1.1.1
For people aged 16 and over presenting with suspected lower respiratory tract infection, see NICE's guideline on suspected respiratory infection in over 16s: assessment at first presentation and initial management. [2014, amended 2023]
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:
Related guidance
If sepsis is suspected, assess and manage the person in line with NICE's guideline on sepsis: recognition, diagnosis and early management.
For babies or children under 5 with fever with no obvious cause, see NICE's guideline on fever in under 5s: assessment and initial management for recommendations about diagnosing pneumonia.
For support to stop smoking, or to reduce harm from smoking, see NICE's guideline on tobacco: preventing uptake, promoting quitting and treating dependence.
For information about vaccination uptake, see NICE's guideline on vaccine uptake in the general population.
For guidance on the health impacts of poor indoor air quality, see NICE's guideline on indoor air quality at home.
1.1 First contact with NHS services, remote or in-person
1.2 Assessing community-acquired pneumonia
Assessment of adults in primary care and deciding place of care
1.2.1
If a clinical diagnosis of community-acquired pneumonia has been made, determine whether adults are at low, intermediate or high risk of death using the CRB65 scoring system (see box 1). [2014]
1.2.2
Use clinical judgement together with the CRB65 score (see box 1) to stratify adults with community-acquired pneumonia into those with low-, moderate- or high-severity disease. The disease severity 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).
1.2.3
Use clinical judgement together with the CRB65 score (bearing in mind this can be affected by other factors, for example, comorbidities or pregnancy) to inform shared decisions about place of care (see recommendation 1.2.11 for further details). Consider:
-
referral to hospital for adults with a CRB65 score of 2 or more
-
one of the following options for adults with a CRB65 score of 1:
-
primary care-led services with safety netting advice or referral to:
-
a virtual ward or
-
same-day emergency care (SDEC) unit or
-
hospital at home service or
-
hospital
-
-
-
primary care-led services with safety netting advice for adults with a CRB65 score of 0. [2025]
1.2.4
Refer adults to hospital if they have any symptoms or signs suggesting a more serious illness or condition (for example, cardiorespiratory failure or sepsis). [2019, amended 2021]
1.2.5
Consider referring adults with community-acquired pneumonia to hospital, or seek specialist advice, if they cannot take oral medicines (exploring locally available options for giving intravenous antibiotics at home or in the community, rather than in hospital, if this is appropriate). [2019]
Children and young people presenting to primary care
1.2.6
Consider referring children and young people with community-acquired pneumonia to hospital or seek specialist paediatric advice on further investigation and management. [2019]
Assessment of adults in hospital and deciding place of care
1.2.7
If a clinical diagnosis of community-acquired pneumonia has been made in hospital, determine whether adults are at low, intermediate or high risk of death using the CURB65 scoring system (see box 2). [2014]
1.2.8
Use clinical judgement together with the CURB65 score (see box 2) to stratify adults with community-acquired pneumonia into those with low-, moderate- or high-severity disease. The disease severity will usually correspond to the risk of death. [2014]
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).
1.2.9
Use clinical judgement together with the CURB65 score (bearing in mind this can be affected by other factors, for example, comorbidities or pregnancy) to inform shared decisions about place of care (see recommendation 1.2.11 for further details). Consider:
-
inpatient care for adults with a CURB65 score of 3 or more, with referral to critical care services if appropriate
-
one of the following options for adults with a CURB65 score of 2:
-
virtual ward or
-
SDEC unit or
-
hospital at home service or
-
inpatient care
-
-
discharge home, with referral to primary care-led services and safety netting advice for adults with a CURB65 score of 0 or 1. [2025]
1.2.10
Consider early discharge to a virtual ward or hospital at home service for adults on an inpatient ward whose clinical condition is improving but requires ongoing monitoring or treatment. [2025]
Prediction tools for under 18s in primary care
NICE has made a recommendation for research on prediction tools for under 18s in primary care.
For a short explanation of why the committee made no recommendations, see the rationale 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.
1.3 Assessment tools for hospital-acquired pneumonia
NICE has made a recommendation for research on assessment tools for hospital-acquired pneumonia.
For a short explanation of why the committee made no recommendations, see the rationale 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.
1.4 Investigations in hospital
Imaging
1.4.1
Put in place processes to allow diagnosis (including chest X-ray) of community-acquired pneumonia in adults within 4 hours of presentation to hospital. [2014, amended 2025]
1.4.2
Recognise that lung ultrasound can be used in the diagnosis of pneumonia in hospital, for example:
-
for rapid point-of-care diagnosis in a sick or deteriorating person
-
where there is a possible alternative diagnosis, for example, heart failure
-
for investigating associated complications such as pleural 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.
C-reactive protein for adults with community-acquired pneumonia on admission
1.4.3
Consider measuring a baseline C-reactive protein (CRP) in adults with community-acquired pneumonia on admission to hospital. See also the section on use of biomarkers after starting treatment. [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.
Microbiological tests
1.4.4
For people with hospital-acquired pneumonia, send a sample (for example, sputum sample, nasopharyngeal swab or tracheal aspirate) for microbiological testing. [2025]
1.4.5
Do not routinely offer microbiological tests to adults with low-severity community-acquired pneumonia or children with non-severe community-acquired pneumonia. [2025]
1.4.6
For adults with moderate- or high-severity community-acquired pneumonia, consider:
-
blood cultures if there are additional clinical indications such as suspected sepsis (see NICE's guideline on sepsis)
-
sputum cultures, taking into account the person's history of antibiotic treatment, their clinical trajectory, the presence of any comorbidities, any recent hospitalisation and the likelihood of getting a good-quality sputum sample
-
pneumococcal urinary antigen tests to support de-escalation to a narrower-spectrum antibiotic
-
legionella urinary antigen tests if the person has risk factors for legionella infection. [2025]
1.4.7
For children and young people with severe community-acquired pneumonia:
-
consider blood cultures if there are additional clinical indications such as suspected sepsis (see NICE's guideline on sepsis) and
-
consider sputum cultures, if possible and age appropriate, taking into account their history of antibiotic treatment, their clinical trajectory, the presence of any comorbidities, any recent hospitalisation and the likelihood of getting a good-quality sputum sample
-
do not routinely use urinary antigen tests. [2025]
For a short explanation of why the committee made the 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.
1.5 Starting and reviewing antibiotics
1.5.1
Start antibiotic treatment as soon as possible after establishing a diagnosis of community-acquired pneumonia, and within 4 hours of presentation to hospital. [2019, amended 2025]
1.5.2
Start antibiotic treatment as soon as possible after establishing a diagnosis of hospital-acquired pneumonia, and within 4 hours of clinical suspicion if symptoms start in hospital or within 4 hours of presentation to hospital. [2019, amended 2025]
1.5.3
If the person has suspected sepsis, see antibiotic treatment recommendations in NICE's guideline on sepsis. [2019]
1.5.4
Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics. [2019]
1.5.5
If intravenous antibiotics are given, review by 48 hours and, if possible, consider switching to oral antibiotics to complete the course. [2019]
1.5.6
If a sample has been sent for microbiological testing:
-
review the choice of antibiotic(s) when results are available and
-
consider changing the antibiotic(s) according to results, using a narrower-spectrum antibiotic, if appropriate. [2019]
1.6 Antibiotic treatment for community-acquired pneumonia
Factors to take into account when offering antibiotics
1.6.1
Offer an antibiotic(s) for people with community-acquired pneumonia. When choosing an antibiotic, take account of:
-
the assessment of disease severity for adults, based on clinical judgement together with the CRB65 score (see box 1) or CURB65 score (see box 2)
-
the severity of symptoms or signs for children and young people, based on clinical judgement
-
the risk of developing complications, for example, if the person has relevant comorbidity such as severe lung disease or immunosuppression
-
local antimicrobial resistance and surveillance data (such as influenza and Mycoplasma pneumoniae infection rates)
-
recent antibiotic use
-
recent microbiological results, including colonisation with multidrug-resistant bacteria. [2019]
Choice, dosage and duration of antibiotic
1.6.2
When prescribing an antibiotic(s) for community-acquired pneumonia, see the following tables for antibiotic choice, dosage and course length:
-
table 1 for adults [2019]
-
table 2 for children and young people. [2025]
1.6.3
For adults with community-acquired pneumonia, stop antibiotic treatment after 5 days unless:
-
microbiological results suggest a longer course is needed or
-
the person is not clinically stable, for example, if they have had a fever in the past 48 hours or have more than 1 of the following signs of clinical instability:
-
systolic blood pressure less than 90 mmHg
-
heart rate more than 100 beats per minute
-
respiratory rate more than 24 breaths per minute
-
oxygen saturations of less than 90% on room air (or failure to meet long-term baseline oxygen requirements); note that oxygen saturation monitors may be inaccurate in people with pigmented skin. [2019, amended 2025]
-
1.6.4
Offer a 3‑day course of antibiotics for babies and children aged 3 months (corrected gestational age) to 11 years with non-severe community-acquired pneumonia without complications or underlying disease. See recommendations 1.10.2 to 1.10.4 for information and advice for parents and carers. [2025]
1.6.5
Consider extending use of antibiotics beyond 3 days for babies and children aged 3 months (corrected gestational age) to 11 years if they are not clinically stable, for example, if they are in respiratory distress or their oxygen saturation levels have not improved as expected. [2025]
1.6.6
For all children and young people with community-acquired pneumonia, stop antibiotic treatment after 5 days unless microbiological results suggest a longer course is needed or the child or young person is not clinically stable. [2019, amended 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.
| Treatment based on disease severity and suitability | Antibiotic, dosage and course length |
|---|---|
|
Low-severity disease: first-line oral antibiotic |
Amoxicillin: 500 mg three times a day (higher doses can be used; see the BNF) for 5 days |
|
Low-severity disease: alternative oral antibiotics for penicillin allergy or if amoxicillin unsuitable (for example, if atypical pathogens suspected) |
Doxycycline: 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total) Clarithromycin: 500 mg twice a day for 5 days Erythromycin (in pregnancy): 500 mg four times a day for 5 days |
|
Moderate-severity disease: first-line oral antibiotics |
Amoxicillin: 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: alternative oral antibiotics for penicillin allergy |
Doxycycline: 200 mg on first day, then 100 mg once a day for 4 days (5‑day course in total) Clarithromycin: 500 mg twice a day for 5 days |
|
High-severity disease: first-line antibiotics |
Co‑amoxiclav: 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: alternative antibiotic for penicillin allergy (consult a local microbiologist if fluoroquinolone not appropriate) |
Levofloxacin: 500 mg twice a day orally or intravenously for 5 days See the Medicines and Healthcare products Regulatory Agency (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 |
Notes for table 1
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.
| Treatment based on severity of symptoms or signs and suitability | Antibiotic, dosage and course length |
|---|---|
|
Non-severe symptoms or signs: first-line oral antibiotic |
Amoxicillin: 1 month to 2 months, 125 mg three times a day for 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 signs: alternative oral antibiotics for penicillin allergy or if amoxicillin is unsuitable (for example, atypical pathogens suspected) |
Clarithromycin: 1 month to 2 months: Under 8 kg, 7.5 mg/kg twice a day for 5 days 3 months to 11 years:
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: 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 signs: first-line antibiotic(s) |
Co‑amoxiclav: Oral doses:
Intravenous doses:
With (if atypical pathogen suspected) Clarithromycin: Oral doses: 1 month to 11 years:
12 years to 17 years: 250 mg to 500 mg twice a day for 5 days Intravenous doses:
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 signs: alternative antibiotics for penicillin allergy |
Consult local microbiologist |
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 MHRA Public Assessment Report on the safety of macrolide antibiotics in pregnancy.
Safe discharge from hospital
1.6.7
Do not routinely discharge adults with community‑acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:
-
temperature more than 37.5°C
-
respiratory rate 24 breaths per minute or more
-
heart rate more than 100 beats per minute
-
systolic blood pressure 90 mmHg or less
-
oxygen saturation of less than 90% on room air (or failure to meet long-term baseline oxygen requirements); note that oxygen saturation monitors may be inaccurate in people with pigmented skin
-
abnormal mental status
-
inability to eat without assistance. [2014, amended 2025]
1.7 Antibiotic treatment for hospital-acquired pneumonia
Factors to take into account when offering antibiotics
1.7.1
For people with symptoms or signs of pneumonia starting within 48 hours of hospital admission, follow the section on antibiotic treatment for community-acquired pneumonia. [2019]
1.7.2
Consider following the section on choice, dosage and duration of antibiotics for community-acquired pneumonia for people with symptoms or signs of pneumonia starting within days 3 to 5 of hospital admission who are not at higher risk of resistance. Higher risk of resistance includes relevant comorbidity (such as severe lung disease or immunosuppression), recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with health and social care settings before current admission. [2019]
1.7.3
Offer an antibiotic(s) for people with hospital-acquired pneumonia. When choosing an antibiotic(s), take account of:
-
disease severity (based on clinical judgement)
-
the number of days in hospital before onset of symptoms
-
the risk of developing complications, for example, if the person has a relevant comorbidity such as severe lung disease or immunosuppression
-
local hospital and ward-based antimicrobial resistance data
-
recent antibiotic use
-
recent microbiological results, including colonisation with multidrug-resistant bacteria
-
recent contact with a health or social care setting before current admission
-
the risk of adverse effects with broad-spectrum antibiotics, such as Clostridium difficile infection. [2019]
Choice, duration and dose of antibiotic
1.7.4
When prescribing an antibiotic(s) for hospital-acquired pneumonia, see the following tables for antibiotic choice, dosage and course length:
-
table 3 for adults
-
table 4 for children and young people. [2019]
1.7.5
For hospital-acquired pneumonia, review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable. [2019]
| Treatment based on severity of symptoms or signs, risk of resistance and suitability | Antibiotic, dosage and course length |
|---|---|
|
Non-severe symptoms or signs and not at higher risk of resistance: first-line oral antibiotic |
Co-amoxiclav: 500/125 mg three times a day for 5 days then review |
|
Non-severe symptoms or signs and not at higher risk of resistance: alternative oral antibiotics for penicillin allergy or if co‑amoxiclav unsuitable |
Options include: Doxycycline: 200 mg on first day, then 100 mg once a day for 4 days (5‑day course) then review Cefalexin (caution in penicillin allergy): 500 mg twice or three times a day (can be increased to 1 g to 1.5 g three or four times a day) for 5 days then review Co‑trimoxazole (off-label use): 960 mg twice a day for 5 days then review (see BNF for information on monitoring) Levofloxacin (only if switching from intravenous levofloxacin; off-label use): 500 mg once or twice a day for 5 days then review See the Medicines and Healthcare products Regulatory Agency (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 signs (for example, symptoms or signs of sepsis) or at higher risk of resistance: first-line intravenous antibiotics |
Options include: Piperacillin with tazobactam: 4.5 g three times a day (increased to 4.5 g four times a day if severe infection) Ceftazidime: 2 g three times a day 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 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 methicillin-resistant Staphylococcus aureus infection: dual therapy with a first-line intravenous antibiotic |
Vancomycin: 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 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) |
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.
| Treatment based on severity of symptoms or signs, risk of resistance and suitability | Antibiotic, dosage and course length |
|---|---|
|
Non-severe symptoms or signs and not at higher risk of resistance: first-line oral antibiotic |
Co‑amoxiclav: 1 month to 11 months, 0.5 ml/kg of 125/31 suspension three times a day for 5 days, then 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 signs and not at higher risk of resistance: alternative oral antibiotic for penicillin allergy or if co-amoxiclav unsuitable (other options may be suitable based on specialist microbiological advice and local resistance data) |
Clarithromycin: 1 month to 11 years:
12 years to 17 years: 500 mg twice a day for 5 days, then review |
|
Severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance: first-line intravenous antibiotics (antibiotic choice should be based on specialist microbiological advice and local resistance data) |
Options include: Piperacillin with tazobactam: 1 month to 11 years, 90 mg/kg three or four times a day (maximum 4.5 g per dose four times a day) 12 years to 17 years, 4.5 g three times a day (increased to 4.5 g four times a day if severe infection) 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) 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 |
|
Suspected or confirmed methicillin-resistant Staphylococcus aureus infection: dual therapy with a first-line intravenous antibiotic |
Teicoplanin: 1 month, initially 16 mg/kg for 1 dose, then 8 mg/kg once daily, subsequent dose to be given 24 hours after initial dose (doses given by intravenous infusion) 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) |
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.
1.8 Corticosteroid treatment in hospital
1.8.1
For adults with high-severity community-acquired pneumonia in hospital, consider a corticosteroid, in addition to antibiotics, for 4 to 7 days or until discharge, if sooner. [2025]
1.8.2
When choosing a corticosteroid, consider starting treatment with intravenous hydrocortisone. If hydrocortisone is not suitable, consider an alternative corticosteroid such as dexamethasone by the most appropriate route of administration.
Note: not all treatments are licensed for this indication, so use may be off label.
See the Medicines and Healthcare products Regulatory Agency (MHRA) advice for restrictions and precautions on the coadministration of fluoroquinolone antibiotics and corticosteroids. [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 corticosteroids.
Full details of the evidence and the committee's discussion are in evidence review E: corticosteroids.
1.9 Non-invasive respiratory support
1.9.1
For people with respiratory failure in whom standard oxygen therapy is insufficient to meet target saturation levels, consider a trial of high-flow nasal oxygen, based on multidisciplinary consensus, clinical trajectory and the person's preferences and ability to tolerate it. [2025]
1.9.2
When deciding the best location in the hospital for delivering non-invasive respiratory support, take into account:
-
the risk of failure and potential need for invasive mechanical ventilation and
-
any advanced directives or established treatment escalation plan and
-
the person's clinical trajectory. [2025]
1.9.3
Be aware that people with certain coexisting conditions may benefit from a trial of non-invasive ventilation or continuous positive 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.
1.10 Information about treatment and recovery for community-acquired pneumonia
1.10.1
Explain to adults with community‑acquired pneumonia that after starting treatment their symptoms should steadily improve, although the rate of improvement will vary with the severity of the pneumonia. Most adults can expect that by:
-
1 week: fever should have resolved
-
4 weeks: chest pain and sputum production should have substantially reduced
-
6 weeks: cough and breathlessness should have substantially reduced
-
3 months: most symptoms should have resolved but fatigue may still be present
-
6 months: they will feel back to normal. [2014]
1.10.2
Explain to parents or carers of children with community-acquired pneumonia that after starting treatment their child's symptoms should steadily improve, although the rate of improvement will vary and some symptoms will persist after stopping antibiotics. For most children:
-
fever (without use of antipyretics) and difficulty breathing should have resolved within 3 to 4 days
-
cough should gradually improve but may persist for up to 4 weeks after discharge and does not usually require further review if the child is otherwise well. [2025]
1.10.3
Give advice to people with community-acquired pneumonia (or their parents or carers, if appropriate) about:
-
possible adverse effects of the antibiotic(s)
-
seeking further advice (if the person is receiving treatment in the community or via hospital at home service) if:
-
symptoms worsen rapidly or significantly or
-
symptoms do not start to improve within 3 days or
-
the person becomes systemically unwell. [2019, amended 2025]
-
1.10.4
Advise parents or carers of children with community-acquired pneumonia to seek further advice if there is persisting fever combined with:
-
increased work of breathing or
-
reduced fluid intake for children or poor feeding for infants or
-
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.
Full details of the evidence and the committee's discussion are in evidence review G: patient information.
1.11 Reassessment
When to reassess
1.11.1
Reassess people with pneumonia if symptoms or signs do not improve as expected or worsen rapidly or significantly. [2019]
Community-acquired pneumonia
1.11.2
When reassessing people with community-acquired pneumonia, be aware of possible non-bacterial causes, such as influenza. [2019]
1.11.3
Refer people with community-acquired pneumonia to hospital if they have symptoms that are not improving as expected with antibiotics. [2019, amended 2025]
1.11.4
Consider referring people with community-acquired pneumonia to hospital, or seek specialist advice, if microbiological samples have identified bacteria that are resistant to oral antibiotics. [2019 amended, 2025]
1.11.5
Send a sample (for example, a sputum sample) for microbiological testing if symptoms or signs have not improved following antibiotic treatment, and this has not been done already. [2019]
Hospital-acquired pneumonia
1.11.6
Seek specialist advice from a microbiologist for people with hospital-acquired pneumonia if they have:
-
symptoms that are not improving as expected with antibiotics or
-
multidrug-resistant bacteria. [2019]
Use of biomarkers after starting treatment
1.11.7
For people in hospital with pneumonia, consider measuring CRP or procalcitonin (PCT) 3 or 4 days after starting treatment if there is clinical concern about treatment failure. (See recommendation 1.4.3 for advice on taking a baseline CRP for adults with community-acquired pneumonia on admission to hospital.) [2025]
1.11.8
Be aware that high levels of CRP or PCT, or levels that do not significantly improve with treatment, are associated with treatment failure and the person may need senior clinical review. [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 biomarkers.
Full details of the evidence and the committee's discussion are in evidence review H: biomarkers.
1.12 Follow-up chest X-rays
1.12.1
Do not routinely offer follow-up chest X-rays to people discharged from inpatient care after an episode of pneumonia. [2025]
1.12.2
Consider follow-up chest X-rays at 6 weeks following discharge for people with:
-
risk factors for lung cancer or other underlying respiratory disease, for example, people who smoke or are over 50 years or
-
persisting or deteriorating symptoms or
-
unexplained weight loss. [2025]
1.12.3
If a follow-up chest X-ray is being considered, make a shared decision with the person taking into account:
-
any recent imaging
-
the presence of any comorbidities or frailty
-
the person's prognosis and treatment options
-
their preferences. [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 follow-up chest X-rays.
Full details of the evidence and the committee's discussion are in evidence review I: chest X-ray.
Terms used in this guideline
Assessment of disease severity of community-acquired pneumonia in adults
A judgement by the managing clinician as to the likelihood of adverse outcomes (including death, development of complications or need for invasive respiratory or circulatory support) in a person. This is based on a combination of clinical understanding and knowledge and is informed by a mortality risk score. The difference between the assessment of disease severity and mortality risk score can be important. This guideline uses 3 categories of disease severity: low, moderate and high. Often, but not always, these will match the mortality risk score. Clinical judgement should always be used, as there may be situations when the mortality risk score does not align with the assessment of disease severity. For example, a person with a low mortality risk score who has an unusually low oxygen saturation level, pleural complications or multiple comorbidities may be assessed as having moderate- or high-severity disease.
Clinical diagnosis of community-acquired pneumonia
Diagnosis based on symptoms and signs of lower respiratory tract infection in a person who, in the opinion of the healthcare professional and in the absence of a chest X-ray, is likely to have community-acquired pneumonia. This might be because of the presence of focal chest signs, increased respiratory rate, low oxygen saturations, illness severity or other features.
Community-acquired pneumonia
Pneumonia that is acquired outside hospital, or within 48 hours of admission. Pneumonia that develops in a nursing home resident is included in this definition. When managed in hospital the diagnosis is usually confirmed by chest X-ray. For further information on symptoms and signs of community-acquired pneumonia, see the section on assessment in NICE's clinical knowledge summary on chest infections in adults.
Hospital at home service and virtual wards
Models of care that enable people to be cared for in their own home, avoiding the need for hospital admission. Sometimes the terms 'hospital at home' and 'virtual ward' are used interchangeably. People are cared for by a multidisciplinary team who can provide a range of tests and treatments. Regular reviews by the clinical team may involve a home visit or use of video technology. Other devices such as apps or wearable technologies can support remote monitoring.
Hospital-acquired pneumonia
Pneumonia that develops 48 hours or more after hospital admission and that was not incubating at hospital admission, or people who present to hospital with pneumonia but who have been discharged within the last 7 to 10 days. When managed in hospital, the diagnosis is usually confirmed by chest X-ray. For the purpose of this guideline, ventilator-associated pneumonia is excluded from the definition (this is pneumonia that occurs in someone on mechanical ventilation 48 hours or more after intubation).
Lower respiratory tract infection
An acute illness (present for 21 days or less), usually with cough as the main symptom, and with at least 1 other lower respiratory tract symptom (such as fever, sputum production, breathlessness, wheeze or chest discomfort or pain) and no alternative explanation (such as sinusitis or asthma). Pneumonia, acute bronchitis and exacerbation of chronic obstructive airways disease are included in this definition.
Pneumonia
Pneumonia refers to both community-acquired pneumonia and hospital-acquired pneumonia.
Severe community-acquired pneumonia in children and young people
Severe community-acquired pneumonia in babies, children and young people is a diagnosis made by the treating physician. Features of this may include difficulty breathing, oxygen saturation less than 90% (percutaneous oxygen saturation monitors may be inaccurate in people with pigmented skin), raised heart rate, grunting, severe chest indrawing, inability to breastfeed or drink, lethargy and a reduced level of consciousness.
Same-day emergency care (SDEC)
People are well enough and ambulatory enough to attend hospital each day and have a review in a rapid clinic setting. Also suitable for people where hospital admission poses a higher risk of hospital-acquired infection or deconditioning such as in people who are frail or immunocompromised. This is a rapidly evolving model of care with multiple local variations.