
signs: alternative oral 1 month to 2 months:
antibiotics for penicillin
Under 8 kg, 7.5 mg/kg twice a day for 5 days
allergy or if amoxicillin is
unsuitable (for example,
atypical pathogens 3 months to 11 years:
suspected) Under 8 kg, 7.5 mg/kg twice a day for 3 days
8 kg to 11 kg, 62.5 mg twice a day for 3 days
12 kg to 19 kg, 125 mg twice a day for 3 days
20 kg to 29 kg, 187.5 mg twice a day for 3 days
30 kg to 40 kg, 250 mg twice a day for 3 days

12 years to 17 years:
250 mg to 500 mg twice a day for 5 days

Erythromycin (in pregnancy):

8 years to 11 years, 250 mg to 500 mg four times a
day for 3 days
12 years to 17 years, 250 mg to 500 mg four times a
day for 5 days

Doxycycline:

17
 12 years to 17 years, 200 mg on first day, then
100 mg once a day for 4 days (5-day course in total)

See BNF for children for use of doxycycline in

children under 12
Severe symptoms or Co-amoxiclav:
signs: first-line Oral doses:
antibiotic(s)
1 month to 11 months, 0.5 ml/kg of 125/31
suspension three times a day for 5 days
1 years to 5 years, 10 ml of 125/31 suspension three
times a day or 0.5 ml/kg of 125/31 suspension three
times a day for 5 days (or 5 ml of 250/62
suspension)
6 years to 11 years, 10 ml of 250/62 suspension
three times a day or 0.3 ml/kg of 250/62 suspension
three times a day for 5 days
12 years to 17 years, 500/125 mg three times a day
for 5 days
Intravenous doses:
1 month to 2 months, 30 mg/kg twice a day
3 months to 17 years, 30 mg/kg three times a day
(maximum 1.2 g per dose three times a day)

With (if atypical pathogen suspected)

Clarithromycin:
Oral doses:
1 month to 11 years:
Under 8 kg, 7.5 mg/kg twice a day for 5 days
8 kg to 11 kg, 62.5 mg twice a day for 5 days
12 kg to 19 kg, 125 mg twice a day for 5 days
20 kg to 29 kg, 187.5 mg twice a day for 5 days
30 kg to 40 kg, 250 mg twice a day for 5 days
12 years to 17 years:
250 mg to 500 mg twice a day for 5 days
Intravenous doses:
1 month to 11 years, 7.5 mg/kg twice a day
(maximum 500 mg per dose)
12 years to 17 years, 500 mg twice a day

Or

Erythromycin (in pregnancy):

8 years to 17 years, 250 mg to 500 mg four times a
day orally for 5 days
Severe symptoms or Consult local microbiologist
signs: alternative
18
 antibiotics for penicillin
allergy

Notes for table 2

See the BNF for children for appropriate use and dosing in specific
populations, for example, hepatic impairment, renal impairment, pregnancy
and breastfeeding, and administering intravenous (or, where appropriate,
intramuscular) antibiotics.

The age bands apply to children of average size and, in practice, the
prescriber will use the age bands in conjunction with other factors such as
the severity of the condition being treated and the child’s size in relation to
the average size of children of the same age.

Notes for tables 1 and 2

Mycoplasma pneumoniae infection occurs in outbreaks approximately

every 4 years and is more common in school-aged children.

Erythromycin is preferred if a macrolide is needed in pregnancy, for

example, if there is true penicillin allergy and the benefits of antibiotic
treatment outweigh the harms. See the Medicines and Healthcare products
Regulatory Agency (MHRA) Public Assessment Report on the safety of
macrolide antibiotics in pregnancy.

19
 1 Safe discharge from hospital
2 1.6.7 Do not routinely discharge adults with community-acquired
3 pneumonia if in the past 24 hours they have had 2 or more of the
4 following findings:

5 • temperature more than 37.5°C

6 • respiratory rate 24 breaths per minute or more
7 • heart rate more than 100 beats per minute
8 • systolic blood pressure 90 mmHg or less
9 • oxygen saturation less than 90% on room air
10 • abnormal mental status
11 • inability to eat without assistance. [2014]

12 1.7 Antibiotic treatment for hospital-acquired pneumonia

13 Factors to take into account when offering antibiotics

14 1.7.1 For people with symptoms or signs of pneumonia starting within
15 48 hours of hospital admission, follow the section on antibiotic
16 treatment for community-acquired pneumonia. [2019]

17 1.7.2 Offer an antibiotic(s) for people with hospital-acquired pneumonia.

18 When choosing an antibiotic(s), take account of:

19 • disease severity (based on clinical judgement)

20 • the number of days in hospital before onset of symptoms
21 • the risk of developing complications, for example, if the person
22 has a relevant comorbidity such as severe lung disease or
23 immunosuppression
24 • local hospital and ward-based antimicrobial resistance data
25 • recent antibiotic use
26 • recent microbiological results, including colonisation with
27 multidrug-resistant bacteria
28 • recent contact with a health or social care setting before current
29 admission
20
 1 • the risk of adverse effects with broad-spectrum antibiotics, such
2 as Clostridium difficile infection. [2019]

3 Choice, duration and dose of antibiotic

4 1.7.3 When prescribing an antibiotic(s) for hospital-acquired pneumonia,
5 see the following tables for antibiotic choice, dosage and course
6 length:

7 • table 3 for adults

8 • table 4 for children and young people. [2019]

9 1.7.4 Consider following the antibiotic recommendations

10 (recommendation 1.6.2) for community-acquired pneumonia for
11 people with symptoms or signs of pneumonia starting within
12 days 3 to 5 of hospital admission who are not at higher risk of
13 resistance. Higher risk of resistance includes relevant comorbidity
14 (such as severe lung disease or immunosuppression), recent use
15 of broad-spectrum antibiotics, colonisation with multidrug-resistant
16 bacteria, and recent contact with health and social care settings
17 before current admission. [2019]

18 1.7.5 For hospital-acquired pneumonia, review treatment after a total of 5

19 days of antibiotics and consider stopping antibiotics if clinically
20 stable. [2019]

21 Table 3 Antibiotics for treating hospital-acquired pneumonia in adults

Treatment based on Antibiotic, dosage and course length

severity of symptoms or
signs, risk of resistance
and suitability
Non-severe symptoms Co-amoxiclav:
or signs and not at 500/125 mg three times a day for 5 days then review
higher risk of
resistance: first-line
oral antibiotic
Non-severe symptoms Options include:
or signs and not at
higher risk of Doxycycline:

21
resistance: alternative 200 mg on first day, then 100 mg once a day for
oral antibiotics for 4 days (5-day course) then review
penicillin allergy or if
co-amoxiclav
Cefalexin (caution in penicillin allergy):
unsuitable
500 mg twice or three times a day (can be increased
(antibiotic choice should to 1 g to 1.5 g three or four times a day) for 5 days
be based on specialist then review
microbiological advice
and local resistance data) Co-trimoxazole (off-label use):
960 mg twice a day for 5 days then review
(see BNF for information on monitoring)

Levofloxacin (only if other first-line antibiotics are

unsuitable; off-label use):
500 mg once or twice a day for 5 days then review
See the MHRA January 2024 advice on restrictions
and precautions for using fluoroquinolone
antibiotics because of the risk of disabling and
potentially long-lasting or irreversible side effects.
Fluoroquinolones must now only be prescribed when
other commonly recommended antibiotics are
inappropriate
Severe symptoms or Options include:
signs (for example,
symptoms or signs of Piperacillin with tazobactam:
sepsis) or at higher risk
4.5 g three times a day (increased to 4.5 g four times
of resistance: first-line
a day if severe infection)
intravenous antibiotics

(antibiotic choice should Ceftazidime:

be based on specialist 2 g three times a day
microbiological advice
and local resistance data)
Ceftriaxone:
2 g once a day

Cefuroxime:
750 mg three times a day (increased to 750 mg four
times a day or 1.5 g three or four times a day if
severe infection) [2019 amended October 2020]

Meropenem:
0.5 g to 1 g three times a day

Ceftazidime with avibactam:

2/0.5 g three times a day

22
 Levofloxacin (only if other first-line antibiotics are
unsuitable; off-label use):
500 mg once or twice a day (use higher dosage if
severe infection)
See the MHRA January 2024 advice on restrictions
and precautions for using fluoroquinolone
antibiotics because of the risk of disabling and
potentially long-lasting or irreversible side effects.
Fluoroquinolones must now only be prescribed when
other commonly recommended antibiotics are
inappropriate
Suspected or confirmed Vancomycin:
methicillin-resistant 15 mg/kg to 20 mg/kg two or three times a day
Staphylococcus aureus intravenously, adjusted according to serum
infection: dual therapy vancomycin concentration (a loading dose of
with a first-line 25 mg/kg to 30 mg/kg can be used in seriously ill
intravenous antibiotic people); maximum 2 g per dose
(see BNF for information on monitoring)

Teicoplanin:
Initially 6 mg/kg every 12 hours for 3 doses, then
6 mg/kg once a day intravenously
(see BNF for information on monitoring)

Linezolid (if vancomycin cannot be used; specialist

advice only):
600 mg twice a day orally or intravenously
(see BNF for information on monitoring)
1

Notes for table 3

See the BNF for appropriate use and dosing in specific populations, for
example, hepatic impairment, renal impairment, pregnancy and
breastfeeding, and administering intravenous (or, where appropriate,
intramuscular) antibiotics.

3 Table 4 Antibiotics for treating hospital-acquired pneumonia in babies

4 aged 1 month and over, children and young people

Treatment based on Antibiotic, dosage and course length

severity of symptoms or

23
signs, risk of resistance
and suitability
Non-severe symptoms or Co-amoxiclav:
signs and not at higher 1 month to 11 months, 0.5 ml/kg of 125/31
risk of resistance: first-line suspension three times a day for 5 days, then
oral antibiotic review

1 year to 5 years, 10 ml of 125/31 suspension (or

5 ml of 250/62 suspension) three times a day, or
0.5 ml/kg of 125/31 suspension three times a day
for 5 days, then review

6 years to 11 years, 10 ml of 250/62 suspension

three times a day or 0.3 ml/kg of 250/62
suspension three times a day for 5 days, then
review

12 years to 17 years, 500/125 mg three times a

day for 5 days, then review
Non-severe symptoms or Clarithromycin:
signs and not at higher 1 month to 11 years:
risk of resistance:
Under 8 kg, 7.5 mg/kg twice a day for 5 days, then
alternative oral antibiotic
review
for penicillin allergy or if
co-amoxiclav unsuitable 8 kg to 11 kg, 62.5 mg twice a day for 5 days, then
review
(other options may be 12 kg to 19 kg, 125 mg twice a day for 5 days,
suitable based on specialist then review
microbiological advice and 20 kg to 29 kg, 187.5 mg twice a day for 5 days,
local resistance data) then review
30 kg to 40 kg, 250 mg twice a day for 5 days,
then review

12 years to 17 years, 500 mg twice a day for

5 days, then review
Severe symptoms or signs Options include:
(for example, symptoms or
signs of sepsis) or at higher Piperacillin with tazobactam:
risk of resistance: first-line
1 month to 11 years, 90 mg/kg three or four times
intravenous antibiotics
a day (maximum 4.5 g per dose four times a day)
(antibiotic choice should be 12 years to 17 years, 4.5 g three times a day
based on specialist (increased to 4.5 g four times a day if severe
microbiological advice and infection)
local resistance data)
Ceftazidime:
1 month to 17 years, 25 mg/kg three times a day
(50 mg/kg three times a day if severe infection;
maximum 6 g per day)

24
 Ceftriaxone:
1 month to 11 years (up to 50 kg), 50 mg/kg to
80 mg/kg once a day (use dose at higher end of
range if severe infection; maximum 4 g per day)
9 years to 11 years (50 kg and above), 2 g once a
day
12 years to 17 years, 2 g once a day
1
Suspected or confirmed Teicoplanin:
methicillin-resistant 1 month, initially 16 mg/kg for 1 dose, then
Staphylococcus aureus 8 mg/kg once daily, subsequent dose to be given
infection: dual therapy 24 hours after initial dose (doses given by
with a first-line intravenous infusion)
intravenous antibiotic
2 months to 11 years, initially 10 mg/kg every
12 hours intravenously for 3 doses, then 6 mg/kg
to 10 mg/kg once daily intravenously
12 years to 17 years, initially 6 mg/kg every
12 hours intravenously for 3 doses, then 6 mg/kg
once daily intravenously
(see BNF for children for information on
monitoring)

Vancomycin:
1 month to 11 years, 10 mg/kg to 15 mg/kg four
times a day intravenously, adjusted according to
serum-vancomycin concentration
12 years to 17 years, 15 mg/kg to 20 mg/kg two or
three times a day intravenously, adjusted
according to serum vancomycin concentration (a
loading dose of 25 mg/kg to 30 mg/kg can be used
in seriously ill people); maximum 2 g per dose
(see BNF for children for information on
monitoring)

Linezolid (if vancomycin cannot be used; off-label

use; specialist advice only):
3 months to 11 years, 10 mg/kg three times a day
orally or intravenously (maximum 600 mg per
dose)
12 years to 17 years, 600 mg twice a day orally or
intravenously
(see BNF for children for information on
monitoring)
2

25
 Notes for table 4

See the BNF for children for appropriate use and dosing in specific
populations, for example, hepatic impairment, renal impairment, pregnancy
and breastfeeding, and administering intravenous (or, where appropriate,
intramuscular) antibiotics.

The age bands apply to children of average size and, in practice, the
prescriber will use the age bands in conjunction with other factors such as
the severity of the condition being treated and the child’s size in relation to
the average size of children of the same age.

Notes for tables 3 and 4

Higher risk of resistance includes symptoms or signs starting more than

5 days after hospital admission, relevant comorbidity such as severe lung
disease or immunosuppression, recent use of broad-spectrum antibiotics,
colonisation with multidrug-resistant bacteria, and recent contact with a
health or social care setting before current admission.

For off-label use, the prescriber should follow relevant professional

guidance, taking full responsibility for the decision. Informed consent should
be obtained and documented. See the General Medical Council's good
practice in prescribing and managing medicines and devices for further
information.

2 1.8 Corticosteroid treatment in hospital

3 1.8.1 For adults with high severity community-acquired pneumonia in
4 hospital, offer a corticosteroid, in addition to antibiotics, for 4 to 7
5 days or until discharge, if sooner. [2025]

6 1.8.2 When choosing a corticosteroid, consider starting treatment with IV

7 hydrocortisone. If hydrocortisone is not suitable, consider an
26
 1 alternative corticosteroid such as dexamethasone. [2025]
2
3 Note: Not all treatments are licensed for this indication, so use
4 would be off label.

5 Note: the Medicines and Healthcare products Regulatory Agency

6 (MHRA) advice for restrictions and precautions on the
7 coadministration of fluoroquinolone antibiotics and corticosteroids.

For a short explanation of why the committee made these recommendations

and how they might affect practice, see the rationale and impact section on
corticosteroids.

Full details of the evidence and the committee’s discussion are in evidence
review E: corticosteroids.

8 1.9 Non-invasive respiratory support

9 1.9.1 For people with respiratory failure in whom standard oxygen
10 therapy is insufficient to meet target saturation levels, consider a
11 trial of high flow nasal oxygen, based on multidisciplinary
12 consensus, clinical trajectory and the person’s preferences and
13 ability to tolerate it. [2025]

14 1.9.2 When deciding the best location in the hospital for delivering non-
15 invasive respiratory support, take into account:

16 • any advanced directives or established treatment escalation plan

17 and
18 • the person’s clinical trajectory and
19 • the risk of failure and potential need for invasive mechanical
20 ventilation. [2025]

27
 1 1.9.3 Be aware that people with certain co-existing conditions may
2 benefit from a trial of non-invasive ventilation or continuous positive
3 airways pressure. [2025]

For a short explanation of why the committee made these recommendations

and how they might affect practice, see the rationale and impact section on
non-invasive respiratory support.

Full details of the evidence and the committee’s discussion are in evidence
review F: non-invasive ventilation.

4 1.10 Information about treatment and recovery for

5 community-acquired pneumonia
6 1.10.1 Explain to adults with community-acquired pneumonia that after
7 starting treatment their symptoms should steadily improve,
8 although the rate of improvement will vary with the severity of the
9 pneumonia. Most adults can expect that by:

10 • 1 week: fever should have resolved

11 • 4 weeks: chest pain and sputum production should have
12 substantially reduced
13 • 6 weeks: cough and breathlessness should have substantially
14 reduced
15 • 3 months: most symptoms should have resolved but fatigue may
16 still be present
17 • 6 months: they will feel back to normal. [2014]

18 1.10.2 Explain to parents or carers of children with community-acquired

19 pneumonia that after starting treatment their child’s symptoms
20 should steadily improve, although the rate of improvement will vary

28
 1 with the severity of the pneumonia and some symptoms will persist
2 after stopping antibiotics. For most children:

3 • fever (without use of antipyretics) and difficulty breathing should

4 have resolved within 3 to 4 days
5 • cough should gradually improve but may persist for up to 4
6 weeks after discharge and does not usually require further
7 review if the child is otherwise well. [2025]

8 1.10.3 Give advice to people with community-acquired pneumonia (or their

9 parents or carers, if appropriate) about:

10 • possible adverse effects of the antibiotic(s)

11 • seeking further advice (if the person is receiving treatment in the
12 community or via hospital at home) if:
13 − symptoms worsen rapidly or significantly or
14 − symptoms do not start to improve within 3 days or
15 - the person becomes systemically unwell. [2019, amended
16 2025]

17 1.10.4 Advise parents or carers of children with community-acquired

18 pneumonia to seek further advice if there is persisting fever
19 combined with:

20 • increased work of breathing or

21 • reduced fluid intake for children or poor feeding for infants or
22 • unresolving fatigue. [2025]

For a short explanation of why the committee made the 2025

recommendations and how they might affect practice, see the rationale and
impact section on information for parents or carers of children with
community-acquired pneumonia.

29
 Full details of the evidence and the committee’s discussion are in evidence
review G: patient information.

1 1.11 Reassessment

2 When to reassess
3 1.11.1 Reassess people with pneumonia if symptoms or signs do not
4 improve as expected or worsen rapidly or significantly. [2019]

5 Community-acquired pneumonia
6 1.11.2 When reassessing people with community-acquired pneumonia, be
7 aware of possible non-bacterial causes, such as influenza. [2019]

8 1.11.3 Refer adults with community-acquired pneumonia to hospital if they

9 have symptoms that are not improving as expected with antibiotics.
10 [2019 amended 2021]

11 1.11.4 Consider referring adults with community-acquired pneumonia to

12 hospital, or seek specialist advice, if microbiological samples have
13 identified bacteria that are resistant to oral antibiotics. [2019]

14 1.11.5 Send a sample (for example, a sputum sample) for microbiological

15 testing if symptoms or signs have not improved following antibiotic
16 treatment, and this has not been done already. [2019]

17 Hospital-acquired pneumonia
18 1.11.6 Seek specialist advice from a microbiologist for people with
19 hospital-acquired pneumonia if they have:

20 • symptoms that are not improving as expected with antibiotics or

21 • multidrug-resistant bacteria. [2019]

22 Use of biomarkers after starting treatment

23 1.11.7 For people in hospital with pneumonia, consider measuring C-
24 reactive protein (CRP) or procalcitonin (PCT) 3 or 4 days after
30
 1 starting treatment if there is clinical concern about treatment failure.
2 [2025]

3 1.11.8 Be aware that high levels of CRP or PCT, or levels that do not
4 significantly improve with treatment, are associated with treatment
5 failure and the person may need senior clinical review. [2025]

For a short explanation of why the committee made these recommendations

and how they might affect practice, see the rationale and impact section on
biomarkers.

Full details of the evidence and the committee’s discussion are in evidence
review H: biomarkers.

6 1.12 Follow-up chest X-rays

7 1.12.1 Do not routinely offer follow-up chest X-rays to people discharged
8 from inpatient care after an episode of pneumonia. [2025]

9 1.12.2 Consider follow-up chest X-rays at 6 weeks following discharge for

10 people with:

11 • risk factors for lung cancer or other underlying respiratory

12 disease, for example, people who smoke or are over 50 years or
13 • persisting or deteriorating symptoms or
14 • unexplained weight loss. [2025]

15 1.12.3 If a follow-up chest X-ray is being considered, make a shared

16 decision with the person taking into account:

17 • any recent imaging

18 • the presence of any comorbidities or frailty
19 • the person’s prognosis and treatment options
20 • their preferences. [2025]

31
 For a short explanation of why the committee made these recommendations
and how they might affect practice, see the rationale and impact section on
follow-up chest X-rays.

Full details of the evidence and the committee’s discussion are in evidence
review I: chest X-ray.

1 Terms used in this guideline

2 Assessment of disease severity of community-acquired

3 pneumonia in adults
4 A judgement by the managing clinician as to the likelihood of adverse
5 outcomes in a person. This is based on a combination of clinical
6 understanding and knowledge in addition to a mortality risk score. The
7 difference between categories of severity and mortality risk can be important.
8 Typically, the mortality risk score will match the severity assessment.
9 However, there may be situations where the mortality score does not
10 accurately predict mortality risk and clinical judgement is needed. An example
11 might be a person with a low mortality risk score who has an unusually low
12 oxygen level, pleural complications or multiple comorbidities who would be
13 considered to have a severe illness.

14 Clinical diagnosis of community-acquired pneumonia

15 Diagnosis based on symptoms and signs of lower respiratory tract infection in
16 a patient who, in the opinion of the healthcare professional and in the absence
17 of a chest X-ray, is likely to have community-acquired pneumonia. This might
18 be because of the presence of focal chest signs, illness severity or other
19 features.

20 Community-acquired pneumonia
21 Pneumonia that is acquired outside hospital, or within 48 hours of admission.
22 Pneumonia that develops in a nursing home resident is included in this

32
 1 definition. When managed in hospital the diagnosis is usually confirmed by
2 chest X-ray.

3 Hospital-acquired pneumonia
4 Pneumonia that develops 48 hours or more after hospital admission and that
5 was not incubating at hospital admission, or patients who present to hospital
6 with pneumonia but who have been discharged within the last 7-10 days.
7 When managed in hospital, the diagnosis is usually confirmed by chest Xray.
8 For the purpose of this guideline, ventilator associated pneumonia is excluded
9 from the definition (this is pneumonia that occurs in someone on mechanical
10 ventilation 48 hours or more after intubation).

11 Lower respiratory tract infection

12 An acute illness (present for 21 days or less), usually with cough as the main
13 symptom, and with at least 1 other lower respiratory tract symptom (such as
14 fever, sputum production, breathlessness, wheeze or chest discomfort or
15 pain) and no alternative explanation (such as sinusitis or asthma).
16 Pneumonia, acute bronchitis and exacerbation of chronic obstructive airways
17 disease are included in this definition.

18 Pneumonia
19 Pneumonia refers to both community-acquired pneumonia and hospital-
20 acquired pneumonia.

21 Severe community-acquired pneumonia in children and young

22 people
23 Severe community acquired pneumonia in babies, children and young people
24 is a diagnosis made by the treating physician. Features of this may include
25 difficulty breathing, oxygen saturation less than 90% (percutaneous oxygen
26 saturation monitors may be in accurate in people with pigmented skin), raised
27 heart rate, grunting, severe chest indrawing, inability to breastfeed or drink,
28 lethargy and a reduced level of consciousness.

33
 1 Same day emergency care (SDEC)
2 Patients are well enough and ambulatory enough to attend hospital each day
3 and have a review in a rapid clinic setting. More suitable for younger people
4 who are more mobile and can easily attend clinics.

5 Recommendations for research

6 Key recommendations for research

7 1 Microbiological tests
8 Which microbiological test, or group of tests, can aid decision making around
9 safely reducing inappropriate antibiotic prescribing in people with suspected
10 pneumonia, community or hospital-acquired?

For a short explanation of why the committee made this recommendation

for research, see the rationale and impact section on microbiological tests

Full details of the evidence and the committee’s discussion are in evidence
review C: microbiological tests.

11 2 Follow-up chest imaging

12 What is the clinical and cost-effectiveness of follow-up chest imaging (chest X-
13 ray) for adults discharged from hospital after treatment for pneumonia? Which
14 people should be offered follow-up chest imaging and when should it be
15 done?

For a short explanation of why the committee made this recommendation

for research, see the rationale and impact section on follow-up chest
imaging

Full details of the evidence and the committee’s discussion are in evidence
review I: chest X-ray.

34
 1 3 Adjunctive corticosteroids
2 In people hospitalised with community-acquired pneumonia (CAP) or hospital
3 acquired pneumonia (HAP), what is the most effective and cost-effective
4 corticosteroid treatment (as an adjunct to antibiotics), including dose, duration,
5 and route of administration, and does the pathogen involved have an impact
6 on efficacy?

For a short explanation of why the committee made this recommendation

for research, see the rationale and impact section on corticosteroids

Full details of the evidence and the committee’s discussion are in evidence
review E: corticosteroids.

7 4 Prediction tools for under 18s in primary care

8 In children and young people presenting to primary care with signs and
9 symptoms of pneumonia, what is the most accurate and cost-effective clinical
10 prediction tool to identify under 18s who require referral to secondary care for
11 assessment, treatment and admission?

For a short explanation of why the committee made this recommendation

for research, see the rationale and impact section on prediction tools for
under 18s in primary care.

Full details of the evidence and the committee’s discussion are in evidence
review J: prediction tools for under 18s in primary care.

12 5 Assessment tools for hospital-acquired pneumonia

13 In people with hospital-acquired pneumonia, what is the most clinically
14 effective and cost-effective assessment tool or method for stratifying disease
15 severity?

35
 For a short explanation of why the committee made this recommendation
for research, see the rationale and impact section on assessment tools for
hospital-acquired pneumonia.

Full details of the evidence and the committee’s discussion are in evidence
review K: early warning scores.

2 Rationale and impact

3 These sections briefly explain why the committee made the recommendations
4 and how they might affect practice.

5 Hospital at home
6 Recommendations 1.2.3 and 1.2.9 to 1.2.11

7 Why the committee made the recommendations

8 The evidence compared home-based care with inpatient care for people with
9 low- to moderate-severity community-acquired pneumonia. The committee
10 agreed that home-based care covers a variety of different care models, such
11 as hospital at home, virtual wards and same day emergency care units. They
12 noted that the evidence was limited to hospital at home models but agreed
13 that the findings could be extrapolated to other types of home-based care. It
14 was noted that ‘hospital at home’ is used as an umbrella term to include virtual
15 wards and other models of home-based care, so this terminology was used in
16 the recommendations.

17 The studies were small, had methodological limitations and included

18 participants not considered to be representative of those who would
19 potentially use virtual wards in practice. It showed that people treated at home
20 tended to do no worse than people treated as inpatients in hospital in terms of
21 hospital readmission, antibiotic duration, symptom improvement and adverse
22 events. There was insufficient evidence to determine the impact of home-
23 based care on mortality or length of stay.

36
 1 People treated at home were more satisfied with the quality and location of
2 their care. The committee agreed other potential benefits of home-based care
3 such as avoiding deconditioning, reducing the risk of hospital-acquired
4 infection, freeing up hospital beds and reducing demand on acute inpatient
5 services. They noted that home-based care could help avoid hospital
6 admission for people attending primary care or emergency departments.

7 The committee discussed the existing recommendations on using CBR65 or

8 CURB65 scores, together with clinical judgement, to inform decisions about
9 place of care. They also identified a list of factors that would need to be
10 discussed with the person when making a shared decision about using these
11 models of care. They noted that family and carers should be consulted, where
12 appropriate, for example, if they will be involved in supporting the person at
13 home.

14 There was no evidence for children, so the committee was not able to make
15 any recommendations about hospital at home for children and young people.

16 How the recommendations might affect practice

17 Most trusts now have established hospital at home services, so where those
18 services already exist, the recommendations are likely to have a positive
19 impact on reducing hospital admissions and length of hospital stay. This
20 would reduce pressure on hospital inpatient care and potentially free up beds
21 for more severely unwell patients who require hospital admission. Early
22 discharge of people who are improving could also improve inpatient capacity.

23 Return to recommendations

24 Prediction tools for under 18s in primary care

25 Why the committee made the recommendation for research

26 The evidence was reviewed on risk assessment tools and clinical prediction
27 tools for identifying children and young people attending primary care who
28 may be at risk of deterioration. Recommendations were unable to be
29 developed in this area.
37
 1 Many children and young people presenting to primary care with respiratory
2 tract infection symptoms will not require antibiotics and can be safely cared for
3 at home. A small number can deteriorate and require secondary care.
4 Identifying those most at risk is important to ensure quick and appropriate
5 referral as well as preventing over-referral to secondary care, so the
6 committee made a recommendation for research on prediction tools for
7 assessing under 18s in primary care with suspected pneumonia.

8 Assessment tools for hospital-acquired pneumonia

9 Why the committee made the recommendation for research

10 The evidence was reviewed on the prognostic accuracy of the national early
11 warning score 2 (NEWS2) and paediatric early warning system (PEWS) for
12 people with pneumonia. Recommendations were unable to be developed in
13 this area.

14 The committee noted that CURB65 is a validated tool that can be used,
15 alongside clinical judgement, to assess the severity of community-acquired
16 pneumonia in hospital. The committee made a recommendation for research
17 to identify or develop tools or methods for stratifying people with hospital-
18 acquired pneumonia according to disease severity. This could include
19 validating an existing model.

20 Lung ultrasound
21 Recommendation 1.4.2

22 Why the committee made the recommendation

23 Evidence showed that lung ultrasound is a good diagnostic tool for people
24 with suspected community-acquired pneumonia, showing high accuracy for
25 both ruling in and ruling out the diagnosis in symptomatic people. The
26 accuracy of lung ultrasound did not depend on the setting within the hospital
27 where it was used.

38
 1 The committee discussed the benefits of lung ultrasound compared to chest
2 X-ray, particularly that it avoids radiation exposure and can be used to rapidly
3 consider diagnosis of pneumonia and promptly start antibiotic treatment if
4 pneumonia is confirmed. Lung ultrasound can be performed at the bedside or
5 point-of-care during other clinical examinations, which in some situations may
6 be more efficient and less time-consuming than transporting someone to the
7 X-ray department and subsequently accessing the images. As such the
8 committee agreed lung ultrasound may be particularly helpful when assessing
9 a sick or deteriorating person with suspected pneumonia or where several
10 possible causes are being considered for the presenting symptoms.

11 Lung ultrasound can take longer to perform than chest X-ray and it can be
12 more difficult to visualise the entire lungs, particularly in people who are lying
13 down or in unwell children who are not able to sit still for the time required to
14 complete the examination. Chest X-ray may detect other potential illnesses or
15 problems with the lungs, such as tumours or mediastinal abnormalities. The
16 committee was also concerned about storage and audit of lung ultrasound
17 images and the current lack of trained operators with sufficient experience to
18 perform diagnostic lung ultrasound for pneumonia.

19 The committee agreed that lung ultrasound can be used for those with
20 suspected pneumonia and gave some examples of how it might be used.

21 How the recommendation might affect practice

22 The recommendations may increase the use of lung ultrasound beyond
23 current levels, particularly point-of-care use in emergency departments or
24 critical care areas to help confirm diagnosis of community-acquired
25 pneumonia and promptly start antibiotic treatment. This may mean a quicker
26 diagnosis, starting treatment earlier and enable assessment of complications.

27 In cases where lung ultrasound clearly supports a diagnosis of pneumonia, it

28 may reduce the need for a chest X-ray or CT, although in cases where a
29 diagnosis cannot be confirmed using lung ultrasound, further chest imaging

39
 1 will still be required. This has the potential to increase resource use although
2 this is not anticipated.

3 To respond to the potential increased use of lung ultrasound, more clinicians

4 will require training and accreditation in this procedure and time to build up
5 experience of this imaging method, which is potentially an implementation
6 issue.

7 Return to recommendation

8 Biomarkers
9 Recommendations 1.4.3 and 1.11.7 to 1.11.8

10 Why the committee made the recommendations

11 The evidence showed a link between elevated biomarker levels (C-reactive
12 protein (CRP), procalcitonin (PCT) and neutrophil to lymphocyte ratio (NLR))
13 and adverse outcomes in people with pneumonia. The evidence also showed
14 that people treated for pneumonia in hospital whose CRP, PCT or NLR levels
15 remained high or increased between admission and day 3 or 4 were more
16 likely to experience adverse clinical outcomes than people whose biomarkers
17 decreased. Though NLR showed a similar pattern of findings, there was less
18 evidence on NLR than CRP or PCT, it is not routinely used (despite being
19 easily obtained through routine blood samples) and so the committee agreed
20 to focus on the use of CRP and PCT.

21 The committee considered extending the existing recommendation on

22 measuring CRP on admission to hospital to also include PCT, but they
23 concluded that adding PCT would not give substantially more information than
24 CRP alone so this would be an unnecessary extra test. There was insufficient
25 evidence to support a switch from routine CRP testing on admission to routine
26 PCT testing on admission, and this would be a significant change in practice
27 without clear justification.

28 The committee agreed that CRP or PCT should be measured 3 to 4 days after
29 starting treatment where there is concern about treatment failure. This will
40
 1 allow clinicians to monitor the person’s CRP or PCT levels at this time and
2 any changes to their levels if a baseline level has been taken. Low or
3 decreasing levels may help to rule out complications or poor prognosis, while
4 levels that remain high may help to identify when senior clinical review is
5 needed. The committee noted that CRP levels that fail to halve in 3 days are a
6 cause for concern. They agreed that people who are responding well to
7 treatment and whose clinical condition is improving are unlikely to need follow-
8 up biomarker testing.

9 Additional evidence compared antibiotic treatment using a PCT-guided

10 algorithm with standard antibiotic treatment and showed that people treated
11 using the PCT-guided approach took antibiotics for a shorter time and
12 experienced fewer side effects. The reduction in duration of antibiotic
13 treatment did not affect rates of pneumonia recurrence, re-hospitalisation,
14 intensive care unit (ICU) admission or mortality. However, the committee was
15 concerned that the average standard duration of antibiotic treatment used in
16 the trials of 10 to 12 days was much longer than UK current recommended
17 practice of 5 days. Furthermore, the trials did not give the committee any
18 information on whether it was safe or effective to use PCT levels to reduce
19 antibiotic treatment below 5 days, so they were not able to make a
20 recommendation about this.

21 There was no evidence linking biomarkers to other aspects of de-escalating

22 care such as discharge from ICU or discharge home, so the committee was
23 unable to make any recommendations about these aspects of care for people
24 with pneumonia.

25 How the recommendations might affect practice

26 The recommendations could increase the use of CRP and PCT testing in
27 people in hospital with pneumonia who are not responding to treatment after 3
28 or 4 days, but this could help to identify complications or allow clinicians to
29 amend the treatment plan to be more effective. CRP and to a lesser extent
30 PCT testing is widely available in most hospitals so although there may be an
31 increase in testing, it would not require significant changes in procedures.

41
 1 Return to recommendations

2 Microbiological tests
3 Recommendations 1.4.4 to 1.4.7

4 Why the committee made the recommendations

5 The existing recommendation to not routinely offer microbiological tests to
6 adults with low-severity community-acquired pneumonia was deemed to be
7 appropriate and reflect current practice, so the committee chose to retain it.
8 They agreed to add children with non-severe community-acquired pneumonia
9 to this recommendation.

10 Noting the lack of evidence identified in this area, the committee discussed
11 when to consider blood cultures for adults and children with severe
12 community-acquired pneumonia if there are additional clinical indications such
13 as suspected sepsis. Where sepsis is suspected, clinicians are advised to
14 follow the NICE guideline on sepsis. No evidence was identified for hospital-
15 acquired pneumonia. The committee noted the existing recommendation on
16 sending microbiological samples for those with hospital-acquired pneumonia.
17 They noted that this would mean a difference in the approaches for
18 community-acquired pneumonia and hospital-acquired pneumonia but agreed
19 that possible differing microbiology findings for community-acquired
20 pneumonia and hospital-acquired pneumonia makes differences in the
21 approaches reasonable.

22 Noting the lack of evidence identified in this area, and the existing
23 recommendations, the committee discussed and agreed a recommendation to
24 consider sputum culture for adults, and for children if age appropriate as they
25 acknowledged that sputum samples from younger children may be difficult to
26 obtain.

27 The committee agreed that legionella infection is a relatively rare cause of

28 pneumonia. It is mostly seen in people who have been exposed to stagnant
29 water. Exposure to legionella can also occur at the workplace, for example

42
 1 among people who frequently work on air conditioning units. Therefore, they
2 recommended that legionella urinary antigen tests should only be considered
3 if there are risk factors for legionella infection.

4 For adults assessed via clinical judgement and CURB65 score as having
5 moderate- or high-severity community-acquired pneumonia there was
6 evidence to support the use of pneumococcal urinary antigen tests to support
7 decision-making around the selection of the most appropriate antibiotic. This
8 will benefit patients, contribute to reducing antimicrobial resistance and would
9 support de-escalation to a narrower antibiotic spectrum.

10 The evidence on pneumococcal urinary antigen tests for babies and children
11 was very limited and mostly not directly applicable to the UK. Based on their
12 expertise, the committee discussed the implications in using urinary antigen
13 tests in babies and children. They made a consensus recommendation not to
14 routinely use these tests for this population as, in their experience, they are
15 not useful in practice.

16 The committee acknowledged that overuse of antibiotics is associated with

17 antimicrobial resistance and is a national and global priority. However, the
18 evidence on how microbiological tests, including blood and sputum cultures
19 may help reduce rates of empirical prescribing and support more directed
20 antibiotic therapy remains limited. Therefore, they made a recommendation
21 for research into which tests could safely reduce inappropriate antibiotic
22 prescribing in people with suspected pneumonia.

23 How the recommendations might affect practice

24 Blood and sputum cultures and urinary antigen tests were previously
25 recommended and therefore will not require additional resource to implement.
26 Therefore, the new recommendations have the potential to reduce the number
27 of these cultures taken, potentially leading to cost-savings for the NHS.
28 Overall, streamlining the testing process to only using urinary antigen tests
29 where needed, is likely to be cost saving strategy without detrimental impact
30 on patient outcomes.

43
 1 Similarly, urinary antigen tests are occasionally used in babies and children.
2 With the new recommendation, their use will potentially decrease, leading to
3 fewer negative outcomes and potential cost savings for the NHS.

4 Return to recommendations

5 Antibiotic duration for children

6 Recommendations 1.6.4 to 1.6.5

7 Why the committee made the recommendations

8 There was evidence that for babies and children (up to 11) with community-
9 acquired pneumonia, a 3-day course of antibiotics was as effective as a 5-day
10 course. There were overall limitations to the evidence found, particularly
11 around the applicability of the populations included, with only 1 UK-based
12 study identified. A difference was not identified in the adverse effects
13 outcomes between the shorter or longer duration courses, this included with
14 the frequency of readmission for further antibiotics. The committee discussed
15 the lower age and agreed that for a child under 3 months they would have
16 concerns about reducing the duration of antibiotics and agreed to keep this as
17 5 days for this age group. The committee further noted that shorter courses of
18 antibiotics are important as part of antimicrobial stewardship.

19 The committee discussed that antibiotics are usually less effective or may be
20 ineffective in children with a cough or lower respiratory tract infection not
21 caused by pneumonia, so it is important that the diagnosis is community-
22 acquired pneumonia.

23 The committee noted that not all community-acquired pneumonia resolves as

24 expected, and longer courses of antibiotics may be needed in some babies
25 and children. This should be guided by clinical judgement.

26 Symptoms of pneumonia can last a long time and having symptoms after
27 stopping antibiotics does not mean that the antibiotics have not worked. The
28 committee agreed that this was an important point to convey to parents and
29 carers, this is reflected in the recommendations in this area.
44
 1 How the recommendations might affect practice
2 The recommendations will reduce duration of antibiotic use for treating
3 community-acquired pneumonia in babies and children. They should
4 contribute to antimicrobial stewardship aims.

5 Return to recommendations

6 Corticosteroids
7 Recommendations 1.8.1 to 1.8.2

8 Why the committee made the recommendations

9 The evidence on use of antibiotics plus corticosteroids, compared to
10 antibiotics alone, for treating community-acquired pneumonia in adults
11 showed it reduced mortality rates and time spent in hospital and ICU,
12 particularly for adults with high severity pneumonia.

13 The evidence showed an increased risk of hyperglycaemia with use of

14 corticosteroids and, for less severe pneumonia, an increase in the risk of
15 secondary infections. The committee noted that these risks are not specific to
16 pneumonia but are amongst the known side effects of corticosteroids. They
17 concluded that benefit in terms of reduced mortality outweighed the risk of
18 adverse effects for people with high severity pneumonia, but not for low and
19 moderate severity pneumonia. The evidence suggested that intravenous
20 hydrocortisone may be more effective than other corticosteroids, though a
21 direct comparison was not available. The committee discussed this and
22 agreed that a recommendation without any indication of the type of steroid to
23 use would not be helpful to clinicians and therefore made an additional
24 recommendation to consider starting treatment with hydrocortisone, based on
25 the available evidence, ability to prescribe intravenously and potential issues
26 with oral administration in patients with severe illness.

27 There was a study in the evidence for children, this study did not report the
28 main outcomes of interest, except for adverse events. The committee
29 reflected on the evidence for the use of corticosteroids in adults and

45
 1 discussed the implications of any extrapolation to children. However, given the
2 weak evidence base and limited applicability of the included trials, the
3 committee agreed that this did not currently support a recommendation on the
4 use of corticosteroids for children with pneumonia.

5 The committee agreed that further research was needed on of adjunctive

6 corticosteroids antibiotics in people hospitalised with community-acquired
7 pneumonia or hospital-acquired pneumonia including for babies, children and
8 young people. They made a recommendation for research on the
9 effectiveness of corticosteroids including which type, dose and route of
10 administration is most effective and whether effectiveness varied depending
11 on the type of pathogen being treated.

12 How the recommendations might affect practice

13 The evidence suggests use of corticosteroids is likely to improve outcomes for
14 adults with community-acquired pneumonia. The additional use of
15 corticosteroids incurs a small cost, but this is likely to be outweighed by the
16 potential benefits such as reduced stay in ICU or overall time spent in
17 hospital, freeing up resources and service capacity.

18 Return to recommendations

19 Non-invasive respiratory support

20 Recommendations 1.9.1 to 1.9.3

21 Why the committee made the recommendations

22 The evidence on use of high flow nasal oxygen, continuous positive airways
23 pressure (CPAP) and non-invasive ventilation (NIV) compared to standard
24 oxygen therapy for people with pneumonia was limited. The committee noted
25 that the populations studied were small and only partially applicable with not
26 all participants having pneumonia. They also noted the evidence showed lack
27 of adverse effects and no impact on mortality at 30 days.

28 Based on the evidence and their expertise and experience, the committee
29 agreed that high flow nasal oxygen was their preferred option because it is
46
 1 less invasive and better tolerated than NIV and CPAP, has fewer safety
2 concerns, and allows the person to eat and drink.

3 The committee also agreed the importance of considering the person’s clinical
4 trajectory in multidisciplinary team decisions about trialling high flow nasal
5 oxygen. Lay members emphasised the importance of respecting people’s
6 preferences, describing the discomfort of CPAP compared to high flow nasal
7 oxygen.

8 The ability of different locations within the hospital to deliver CPAP or non-
9 invasive ventilation was discussed, and a number of factors were identified
10 that should be taken into account when making decisions around this,
11 including the possible need for escalation of care.

12 The committee agreed that some people with pneumonia and a co-existing
13 condition, such as type 2 respiratory failure in a person with chronic
14 obstructive pulmonary disease or acute pulmonary oedema in a patient with
15 heart failure, may benefit from a trial of NIV or CPAP for respiratory support.

16 How the recommendations might affect practice

17 The recommendations align with current practice in the UK. No cost
18 implications are expected as hospitals are likely to already have the resources
19 to deliver non-invasive ventilation or CPAP and will already routinely use high
20 flow nasal oxygen in acute care areas.

21 Return to recommendations

22 Information for parents or carers of children with community-

23 acquired pneumonia
24 Recommendations 1.10.2 and 1.10.4

25 Why the committee made the recommendations

26 The committee agreed that it is important to give parents and carers of
27 children with community-acquired pneumonia advice and information on the
28 usual timeframe for symptom improvement. They agreed that although there
47
 1 can be variation in the time to symptom resolution, for most otherwise healthy
2 children, their symptoms will steadily improve after starting treatment. The
3 committee acknowledged that some symptoms take longer to resolve than
4 parents or carers may expect, particularly cough, which can contribute to
5 unnecessary repeat visits to the GP, so they wanted to reassure parents and
6 carers that cough may persist for up to 4 weeks.

7 The committee discussed symptoms that may indicate more serious illnesses
8 or complications. These symptoms include persistent fever, increased work of
9 breathing, and reduced fluid intake or fatigue. They agreed parents or carers
10 should seek further advice if their child continued to present with those
11 symptoms.

12 Given the frequency and severity of hospital-acquired pneumonia it would be

13 useful to be able to offer patients and their families similarly informed advice.
14 However, searches revealed no evidence to support advice on recovery
15 trajectories in hospital-acquired pneumonia and so no recommendation was
16 made for hospital-acquired pneumonia for parents and carers.

17 How the recommendations might affect practice

18 The committee agreed that providing parents and carers with information
19 about expected symptom duration in children could reduce unnecessary visits
20 to GPs and other services about symptoms that will resolve with time without
21 the need for further treatment or testing. They also noted that by outlining
22 symptoms that may indicate complications or a deterioration in their child’s
23 condition, parents and carers may be better able to identify when they should
24 reconsult a healthcare professional and this may mean their child is seen
25 earlier. This could reduce downstream costs of treatment and resource use.
26 Return to recommendations

27 Follow-up chest X-rays

28 Recommendations 1.12.1 to 1.12.3

48
 1 Why the committee made the recommendations
2 The evidence looked at follow-up chest X-rays following discharge from
3 hospital for detecting cancers and other lung conditions and to check whether
4 the pneumonia has resolved. The X-rays took place 4 to 8 weeks after
5 discharge from inpatient care. The evidence showed a cancer detection rate
6 of around 2% and moderate to high rates of pneumonia resolution.

7 The committee agreed that some radiological changes may persist after
8 symptoms of pneumonia have resolved and these do not always indicate a
9 need for further investigation or treatment. As such offering routine follow-up
10 chest X-rays to all people hospitalised with pneumonia is not always useful for
11 checking if pneumonia has resolved. It was also unclear if it would provide
12 timeliness of cancer detection. The committee noted that the severity of HAP
13 and the frequent association with comorbidities implied that follow-up
14 radiological assessment may be beneficial however no evidence was
15 available.

16 The evidence suggested that people whose follow-up chest X-ray detected
17 cancer were older and had a history of smoking. The committee agreed that
18 smoking or being aged over 50 years are risk factors for lung cancer and
19 other underlying respiratory disease, so follow-up chest imaging should be
20 considered. They agreed that clinicians should also consider follow-up chest
21 X-rays for people with unresolved symptoms or who have unexplained weight
22 loss because these can also be indications of cancer or other underlying
23 conditions.

24 The committee discussed that people with hospital-acquired pneumonia may

25 have had recent chest imaging during their admission for non-pneumonia
26 reasons, so there may not be a requirement to perform further chest imaging
27 in this group. The committee agreed that the result of recent chest imaging
28 should be considered when deciding whether to request a follow-up chest X-
29 ray.

49
 1 The committee acknowledged that some people may not want to attend for
2 further investigations. The committee agreed that people’s preferences and
3 medical factors should be discussed so a shared decision can be made about
4 follow-up chest X-ray.

5 The evidence only looked at cancer detection in people who received a follow-
6 up chest X-ray at 6 weeks, so the committee made a recommendation for
7 research to compare follow-up chest X-rays with standard care for detecting
8 cancer. The committee noted that information on long-term survival rates of
9 people diagnosed with cancer as a result of routine follow-up chest X-rays and
10 stage of cancer detected would allow better understanding of the benefits of
11 cancer detection using this method. The committee agreed that this research
12 should focus on adult populations only, because the evidence showed that
13 follow-up chest X-rays are not clinically useful for children and young people.

14 How the recommendations might affect practice

15 These recommendations should reduce the number of chest X-rays required,
16 although a large proportion of people with pneumonia will have the risk factors
17 listed. This would prevent unnecessary investigations and reduce demand on
18 imaging services and associated administration.

19 Return to recommendations

20 Context
21 In 2022 a NICE surveillance report identified areas that required updating in
22 CG191, particularly around the inclusion of guidance for those under 18 who
23 had been excluded from CG191. There are also 2 related NICE antimicrobial
24 prescribing guidelines for both under and over 18s, NG138 (pneumonia
25 (community-acquired): antimicrobial prescribing and NG139 (pneumonia
26 (hospital-acquired): antimicrobial prescribing. This update amalgamates the
27 antimicrobial prescribing guidelines with a partial update of CG191 to provide
28 consolidated pneumonia recommendations.

50
 1 The recommendations for pneumonia in children and adults provide guidance
2 on a common respiratory infection that can have a considerable impact both
3 on the individual and on healthcare provision and resources.

4 Community-acquired pneumonia has an annual incidence of 5 to 10 per 1000

5 adult population, and accounts for 5 to 12% of all lower respiratory tract
6 infections managed by GPs in the community. Between 22% and 42% of
7 people with community-acquired pneumonia will require hospital-based care.

8 Hospital-acquired pneumonia occurs in around 0.5 to 2% of hospitalised

9 patients and is a common cause of morbidity and mortality. The presence of
10 hospital-acquired pneumonia increases hospital stays by an average of 7 to 9
11 days per patient and accounts for a large number of antibiotics prescribed.

12 Pneumonia accounts for 29,000 deaths per year in the UK, and 5 to 15% of
13 people hospitalised with community-acquired pneumonia die within 30 days of
14 admission, rising to 30% for those admitted to an intensive care unit.

15 Finding more information and committee details

16 To find NICE guidance on related topics, including guidance in development,
17 see the NICE topic page on infections.

18 For full details of the evidence and the guideline committee’s discussions, see
19 the full guideline. You can also find information about how the guideline was
20 developed, including details of the committee.

21 NICE has produced tools and resources to help you put this guideline into
22 practice. For general help and advice on putting our guidelines into practice,
23 see resources to help you put NICE guidance into practice.

24 Update information
25 This update amalgamates the NICE antimicrobial prescribing guidelines on
26 community-acquired pneumonia NG138 and hospital-acquired pneumonia
27 NG139 (both published September 2019) with a partial update of NICE
28 guideline CG191 (published 2014).
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 1 Recommendations are marked [2025] if the evidence has been reviewed.

2 Recommendations that have been deleted, or changed

3 without an evidence review
4 We propose to delete some recommendations from the 2014 guideline. Table
5 1 sets out these recommendations and includes details of replacement
6 recommendations. If there is no replacement recommendation, an explanation
7 for the proposed deletion is given.

8 For the recommendation shaded in grey and ending [2019, amended 2025],
9 we have made changes that could affect the intent without reviewing the
10 evidence. The reasons for the changes are given in table 2.

11 For other recommendations shaded in grey, we have not reviewed the

12 evidence. In some cases minor changes have been made – for example, to
13 update links, or bring the language and style up to date – without changing the
14 intent of the recommendation. Minor changes are listed in table 3.

15 See also the previous NICE guideline and supporting documents.

16 Table 1 Recommendations that have been deleted

Recommendation in 2014 guideline Comment

1.2.20 Consider delaying discharge for This recommendation has been deleted
people with community-acquired because this area has been updated
pneumonia if their temperature is higher within the shared decision-making
than 37.5 C. recommendations around place of care.
1.2.22 Advise people with community- Replaced by recommendation 1.1.7
acquired pneumonia to consult their from NG138.
healthcare professional if they feel that
their condition is deteriorating or not
improving as expected.
17

18 Table 2 Amended recommendation wording (change to intent) without

19 an evidence review

Recommendation in NG138 Recommendation in Reason for change

current guideline

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 1.1.7 Give advice to adults, 1.10.3 Give advice to people Removed the
young people and children with community-acquired reference to how
with community-acquired pneumonia (or their parents long symptoms are
pneumonia about: or carers, if appropriate) likely to last as
possible adverse effects of about: covered by
the antibiotic(s) possible adverse effects of recommendations
the antibiotic(s) 1.10.1 and 1.10.2.
how long symptoms are
Changed ‘medical
likely to last seeking further advice (if the
help’ to ‘further
seeking medical help (if the person is receiving treatment
advice’ because
person is receiving treatment in the community or via
advice may be
in the community or via hospital at home) if:
sought from doctors
hospital at home) if: symptoms worsen rapidly or or other healthcare
symptoms worsen rapidly or significantly or professionals.
significantly or symptoms do not start to
symptoms do not start to improve within 3 days or
improve within 3 days or the person becomes
the person becomes systemically unwell.
systemically unwell.
1

2 Table 3 Minor changes to recommendation wording (no change to

3 intent)

Recommendation numbers in Comment

2014 guideline
1.1.1 Wording amended for clarity
1.2.1 and 1.2.3 Wording amended for consistency.
1.2.5 Recommendation replicated for primary
care as supported by NG138.
NG138 and NG139 Comment
Recommendations, tables and Information has been combined and
footnotes to tables consolidated to remove repetition and
taking into account that the
recommendations from these guidelines
now appear alongside the
recommendations from CG191.
4

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