Guidance

Recommendations

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.

For recommendations on identifying and treating hospital-acquired bacterial pneumonia secondary to COVID-19, see our rapid guideline on managing acute COVID-19.

1.1 Managing hospital-acquired pneumonia

Treatment for adults, young people and children

1.1.2

Offer an antibiotic(s) for adults, young people and children with hospital-acquired pneumonia. When choosing an antibiotic(s) (see the recommendations on choice of antibiotic), take account of:

  • the severity of symptoms or signs (at the time of publication, in September 2019, no validated severity assessment tools are available for hospital-acquired pneumonia, and severity of symptoms or signs should be 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.

1.1.3

Start antibiotic treatment as soon as possible after establishing a diagnosis of hospital-acquired pneumonia, and certainly within 4 hours (within 1 hour if the person has suspected sepsis and meets any of the high risk criteria for this – see the NICE guideline on sepsis).

1.1.4

Give oral antibiotics first line if the person can take oral medicines, and the severity of their condition does not require intravenous antibiotics.

1.1.5

If intravenous antibiotics are given, review by 48 hours and consider switching to oral antibiotics if possible.

1.1.6

Send a sample (for example, sputum sample, nasopharyngeal swab or tracheal aspirate) for microbiological testing.

Reassessment and specialist advice

1.1.7

When microbiological results are available:

  • review the choice of antibiotic(s) and

  • change the antibiotic(s) according to results, using a narrower-spectrum antibiotic, if appropriate.

1.1.8

Reassess adults, young people and children with hospital-acquired pneumonia if symptoms do not improve as expected or worsen rapidly or significantly.

1.1.9

Seek specialist advice from a microbiologist for adults, young people and children with hospital-acquired pneumonia if they have:

  • symptoms that are not improving as expected with antibiotics or

  • multidrug-resistant bacteria.

See the evidence and committee discussions on antibiotic prescribing strategies and choice of antibiotics.

1.2 Choice of antibiotic

1.2.1

When prescribing an antibiotic(s) for hospital-acquired pneumonia:

  • follow table 1 for adults aged 18 years and over

  • follow table 2 for children and young people under 18 years.

1.2.2

Consider following the NICE guideline on community-acquired pneumonia for choice of antibiotic for adults, young people and children 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.

Table 1 Antibiotics for adults aged 18 years and over
Treatment Antibiotic, dosage and course length

First-choice oral antibiotic if non‑severe symptoms or signs, and not at higher risk of resistance (guided by microbiological results when available)

Co-amoxiclav:

500/125 mg three times a day for 5 days then review

Alternative oral antibiotics if non‑severe symptoms or signs, and not at higher risk of resistance, for penicillin allergy or if co‑amoxiclav unsuitable (based on specialist microbiological advice and local resistance data)

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:

960 mg twice a day for 5 days then review (see BNF for information on monitoring)

In September 2019, this was an off‑label use of co‑trimoxazole. See NICE's information on prescribing medicines

Levofloxacin (only if switching from intravenous levofloxacin with specialist advice):

500 mg once or twice a day for 5 days then review

In September 2019, this was an off‑label use of levofloxacin. See NICE's information on prescribing medicines

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

First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis) or at higher risk of resistance (based on specialist microbiological advice and local resistance data)

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) [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-choice antibiotics are unsuitable):

500 mg once or twice a day (use higher dosage if severe infection)

In September 2019, this was an off‑label use of levofloxacin. See NICE's information on prescribing medicines

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

Antibiotics to be added if suspected or confirmed meticillin-resistant Staphylococcus aureus infection (dual therapy with a first-choice 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)

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.

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.

Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics for a total of 5 days, then review.

Table 2 Antibiotics for children and young people under 18 years
Treatment Antibiotic, dosage and course length

Choice for children under 1 month

Antibiotic choice based on local resistance data and specialist microbiological advice

First choice oral antibiotic for children aged 1 month and over if non-severe symptoms or signs and not at higher risk of resistance (guided by microbiological results when available)

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

Alternative oral antibiotic for children aged 1 month and over if non-severe symptoms or signs and not at higher risk of resistance, 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:

  • Under 8 kg, 7.5 mg/kg twice a day for 5 days, then review

  • 8 kg to 11 kg, 62.5 mg twice a day for 5 days, then review

  • 12 kg to 19 kg, 125 mg twice a day for 5 days, then review

  • 20 kg to 29 kg, 187.5 mg twice a day for 5 days, 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

First-choice intravenous antibiotics if severe symptoms or signs (for example, symptoms or signs of sepsis), or at higher risk of resistance (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

Antibiotics to be added if suspected or confirmed meticillin-resistant Staphylococcus aureus infection (dual therapy with a first-choice 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

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.

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.

Review treatment after a total of 5 days of antibiotics and consider stopping antibiotics if clinically stable. Review intravenous antibiotics by 48 hours and consider switching to oral antibiotics for a total of 5 days, then review.

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.

See the evidence and committee discussions on choice of antibiotic and antibiotic course length, dosage and route of administration.

Terms used in the guideline

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.