Community Acquired Pneumonia 🫁
UK guide to adult community-acquired pneumonia: interactive CURB-65 hospital severity calculator, NICE NG250 antibiotic pathways by severity, and when to escalate.
CURB-65 Severity Score
NICE NG250 hospital assessment. Tick criteria present (each scores 1 point)
CURB-65 score
0 / 5
LowNo criteria or prescribing factors ticked yet.
Low risk of death (NICE hospital CURB-65)
Consider discharge home with primary care-led services and safety-netting if clinically appropriate. Use clinical judgement for hypoxia, comorbidity, immunosuppression, or multilobar disease.
NICE NG250 regimen
Amoxicillin 500 mg three times daily for 5 days (higher doses: see BNF). Oral first line if the patient can take oral medicines.
NICE low-severity CAP (Table 1)
Prescribing factors
Tailors NICE Table 1 adult regimens. Confirm local AMS and BNF for organ impairment.
Disease severity is a clinical judgement informed by CURB-65; they often align but not always. Primary care uses CRB65 (no urea). Educational aid: confirm NICE NG250 and your Trust guideline.
📖 Definition (NICE NG250)
- Community-acquired pneumonia: pneumonia acquired outside hospital, or within 48 hours of admission. Nursing-home acquired pneumonia is included.
- Clinical diagnosis is based on symptoms and signs of lower respiratory tract infection when pneumonia is likely (for example focal chest signs, raised respiratory rate, low oxygen saturations, or illness severity), even before chest X-ray.
- If sepsis is suspected, follow your Trust sepsis pathway and NICE suspected sepsis guidance (see Sepsis).
- Start antibiotics as soon as possible after diagnosing CAP, and within 4 hours of presentation to hospital.
📊 CURB-65 (hospital)
- Use the interactive CURB-65 calculator at the top. Each criterion scores 1 point (maximum 5). Urea >7 mmol/L is included in hospital assessment.
- NICE risk bands: 0–1 low; 2 intermediate; 3–5 high. Disease severity is a clinical judgement informed by the score; they often align but not always.
- In primary care, NICE uses CRB65 (no urea). This topic targets hospital / on-call assessment.
- Antibiotic sections below follow NICE Table 1 for adults by low, moderate, and high severity.
🔍 Assessment & Investigations
- Vitals: temperature, HR, RR, BP, SpO₂. Document confusion carefully (AMT or new disorientation).
- Aim to diagnose CAP (including chest X-ray) within 4 hours of hospital presentation where processes allow. Lung ultrasound may help in selected cases.
- Bloods: FBC, U&E (needed for urea / CURB-65), CRP on admission if useful; lactate if unwell or sepsis possible.
- Do not routinely send microbiology in low-severity CAP. For moderate or high severity, consider blood cultures when sepsis is suspected, sputum if useful, pneumococcal urinary antigen to support de-escalation, and legionella antigen if risk factors.
- Consider influenza / COVID / RSV testing per local protocol.
- Give oral antibiotics first line if the person can take oral medicines and severity does not require IV therapy. Review IV by 48 hours for switch.
💊 Antibiotics: low severity (NICE)
- Usually aligns with CURB-65 0–1 when clinical severity is low.
- Stop antibiotics after 5 days unless not clinically stable or microbiology suggests longer.
- Also take account of local resistance, recent antibiotics, and recent microbiology.
💊 Antibiotics: moderate severity (NICE)
- Usually aligns with CURB-65 2 when clinical severity is moderate.
- Add a macrolide to amoxicillin if atypical pathogens are suspected.
🚨 Antibiotics: high severity (NICE)
- Usually aligns with CURB-65 ≥3. Consider inpatient care and critical care if appropriate.
- For adults with high-severity CAP in hospital, NICE also recommends considering a corticosteroid for 4–7 days (or until discharge if sooner), typically starting with IV hydrocortisone. Do not combine a corticosteroid with a fluoroquinolone.
🩹 Supportive care & review
- Oxygen to target saturations per BTS emergency oxygen guidance and local protocol.
- Analgesia for pleuritic pain; keep PE in the differential when features are atypical.
- Review choice when microbiology returns; narrow spectrum if appropriate.
- Do not routinely discharge if two or more instability findings in the past 24 hours (fever >37.5°C, RR ≥24, HR >100, SBP ≤90, SpO₂ <90% on air or below baseline, abnormal mentation, inability to eat without assistance).
- Explain expected recovery: fever often settles by about 1 week; cough and breathlessness may take weeks.
- Switch IV to oral when improving. Confirm local AMS for IV-to-oral switch.
Note Template
Ready-to-use clinical note structure
🕒 08 / 10 / 2026 — 16:13 ATRP re: community acquired pneumonia (CAP) Patient: [age] [sex] Admission Dx: [reason for admission] PMHx: [COPD, heart failure, immunosuppression, malignancy] 🧾 Hx: • Onset: cough, fever, pleuritic pain, breathlessness • Duration and progression • Recent antibiotics or hospital attendance • Vaccination status (COVID, influenza, pneumococcal) • Aspiration risk: dysphagia, reduced GCS, vomiting • Allergies: penicillin [Y/N] macrolide [Y/N] • Pregnant: [Y/N] 🩺 Exam: • Vitals: HR __ BP __ RR __ Temp __ SpO₂ __ • CRB65: Confusion [Y/N] RR≥30 [Y/N] BP≤90/60 [Y/N] Age≥65 [Y/N] → score __ • Chest: focal crackles / bronchial breathing / dullness [site] • Severity markers: hypoxia, multilobar signs, hypotension 🔬 Investigations: • CXR: [consolidation site / effusion / multilobar] • Bloods: FBC, U&E, CRP, lactate [if unwell] • Cultures: blood / sputum [if taken] • Viral testing: [COVID / influenza / RSV per protocol] 📋 Impression: Community acquired pneumonia — CRB65 __ — [mild / moderate / severe] 📌 Plan: • Empirical antibiotics per HSE community CAP v2.0 / local protocol if inpatient: [regimen] • Oxygen to target saturations; fluids if dehydrated • Sepsis screen — Sepsis 6 if indicated • Analgesia for pleuritic pain • Review at 48 h if on amoxicillin monotherapy (CRB65 0); otherwise review if not improving • Vaccination at discharge if not up to date • Escalate to respiratory / ICU if deteriorating 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer