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Pneumonia in adults: diagnosis and management – NICE guideline

This National Institute for Health and Care Excellence (NICE) guideline covers diagnosing and managing community- and hospital-acquired pneumonia in adults. It aims to improve accurate assessment and diagnosis of pneumonia to help guide antibiotic prescribing and ensure that people receive the right treatment.

Key recommendations

Presentation with lower respiratory tract infection

  • For people presenting with symptoms of lower respiratory tract infection in primary care, consider a point of care C‑reactive protein test if after clinical assessment a diagnosis of pneumonia has not been made and it is not clear whether antibiotics should be prescribed. Use the results of the C‑reactive protein test to guide antibiotic prescribing in people without a clinical diagnosis of pneumonia as follows:
    • Do not routinely offer antibiotic therapy if the C‑reactive protein concentration is less than 20 mg/litre.
    • Consider a delayed antibiotic prescription (a prescription for use at a later date if symptoms worsen) if the C‑reactive protein concentration is between 20 mg/litre and 100 mg/litre.
    • Offer antibiotic therapy if the C‑reactive protein concentration is greater than 100 mg/litre.

Community-acquired pneumonia

Microbiological tests

  • For patients 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

  • 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

Low-severity community-acquired pneumonia

  • Offer a 5‑day course of a single antibiotic to patients with low‑severity community‑acquired pneumonia.
  • Do not routinely offer patients with low‑severity community‑acquired pneumonia:
    • a fluoroquinolone
    • dual antibiotic therapy.

Patient information

  • Explain to patients 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.

Every year between 0.5% and 1% of adults in the UK will have community‑acquired pneumonia. Between 1.2% and 10% of adults admitted to hospital with community‑acquired pneumonia are managed in an intensive care unit, and for these patients the risk of dying is more than 30%. More than half of pneumonia‑related deaths occur in people older than 84 years.

At any time 1.5% of hospital inpatients in England have a hospital‑acquired respiratory infection, more than half of which are hospital‑acquired pneumonia and are not associated with intubation. Hospital‑acquired pneumonia is estimated to increase hospital stay by about 8 days and has a reported mortality rate that ranges from 30–70%.

Reasons for the guideline

The guideline is needed because pneumonia is common and has a high mortality rate. The British Thoracic Society (2009) has published guidance on the management of community-acquired pneumonia in adults, but there is a lack of evidence‑based guidance on the management of hospital‑acquired pneumonia. For both types of pneumonia there is variation in care and areas of uncertainty for best practice, and these are the main focus of this guideline.

This guideline provides recommendations for the management of suspected and confirmed community‑ and hospital‑acquired pneumonia in adults. However, it does not provide recommendations on areas of care where best practice is already established, such as diagnosis using chest X‑ray.

This guideline does not cover:

  • bronchiectasis complicated by pneumonia
  • people younger than 18 years
  • patients who acquire pneumonia while intubated or in an intensive care unit, who are immunocompromised, or in whom management of pneumonia is an expected part of end‑of‑life care.

You can read the guideline on NICE's website.