Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2020-319376 on 19 November 2020. Downloaded from http://ep.bmj.

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Guideline review

NICE community-­acquired
pneumonia guideline review
Sarah Murphy  ‍ ‍,1 Louise Thomson2

1
Department of Paediatrics,
Mercy University Hospital, Cork,
Ireland
2 significant morbidity and mortality in chil-
Department of Respiratory,
Royal Hospital for Children,
Glasgow, UK
Correspondence to
Dr Sarah Murphy, Department
of Paediatrics, Mercy University
Hospital, Cork, Ireland; ​
murphysarah19@y​ ahoo.​com
Received 17 June 2020
INTRODUCTION
Globally, pneumonia is responsible for
dren. The incidence of community-­acquired
pneumonia (CAP) in Europe is estimated to
be approximately 33 per 10 000 in those
under 5 years of age and 14.5 per 10 000
in those aged 0–16 years.1
In 2019, the National Institute for Health
and Care Excellence (NICE) published a
guideline on prescribing antibiotics for CAP
in adults and children.2 The purpose of the
►► Risk of complications (eg, comorbidity—
severe lung disease/immunosuppression).
►► Local antimicrobial resistance and surveil-
lance data (eg, influenza/mycoplasma
rates).
►► Recent antibiotic use.
►► Recent microbiological results, including
colonisation with multidrug-­ resistant
bacteria.
Advice to patients and parents
►► Advise of possible adverse effects of anti-
biotics and how long symptoms are likely

Service REF: 44144903. Protected by copyright.

Revised 4 October 2020
Accepted 26 October 2020
guidance was to optimise antibiotic use
and decrease antibiotic resistance. It does
not address the management of hospital-­
acquired pneumonia. This review concen-
trates on the relevant paediatric advice.
RELATED GUIDELINES
Other relevant guidelines include: ‘Fever
in under 5s: assessment and initial manage-
ment’ (NICE 2019, NG143), Self-­limiting
respiratory tract and ear infections—anti-
biotic prescribing overview (NICE January
2020) and Cough (acute): antimicrobial
prescribing NICE guideline (NG120)
(February 2019) (box 1).
KEY ISSUES THIS GUIDELINE
ADDRESSES
1. General prescribing strategies.
2. Which antibiotics to prescribe.
3. Dosing, course length and route of
administration.
to last.
►► Advise to seek help if symptoms worsen
rapidly, they are no better in 3 days or
patient becomes very unwell.
Reassessment
►► Reassess if symptoms or signs do not
improve as expected or worsen rapidly/
significantly.
►► Consider possible non-­bacterial causes, for
example, influenza.
►► If severe symptoms or signs or a comor-
bidity, consider sending a sample (eg,
sputum) for microbiological testing if
possible.
►► Review the choice of antibiotic(s) if micro-
biological results are available. Change
to narrower-­ spectrum antibiotic, if
appropriate.
Which antibiotics to prescribe?
Recommendations are categorised by
severity as suggested by the NICE guide-
line2 and are outlined in boxes 2–4

General prescribing strategies Features of severe CAP in infants and children as

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To cite: Murphy S,
Thomson L. Arch Dis Child
Educ Pract Ed Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
archdischild-2020-319376
►► Start antibiotic treatment as soon as suggested by the NICE guideline (2)
possible and within 4 hours (1 hour if ►► Difficulty breathing.
suspected sepsis). ►► Oxygen saturation <90%.
►► Give oral antibiotics as first line unless ►► Raised heart rate.
the child is unable to tolerate them or has ►► Grunting.
increased severity of illness. ►► Very severe chest indrawing.
►► Inability to breast feed or drink.
►► If intravenous antibiotics have been
prescribed, the need for continued intra- ►► Lethargy.
venous treatment should generally be ►► Reduced level of consciousness.
reviewed by 48 hours.
Other prescribing recommendations
Factors to consider ►► Add a macrolide antibiotic if mycoplasma
►► Severity of symptoms or signs. or Chlamydia pneumoniae is suspected or

Murphy S, Thomson L. Arch Dis Child Educ Pract Ed 2020;0:1–3. doi:10.1136/archdischild-2020-319376     1

Guideline review
Box 1  Relevant guidelines
►► https://www.nice.org.uk/guidance/ng120
►► https://pathways.nice.org.uk/pathways/self-limiting-
respiratory-tract-and-ear-infections-antibiotic-prescribing
►► https://www.nice.org.uk/guidance/ng143
there is no response to first-­line empirical therapy and/
or in very severe disease.
Dosing, course length and route of administration
COMMENTARY
NICE recognises that the current evidence base for
choice of antibiotics and length of course in children has
major limitations and not all is relevant to UK practice.
At present, Most evidence for the treatment of severe
CAP comes from low-­income countries. However, this
is set to be updated with results from the eagerly antic-
ipated Community-­Acquired Pneumonia: a randomIsed
controlled Trial (CAP-­IT) study. This is a UK randomised
control trial which is reviewing efficacy, safety and
impact of amoxicillin on antimicrobial resistance with
regards to duration and dose of amoxicillin in young
children with CAP.3
It is worth noting that the NICE guideline recognises
that there are no validated severity assessment tools avail-
able for assessing pneumonia in children, unlike adults
whereby the CURB65 score is commonly employed to
aid decision making regarding severity of illness.2 The
British Thoracic Society (BTS), defines CAP in children
as the ‘presence of signs and symptoms of pneumonia
in a previously healthy child due to an infection which
has been acquired outside hospital’.1 However, it is
important to remember that many children with severe
CAP in the UK will have underlying health and respira-
tory conditions and thus the available evidence may not
be directly relevant to those patients.
Evidence to evaluate the efficacy of antibiotics for
severe CAP in children and young people is based on
one systematic review4 and two randomised controlled
trials.5 6
The NICE guideline focuses on the antibiotic treat-
ment of CAP, whereas the most recent BTS guideline on
Box 2  Antibiotics for infants >1 month, children
and young people under 18 with non-­severe
community-­acquired pneumonia
First choice
Amoxicillin
If penicillin allergy or atypical pathogens suspected
Clarithromycin or
Erythromycin (in pregnancy) or children ≥8 to 17 years or
Doxycycline (≥12 to 17 years)
For dosage recommendations, please consult the British
National Formulary for Children
2 Murphy S, Thomson L. Arch Dis Child Educ Pract Ed 2020;0:1–3. doi:10.1136/archdischild-2020-319376
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2020-319376 on 19 November 2020. Downloaded from http://ep.bmj.com/ on November 27, 2020 at Swets Subscription
Box 3  Antibiotics for infants >1 month, children
and young people under 18 with severe community-­
acquired pneumonia
First choice
Co-­amoxiclav high dose orally three times a day for 5 days
or
Co-­amoxiclav intravenous three times a day (or two times a
day if 1–2 months old)
If atypical pathogen suspected, add:
Clarithromycin or erythromycin (for use in pregnancy) orally
or intravenous depending on clinical situation
If penicillin allergy
Consult local microbiologist
For dosage recommendations, please consult the British
National Formulary for Children
CAP in children (2011) also reviewed clinical features,
investigations and complications.1 2 Of note, the BTS
guideline was last updated in 2011 so a revised version
is awaited.1 There are minor differences in antibiotic
Service REF: 44144903. Protected by copyright.
recommendations between the guidelines.
►► BTS suggested that antibiotic treatment is not required
in children under age 2 years with mild CAP due to like-
lihood of a viral cause and the relative reassurance of the
pneumococcal vaccine in young children.
►► Of note, the BTS guidelines do recommend that if a child
is suspected to have influenza in addition to pneumonia,
co-­amoxiclav should be prescribed. This is due to asso-
ciation with Staphylococcus aureus infection which has
long been associated with increased mortality in influ-
enza. This is not specifically mentioned in the NICE
guideline.
►► NICE recommends that all infants under 1 month of age
are reviewed by a paediatric specialist.
Box 4  Dosing, course length and route of
administration
Dosing
►► Standard dose in non-­severe CAP with care in specific
populations, for example, liver/renal impairment.
►► High-­dose co-­amoxiclav should be used for severe
pneumonia.
Course length
►► Shortest course effective to treat.
►► Generally 5-­day course.
►► Consider longer course
1. In high-­risk populations.
2. If microbiology results suggest longer course required.
3. If not clinically stable.
Route
►► Oral as first line if no contraindications.
►► If intravenous required review at 48 hours and consider
switch to oral.

Box 5  Useful links
►► https://www.nice.org.uk/guidance/ng138/chapter/
Recommendations
►► https://pathways.nice.org.uk/pathways/self-limiting-
respiratory-tract-and-ear-infections-antibiotic-prescribing
►► https://www.nice.org.uk/guidance/ng120
►► https://www.cochranelibrary.com/cdsr/
doi/10.1002/14651858.CD004874.pub4/abstract
►► https://thorax.bmj.com/content/thoraxjnl/66/Suppl_2/ii1.
full.pdf
►► Both recommend amoxicillin as first-­line choice although
NICE suggests co-­amoxiclav for ‘severe disease’ in all
age groups initially.
►► Both recommend oral antibiotics as first line, even in
severe disease with intravenous reserved for those unable
to tolerate fluids, with sepsis or complicated pneumonia.
►► NICE advise dual therapy with a macrolide when an
atypical pathogen is ‘suspected’. Azithromycin is not
recommended as first-­ line macrolide due to concerns
that the long half life may lead to increased antibiotic
resistance.
Take home messages
►► Give antibiotics within 4 hours of diagnosis.
►► Give oral antibiotics as first line unless not tolerated.
►► Give amoxicillin as first choice antibiotic in non-­severe
pneumonia.
►► Add a macrolide if atypical pneumonia suspected, very
severe pneumonia or no response to first-­line treatment.
►► Give standard dose amoxicillin for 5 days except in high-­
risk situations.
►► Obtain sputum as microbiological sample if possible in
severe disease or those with comorbidities.
Murphy S, Thomson L. Arch Dis Child Educ Pract Ed 2020;0:1–3. doi:10.1136/archdischild-2020-319376
Arch Dis Child Educ Pract Ed: first published as 10.1136/archdischild-2020-319376 on 19 November 2020. Downloaded from http://ep.bmj.com/ on November 27, 2020 at Swets Subscription
Guideline review
Contributors SM and LT contributed equally to the manuscript.
Funding  The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; externally peer reviewed.
ORCID iD
Sarah Murphy http://​orcid.​org/​0000-​0002-​8985-​316X
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2 National institute for Health and Care Excellence. Pneumonia
(community- acquired): antimicrobial prescribing ng138.
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pneumonia-​communityacquired-​antimicrobial-​prescribing-​pdf-​
66141726069445 [Accessed 16 Sept 2019].
3 CAP-­IT: efficacy, safety and impact on antimicrobial resistance
of duration and dose of amoxicillin treatment for young
children with community acquired pneumonia(CAP):A
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