NICE NG138 2019: antimicrobial prescribing for community-acquired pneumonia

Who it applies to

Adults, young people and children with community-acquired pneumonia managed in primary care or hospital settings, excluding hospital-acquired pneumonia.

Key recommendations

• Assess severity using clinical judgement supported by a validated severity score such as CRB65 in primary care to guide the decision between community and hospital management.
• For low-severity CAP managed in the community, a single narrow-spectrum agent such as amoxicillin is recommended as first-line treatment for a short course, typically five days.
• In patients with true penicillin allergy, a macrolide or tetracycline is suggested as an alternative first-line choice.
• For moderate-severity CAP, dual therapy with amoxicillin plus a macrolide is advised, again generally for five days initially.
• For high-severity CAP, a broader-spectrum beta-lactam combined with a macrolide is recommended, with treatment courses of around seven to ten days depending on clinical response.
• Review the patient and antibiotic choice if there is no improvement within the expected timeframe, or sooner if clinical deterioration occurs, considering culture and sensitivity results where available.
• Offer safety netting advice to patients managed in the community about when and how to seek further help if symptoms worsen.
• Base choice and route of antibiotic on severity assessment, local resistance data, microbiological results, and patient factors such as allergy and ability to tolerate oral therapy.
• Switch from intravenous to oral antibiotics as soon as clinically appropriate, guided by signs of clinical improvement.

Practice points for students

• CRB65 is the practical severity tool for primary care since urea levels (a blood test) are not routinely available outside hospital.
• Short-course amoxicillin monotherapy remains first-line for low-severity disease to limit unnecessary broad-spectrum use.
• Dual beta-lactam plus macrolide therapy is reserved for moderate and high-severity disease, not routinely for mild cases.
• Always document a clear review plan and safety netting advice when treating CAP in the community.
• Consider local antimicrobial resistance patterns and recent antibiotic use before finalising the choice of agent.

Condition

Other guidelines on this topic

• Diagnosis and Management of Community-acquired Pneumonia: An Official American Thoracic Society Clinical Practice GuidelineATS2026Official guideline
• ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumoniaERS2023Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.