NICE COVID-19 guidelines on antibiotics for pneumonia in hospitalised patients: a summary

  • National Institute for Health and Care Excellence

  • curated by Dawn O'Shea
  • Clinical Guidance Summaries
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NICE has published rapid guidance on the use of antibiotics to treat bacterial pneumonia in hospitalised adult patients during the COVID‑19 pandemic, including people presenting to hospital with community-acquired pneumonia and people who develop pneumonia while in hospital. Below, Univadis has created a summary of the key recommendations.

Communicate with patients

  • Discuss the risks, benefits and likely outcomes of treatment with patients with COVID‑19.
  • Discuss enrolling in a COVID‑19 clinical trial.


  • Tests to inform antibiotics use include:
    • microbiology for routine culture and sensitivities;
    • SARS‑CoV2 polymerase chain reaction (PCR) assay;
    • chest imaging;
    • full blood count; and
    • legionella and pneumococcal antigen tests.
  • There is insufficient evidence to recommend routine procalcitonin testing.
  • High C‑reactive protein does not necessarily indicate bacterial pneumonia or COVID‑19.

Moderate or severe community-acquired pneumonia

  • Oral options include:
    • doxycycline 200 mg on first day, then 100 mg once daily (od) and
    • co‑amoxiclav 500 mg/125 mg three times daily (tds) with clarithromycin 500 mg twice daily (bd).

For severe pneumonia or unsuitability of above, consider levofloxacin 500 mg od/bd (consider safety issues with fluoroquinolones).

  • Intravenous (IV) options include:
    • clarithromycin 500 mg bd with co-amoxiclav 1.2 g tds or cefuroxime 750 mg tds or four times daily (qd; 1.5 g tds for severe infection).

Where above are unsuitable, consider levofloxacin 500 mg od/bd.

Hospital ‑acquired pneumonia

  • Oral antibiotics for non-severe pneumonia without high risk for resistance, options include:
    • doxycycline 200 mg on first day, then 100 mg od;
    • co-amoxiclav 500 mg/125 mg tds; and
    • co-trimoxazole 960 mg bd.
  • IV antibiotics for severe pneumonia or high risk for resistance, options include:
  • piperacillin with tazobactam 4.5 g tds increased to 4.5 g qd for severe infection and
  • ceftazidime 2 g tds.

If other oral or IV options are unsuitable: levofloxacin 500 mg od/bd.

Meticillin-resistant Staphylococcus aureus infection

  • Dual therapy with IV antibiotic listed above added to:
    • IV vancomycin 15-20 mg/kg bd/tds.
    • IV teicoplanin: initially 6 mg/kg every 12 hours for three doses, then 6 mg/kg od.
    • Linezolid 600 mg bd orally or IV where above are unsuitable.

When to stop antibiotics

  • Use the following signs, symptoms and test results to inform decision-making:
  • no evidence of bacterial infection in blood, urine or sputum samples;
  • positive SARS‑CoV2 PCR;
  • fever resolved or resolving;
  • symptoms and blood test results (particularly lymphopenia) consistent with COVID‑19; and
  • chest imaging consistent with COVID‑19 pneumonia.
  • The patterns of COVID-19 computed tomography‑chest imaging are:
  • early (zero to two days): normal or rounded ground-glass opacities;
  • intermediate (five days to 10 days): crazy-paving opacities; and
  • late (more than ten days): consolidation.
  • Chest imaging changes are bilateral in most patients (>60%), with lung periphery and lower lobes being most involved.
  • Early ground-glass appearances may not be visible on plain chest X‑rays.

Continuing antibiotics

  • Continue antibiotics if there is evidence of bacterial infection, regardless of SARS‑CoV2 PCR test.
  • Consider continuing antibiotics if SARS‑CoV2 PCR is positive but clinical features are atypical for COVID‑19.
  • If antibiotics are continued:
  • review treatment based on microbiological testing and switch to narrower spectrum antibiotic when appropriate;
  • prescribe for five days, then stop unless there is a clear indication to continue; and
  • review IV antibiotic use within 48 hours and consider switching to oral antibiotics.