Hospital-Acquired Pneumonia (HAP)

Pneumonia developing 48 hours or more after admission, or in someone discharged within the last 7–10 days. It is not CAP that happened to be diagnosed on a ward — the organisms differ, the resistance risk differs, and so does the antibiotic…

NICE NG250 — Pneumonia

The pathway

1 · Is it actually HAP?

48 hours or more after admission, not incubating on arrival
Or presenting having been discharged in the last 7–10 days
Under 48 hours: treat as community-acquired, whatever ward they are on
VAP is excluded from this definition — that is an ICU problem

Rule out the ward mimics first: aspiration · pulmonary oedema after days of IV fluids · atelectasis post-op · PE · drug reaction.

2 · Assess and investigate

NEWS2. If septic, run the sepsis pathway alongside
CXR
Send a respiratory sample — sputum, nasopharyngeal swab or tracheal aspirate. Routine in HAP, unlike CAP
FBC, CRP, U&E, LFTs, gas. Blood cultures if septic

There is no validated severity score for HAP. Severity is clinical judgement — CURB-65 is for CAP and will mislead you here.

3 · Higher risk of resistance? This is the decision

Onset more than 5 days after admission
Severe lung disease or immunosuppression
Recent broad-spectrum antibiotics
Known MDR colonisation
Recent health or social care contact before this admission

Onset day 3–5 with none of these can follow the community-acquired choices. Weigh the C. difficile risk of broad-spectrum cover — that is why this is not automatic.

4 · Antibiotics — within 4 hours

Non-severe, no resistance risk: co-amoxiclav 500/125mg TDS, 5 days then review. Allergy: doxycycline, cefalexin or co-trimoxazole
Severe or higher resistance risk (IV, on microbiology advice): piperacillin-tazobactam 4.5g TDS · ceftazidime 2g TDS · ceftriaxone 2g OD · cefuroxime 750mg TDS · meropenem 0.5–1g TDS
MRSA suspected or confirmed: add vancomycin or teicoplanin. Linezolid only on specialist advice
Levofloxacin only if nothing else is suitable — MHRA Jan 2024

Local antimicrobial policy outranks every drug named here.

5 · Review at 5 days

Review at 5 days and consider stopping if clinically stable
IV to oral by 48 hours where severity allows
Narrow the antibiotic when the sample result lands — that is why you sent it
CRP or procalcitonin at day 3–4 if worried about failure
Not improving, or MDR organism: microbiology advice, not empirical escalation

6 · Prevent the next one

Sit them up — 30–45° unless contraindicated
Swallow assessment after stroke, or with a wet voice or cough on drinking
Mouth care
Mobilise, and involve physiotherapy early after surgery
Review the PPI — acid suppression is a risk factor and many inpatient PPIs have no indication
Deprescribe sedatives where you can

Drugs

Drug	Dose	Route	Notes
Co-amoxiclav	500/125mg TDS, 5 days then review	PO	Non-severe HAP not at higher risk of resistance.
Piperacillin-tazobactam	4.5g TDS (QDS if severe)	IV	Severe, or higher resistance risk. One option among several — local policy and microbiology advice decide.
Ceftriaxone	2g OD	IV	Alternative IV first-line. Per local policy.
Meropenem	0.5–1g TDS	IV	Reserve. Specialist microbiological advice, usually for known or likely resistant organisms.
Vancomycin	15–20mg/kg BD–TDS, level-adjusted	IV	Added to an IV first-line agent for suspected or confirmed MRSA. Loading dose 25–30mg/kg if seriously ill; max 2g per dose. Monitor levels.
Doxycycline	200mg day 1, then 100mg OD (5 days)	PO	Oral alternative in penicillin allergy, non-severe, low resistance risk.

When to escalate

Septic — run the sepsis pathway alongside this, NEWS2 sets the antibiotic clock,Severe, or higher risk of resistance — IV antibiotics on specialist microbiological advice,Not improving at 5 days, or a multidrug-resistant organism — microbiology, not empirical escalation,Rising oxygen requirement or type 1 failure — critical care review; consider HFNO,Suspected empyema or parapneumonic effusion — ultrasound and respiratory referral

Reference: NICE NG250 Pneumonia: diagnosis and management (2025, replaced NG138 and NG139) — hospital-acquired pneumonia sections 1.5, 1.7 and 1.11

This page is the reference half

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