See separate guidance for severe pneumonia in the frail elderly to avoid harms of 4C antibiotics.
- Blood cultures
- Viral throat swab if being admitted (swab throat and nose at same time with single swab, send in viral transport medium)
- Sputum for culture and
- Legionella PCR on sputum – document on TRAK request “CAP CURB 3-5/severe”.
- Do not routinely send urine for Legionella urinary antigen. If patient unable to produce sputum, send urine for Legionella antigen (Document on request form “CAP CURB 3-5/severe, unable to produce sputum”)
Recommended total duration: 5 days (total duration = IV + oral)
Co-amoxiclav 1.2g every 8 hours IV
Clarithromycin 500mg every 12 hours orally, IV only if oral route unavailable.
Risk of phlebitis with IV, oral formulation has very good bioavailability.
Vancomycin (use NHS Lothian Calculator located on AMT intranet page, choose trough levels 10-15 mg/L)
Ciprofloxacin 500mg every 12 hours orally (if oral route unavailable: 400mg every 12 hours IV)
Avoid fluruoquinolones if taking steroids and the elderly.
Review MHRA Quinolone Warning before prescribing.
DO NOT ADD CLARITHROMYCIN IF CIPROFLOXACIN USED AS BOTH COVER ATYPICALS (SEE SECTION BELOW), AS DOES DOXYCYCLINE.
Amoxicillin 500mg every 8 hours orally
Co-amoxiclav 625mg every 8 hours orally
Consider need for ongoing atypical pneumonia cover see atypical pneumonia section below.
||Doxycycline 200mg on first day and then 100mg daily orally
Stop antibiotic treatment after 5 days unless
- microbiological results suggest a longer course is needed or
- the patient is not clinically stable (fever in past 48 hours or more than 1 sign of clinical instability [systolic blood pressure <90 mmHg, heart rate >100/minute, respiratory rate >24/minute, arterial oxygen saturation <90% or PaO2 <60 mmHg in room air]).