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Pneumonia

Emergencies

Assess severity with CURB-65 alongside clinical judgement; sepsis signs mean the sepsis pathway first.

Start antibiotics as soon as the diagnosis is made and within 4 hours of presentation — within 1 hour if high-risk sepsis criteria are met.

Act now

  1. 1

    Oxygen to target.

  2. 2

    Blood cultures, then antibiotics.

  3. 3

    IV fluids if hypovolaemic.

Assess

  • ABCDE, NEWS2, sepsis screen.
  • Community- or hospital-acquired? Aspiration risk (swallow, reduced GCS)? Immunosuppressed?
  • Recent antibiotics and cultures; allergies.

Investigations

  • CXR, FBC, U&E (urea for CURB-65), CRP, blood cultures, sputum culture.
  • Moderate or high severity: urine pneumococcal and legionella antigens; consider respiratory virus testing.
  • Blood gas if SpO₂ is below target.

Manage

  • CURB-65 0–1: low severity; 2: moderate; 3–5: high — use clinical judgement where the score and the patient disagree.
  • Antibiotic choice by severity and setting (see doses); stop after 5 days unless cultures or clinical instability say otherwise.
  • High severity: consider a corticosteroid (e.g. dexamethasone) alongside antibiotics.
  • Review at 48 hours: switch IV to oral when improving; check cultures.
  • Repeat CXR at 6 weeks only if symptoms persist or there is a risk of malignancy.

Escalate when

  • CURB-65 3 or more, sepsis, rising oxygen need or hypercapnia: senior and critical care outreach.

Doses and prescribing

Community-acquired, low or moderate severity: amoxicillin 500 mg oral 3 times daily for 5 days. Moderate: add clarithromycin 500 mg twice daily only if atypical infection is suspected.

Community-acquired, high severity: co-amoxiclav 1.2 g IV 3 times daily plus clarithromycin 500 mg twice daily for 5 days. Penicillin allergy: follow local policy (NICE lists levofloxacin).

Hospital-acquired, non-severe and not at higher risk of resistance: co-amoxiclav 500/125 mg oral 3 times daily for 5 days, then review. Otherwise follow local policy.

Check doses against the BNF and your local antimicrobial guide.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE NG250, NG253) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

Calculators for this

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.