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

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.

Testing

• 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.