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Low doses of penicillins are more likely to select out resistance, amoxicillin doses of 500mg or above are recommended. Do not use quinolones (ciprofloxacin, ofloxacin) first line due to poor pneumococcal activity. Reserve all quinolones (including levofloxacin) for proven resistant organisms.
Antibiotics are of no benefit in otherwise healthy adults. Symptom resolution can take 3 weeks. Pneumonia is unlikely if there are no new focal chest signs on auscultation in otherwise healthy, non-elderly patients.
Consider no prescription, or delaying a prescription by 7-14 days for the majority of cases.
Sputum samples are generally not useful.
Immediate prescription of antibiotics is recommended in the following patients who are at risk of developing complications (as per NICE CG69):
See guidance on COPD for information on COPD Rescue packs
Antibiotics are only indicated if there is purulent sputum and increased shortness of breath and/or increased sputum volume.
If clinical evidence of pneumonia, follow community-acquired pneumonia advice below.
Risk factors for antibiotic resistance organisms include co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months.
Consider review of COPD management if frequent exacerbations.
Alternative antibiotics: if recent culture, review sensitivities and treat accordingly
If failing on a doxycycline containing regimen consider co-amoxiclav.
Start antibiotics immediately
Consider using CRB65 score to help guide and review
Each scores 1:
Mortality rates are as follows:
CRB-65 score is not a substitute for good clinical judgement; clinicians should take into account other prognostic factors. Care should be taken with younger fit adults, as it is possible that the score may be low in patients who nevertheless have severe illness.
The formulary gives dose and duration of treatment for adults unless stated otherwise.
Do not routinely offer dual therapy to treat low-severity infection
Patient information (NICE CG191)
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:
Advise patients with community‑acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.
Doxycycline alone for 7-10 days, or dual therapy adding amoxicillin
Treatment with an antibiotic in the community is recommended for patients with suspected CAP who are severely ill provided this does not delay transfer to hospital.
Benzylpenicillin IV 1.2g or oral Amoxicillin 1g (or oral doxycycline 200mg if penicillin sensitivity)