Community-Acquired Pneumonia (CAP)

CAP severity is assessed with clinical judgement plus CURB-65 (Confusion, Urea >7mmol/L, RR ≥30, BP <90 systolic or ≤60 diastolic, age ≥65). NG250 (2025) changed where people are cared for: 0–1 discharge home with safety netting; 2 is a shared…

NICE NG250 / CURB-65

The pathway

1 · CURB-65 and where they are cared for

Confusion (AMT ≤8) · Urea >7 · RR ≥30 · BP <90 systolic or ≤60 diastolic · 65 or over
0–1 low risk — discharge home, primary care follow-up, safety netting
2 intermediate — virtual ward, SDEC, hospital-at-home or admit, decided with her
3–5 high — inpatient, critical care review if appropriate

The score informs the decision; it does not make it. In primary care use CRB65, without the urea.

2 · Investigations

CXR within 4 hours of presentation
Lung ultrasound is now recognised — point-of-care, possible heart failure, or pleural complications
ABG/SpO₂, FBC, U&E, LFTs, CRP on admission
Moderate or high severity, consider: blood cultures if sepsis suspected · sputum culture · pneumococcal urinary antigen to allow de-escalation · Legionella antigen if risk factors
CRP or procalcitonin at day 3–4 if treatment failure is a concern

3 · Oxygen

Target SpO₂ 94–98%
88–92% if at risk of hypercapnic respiratory failure
High-flow nasal oxygen: consider a trial if standard oxygen is not meeting target

4 · Antibiotics — within 4 hours

Low: amoxicillin 500mg TDS, 5 days. Allergy or atypicals: doxycycline or clarithromycin
Moderate: amoxicillin 500mg TDS, + clarithromycin if atypicals suspected
High: co-amoxiclav 500/125mg TDS PO or 1.2g TDS IV + clarithromycin 500mg BD
High + penicillin allergy: levofloxacin 500mg BD — see MHRA Jan 2024 fluoroquinolone restrictions
Pregnancy: erythromycin rather than clarithromycin
Oral first-line if she can swallow. If IV, review by 48h and switch
Check local antimicrobial policy

5 · Stopping at 5 days

Stop at 5 days unless microbiology says longer, or she is not clinically stable
Not stable = fever in the past 48h, or more than one of: SBP <90 · HR >100 · RR >24 · SpO₂ <90% on air

A longer course is a decision, not a default.

6 · Supportive care

IV fluids if unable to take oral or haemodynamically compromised
DVT prophylaxis
Analgesia for pleuritic pain
Physiotherapy for sputum clearance
Corticosteroids: for high-severity CAP in hospital, consider one for 4–7 days or until discharge. IV hydrocortisone first. Off-label. Note the MHRA warning on fluoroquinolones with corticosteroids

7 · Review, and before they go home

Worsening: repeat CXR, think atypicals, empyema, influenza, non-infective causes
IV to oral by 48 hours where severity allows
Do not discharge if 2 or more in the last 24h: temp >37.5 · RR ≥24 · HR >100 · SBP ≤90 · SpO₂ <90% on air · abnormal mental status · unable to eat unaided
No routine follow-up CXR. Consider at 6 weeks only for lung cancer risk factors (smoker, over 50), persisting symptoms, or unexplained weight loss
Recovery: fever gone by 1 week · chest pain and sputum by 4 weeks · cough and breathlessness by 6 weeks · normal by 6 months

Drugs

Drug	Dose	Route	Notes
Amoxicillin	500mg TDS for 5 days	PO	Low and moderate severity (higher doses possible — see BNF). IV if vomiting or severely ill.
Clarithromycin	500mg BD	PO/IV	Covers atypicals (Mycoplasma, Legionella). Add to amoxicillin.
Co-amoxiclav	500/125mg TDS PO or 1.2g TDS IV, 5 days	PO/IV	High severity, with clarithromycin. Oral is first-line if they can swallow and severity allows.
Doxycycline	200mg day 1, then 100mg OD (5 days total)	PO	Penicillin allergy in low or moderate severity, or where atypicals are suspected.
Levofloxacin	500mg BD, 5 days	PO/IV	High severity with penicillin allergy. MHRA January 2024: fluoroquinolones only when other antibiotics are inappropriate — risk of disabling, potentially irreversible effects. Consult microbiology if not suitable.

When to escalate

CURB-65 4–5 or rising — HDU/ITU review,Worsening SpO₂ despite O₂ — NIV or intubation,Pleural effusion / empyema — chest drain + cardiothoracic surgery,Not responding to antibiotics at 48h — broaden cover, seek microbiology advice,Legionella (high-risk travel history) — levofloxacin + rifampicin,Two or more instability criteria in the last 24 hours — not safe for routine discharge (NG250 1.6.7)

Reference: NICE NG250 Pneumonia: diagnosis and management (2025, replaced NG138 and NG139)

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