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Summary for primary care

Pneumonia in Adults: Diagnosis and Management

Latest Guidance Updates

October 2023: the recommendations in the section on Presentation with Lower Respiratory Tract Infection were replaced with a link to NICE's guideline on suspected acute respiratory infection (ARI) in over 16s. Recommendations in the section on Community-acquired Pneumonia: Severity Assessment Outside Hospital were updated in line with the guideline on ARI in over 16s.


This Guidelines summary covers diagnosing and managing community- and hospital-acquired pneumonia in adults. It aims to improve accurate assessment and diagnosis of pneumonia to help guide antibiotic prescribing and ensure that people receive the right treatment.

Presentation with Lower Respiratory Tract Infection

Community-acquired Pneumonia

Severity Assessment Outside Hospital

  • If a clinical diagnosis of community-acquired pneumonia has been made, carry out a risk assessment using the CRB65 scoring system (see box 1).
Box 1: CRB65 Score for Mortality Risk Assessment in Primary Care
CRB65 score is calculated by giving 1 point for each of the following prognostic features:
  • confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or time). For guidance on delirium, see NICE's guideline on delirium. 
  • raised respiratory rate (30 breaths per minute or more)
  • low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
  • age 65 years or more.
Patients are stratified for risk of death (within 30 days) as follows:
  • 0: low risk (less than 1% mortality risk)
  • 1 or 2: intermediate risk (1 to 10% mortality risk)
  • 3 or 4: high risk (more than 10% mortality risk).
  • Use clinical judgement in conjunction with the CRB65 score (bearing in mind this can be affected by other factors, for example, comorbidities or
    pregnancy) to inform decisions about whether people with a clinical diagnosis of community-acquired pneumonia need hospital assessment as follows:
    • consider hospital assessment for people with a CRB65 score of 2 or more
    • discuss the options with people with a score of 1 and make a shared decision about the best care pathways for them, for example supported home-based care using a virtual ward or community intervention team
    • consider home based care for patients with a CRB65 score of 0.

Microbiological Tests

  • Do not routinely offer microbiological tests to patients with low-severity community-acquired pneumonia.
  • For patients with moderate- or high-severity community-acquired pneumonia:
    • take blood and sputum cultures and
    • consider pneumococcal and legionella urinary antigen tests.

Antibiotic Therapy

See the NICE guideline on pneumonia (community-acquired): antimicrobial prescribing for recommendations on antibiotic therapy.

Glucocorticoid Treatment

  • Do not routinely offer a glucocorticoid to people with community-acquired pneumonia unless they have other conditions for which glucocorticoid treatment is indicated.

Patient Information

  • Explain to people 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:
    • 1 week: fever should have resolved
    • 4 weeks: chest pain and sputum production should have substantially reduced
    • 6 weeks: cough and breathlessness should have substantially reduced
    • 3 months: most symptoms should have resolved but fatigue may still be present
    • 6 months: most people will feel back to normal.
  • Advise patients with community-acquired pneumonia to consult their healthcare professional if they feel that their condition is deteriorating or not improving as expected.

Hospital-acquired Pneumonia

Antibiotic Therapy

See the NICE guideline on pneumonia (hospital-acquired): antimicrobial prescribing for recommendations on antibiotic therapy for hospital-acquired pneumonia.