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
Access to the full content of this site is available only to registered healthcare professionals. Access to the full content of this site is available only to registered healthcare professionals.

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.