Guidance

Recommendations

Recommendations

The following guidance is based on the best available evidence. The full guideline gives details of the methods and the evidence used to develop the guidance.

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.

1.1 Presentation with lower respiratory tract infection

1.2 Community-acquired pneumonia

Severity assessment outside hospital

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.

Lim WS, van der Eerden MM, Laing R, et al. (2003) Defining community‑acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82

People 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).

1.2.2

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 decisions about whether people with a clinical diagnosis of community-acquired pneumonia need hospital assessment as follows:

  • consider hospital assessment for people with a CRB65 score of 2 or more

  • discuss the options with people with a score of 1 and make a shared decision about the best care pathways for them, for example supported home-based care using a virtual ward or community intervention team

  • consider home based care for patients with a CRB65 score of 0.

Severity assessment in hospital

1.2.3

When a diagnosis of community-acquired pneumonia is made at presentation to hospital, determine whether people are at low, intermediate or high risk of death using the CURB65 score (see box 2).

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.

People are stratified for risk of death as follows:

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

  • 2: intermediate risk (3‑15% mortality risk)

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

Lim WS, van der Eerden MM, Laing R, et al. (2003) Defining community‑acquired pneumonia severity on presentation to hospital: an international derivation and validation study. Thorax 58: 377–82

1.2.4

Use clinical judgement in conjunction with the CURB65 score to guide the management of community‑acquired pneumonia, as follows:

  • consider home‑based care for people with a CURB65 score of 0 or 1

  • consider hospital‑based care for people with a CURB65 score of 2 or more

  • consider intensive care assessment for people with a CURB65 score of 3 or more.

1.2.5

Stratify people presenting with community‑acquired pneumonia into those with low‑, moderate‑ or high‑severity disease. The grade of severity will usually correspond to the risk of death.

Microbiological tests

1.2.6

Do not routinely offer microbiological tests to people with low‑severity community‑acquired pneumonia.

1.2.7

For people with moderate‑ or high‑severity community‑acquired pneumonia:

  • take blood and sputum cultures and

  • consider pneumococcal and legionella urinary antigen tests.

Timely diagnosis and treatment

1.2.8

Put in place processes to allow diagnosis (including X‑rays) and treatment of community‑acquired pneumonia within 4 hours of presentation to hospital.

Antibiotic therapy

See NICE's guideline on pneumonia (community-acquired): antimicrobial prescribing for recommendations on antibiotic therapy.

Low-severity community-acquired pneumonia
1.2.9

Deleted.

1.2.10

Deleted.

1.2.11

Deleted.

1.2.12

Deleted.

1.2.13

Deleted.

Moderate- and high-severity community-acquired pneumonia
1.2.14

Deleted.

1.2.15

Deleted.

1.2.16

Deleted.

Glucocorticoid treatment

1.2.17

Do not routinely offer a glucocorticoid to people with community‑acquired pneumonia unless they have other conditions for which glucocorticoid treatment is indicated.

Monitoring in hospital

1.2.18

Consider measuring a baseline C‑reactive protein concentration in people with community‑acquired pneumonia on admission to hospital, and repeat the test if clinical progress is uncertain after 48 to 72 hours.

Safe discharge from hospital

1.2.19

Do not routinely discharge people with community‑acquired pneumonia if in the past 24 hours they have had 2 or more of the following findings:

  • temperature higher than 37.5°C

  • respiratory rate 24 breaths per minute or more

  • heart rate over 100 beats per minute

  • systolic blood pressure 90 mmHg or less

  • oxygen saturation under 90% on room air

  • abnormal mental status

  • inability to eat without assistance.

1.2.20

Consider delaying discharge for people with community‑acquired pneumonia if their temperature is higher than 37.5°C.

Patient information

1.2.21

Explain to people 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, and most people 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: most people will feel back to normal.

1.2.22

Advise people with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.

1.3 Hospital-acquired pneumonia

Terms used in this guideline

Clinical diagnosis of community-acquired pneumonia

Diagnosis based on symptoms and signs of lower respiratory tract infection in a patient who, in the opinion of the GP 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, illness severity or other features.

Community-acquired pneumonia

Pneumonia that is acquired outside hospital. 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.

Hospital-acquired pneumonia

Pneumonia that develops 48 hours or more after hospital admission and that was not incubating at hospital admission. When managed in hospital the diagnosis is usually confirmed by chest X‑ray. For the purpose of this guideline, pneumonia that develops in hospital after intubation (ventilator‑associated pneumonia) is excluded from this definition.

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.

Mortality risk

The percentage likelihood of death occurring in a patient in the next 30 days.

Severity assessment

A judgement by the managing clinician as to the likelihood of adverse outcomes in a patient. This is based on a combination of clinical understanding and knowledge in addition to a mortality risk score. The difference between categories of severity and mortality risk can be important. Typically the mortality risk score will match the severity assessment. However, there may be situations where the mortality score does not accurately predict mortality risk and clinical judgement is needed. An example might be a patient with a low mortality risk score who has an unusually low oxygen level, who would be considered to have a severe illness.