Diagnosing pneumonia

3.1.

During the COVID-19 pandemic, face to face examination of patients may not be possible. Advice on how to conduct a remote consultation can be found in BMJ guidance on COVID-19: a remote assessment in primary care, which includes a visual summary for remote consultations.

3.2.

Where physical examination and other ways of making an objective diagnosis are not possible, the clinical diagnosis of community-acquired pneumonia of any cause in an adult can be informed by other clinical signs or symptoms such as:

• temperature above 38°C
• respiratory rate above 20 breaths per minute
• heart rate above 100 beats per minute
• new confusion

(see the CEBM’s rapid diagnosis of community-acquired pneumonia for clinicians).

3.3.

Assessing shortness of breath (dyspnoea) is important, but may be difficult via remote consultation. Tools such as the Medical Research Council’s dyspnoea scale or the CEBM’s review of ways of assessing dyspnoea (breathlessness) by telephone or video can be useful.

Assessing severity

3.4.

Use the following symptoms and signs to help identify patients with more severe illness to help make decisions about hospital admission:

• severe shortness of breath at rest or difficulty breathing
• coughing up blood
• blue lips or face
• feeling cold and clammy with pale or mottled skin
• collapse or fainting (syncope)
• new confusion
• becoming difficult to rouse
• little or no urine output.

Differentiating viral COVID-19 pneumonia from bacterial pneumonia

It is difficult to determine whether pneumonia has a COVID-19 viral cause or a bacterial cause (either primary or secondary to COVID-19) in primary care, particularly during remote consultations. However, as COVID-19 becomes more prevalent in the community, patients presenting with pneumonia symptoms are more likely to have a COVID-19 viral pneumonia than a community-acquired bacterial pneumonia.

3.8.

COVID-19 viral pneumonia may be more likely if the patient:

• presents with a history of typical COVID-19 symptoms for about a week
• has severe muscle pain (myalgia)
• has loss of sense of smell (anosmia)
• is breathless but has no pleuritic pain
• has a history of exposure to known or suspected COVID-19, such as a household or workplace contact.

3.9.

A bacterial cause of pneumonia may be more likely if the patient:

• becomes rapidly unwell after only a few days of symptoms
• does not have a history of typical COVID-19 symptoms
• has pleuritic pain
• has purulent sputum.

Deciding about hospital admission

4.1.

Be aware that older people, or those with comorbidities, frailty, impaired immunity or a reduced ability to cough and clear secretions, are more likely to develop severe pneumonia. Because this can lead to respiratory failure and death, hospital admission would have been the usual recommendation for these people before the COVID-19 pandemic.

4.2.

When making decisions about hospital admission, take into account:

• the severity of the pneumonia, including symptoms and signs of more severe illness (see recommendation 3.4)
• the benefits, risks and disadvantages of hospital admission
• the care that can be offered in hospital compared with at home
• the patient’s wishes and care plans (see the section on treatment and care planning)
• service delivery issues and local NHS resources during the COVID-19 pandemic.

4.3.

Explain that:

• the benefits of hospital admission include improved diagnostic tests (chest X-ray, microbiological tests and blood tests) and respiratory support
• the risks and disadvantages of hospital admission may include spreading or catching COVID-19 and loss of contact with families. [amended 19 August 2020]

Managing breathlessness

4.4.

Be aware that severe breathlessness often causes anxiety, which can then increase breathlessness further. See the NICE COVID-19 rapid guideline on managing symptoms (including at the end of life) in the community for advice on how to manage breathlessness.

Antibiotic treatment

4.5.

As COVID-19 pneumonia is caused by a virus, antibiotics are ineffective.

4.6.

Do not offer an antibiotic for treatment or prevention of pneumonia if:

• COVID-19 is likely to be the cause and
• symptoms are mild.

Inappropriate antibiotic use may reduce availability if used indiscriminately, and broad-spectrum antibiotics in particular may lead to Clostridioides difficile infection and antimicrobial resistance.

4.7.

Offer an oral antibiotic for treatment of pneumonia in people who can or wish to be treated in the community if:

• the likely cause is bacterial or
• it is unclear whether the cause is bacterial or viral and symptoms are more concerning or
• they are at high risk of complications because, for example, they are older or frail, or have a pre-existing comorbidity such as immunosuppression or significant heart or lung disease (for example bronchiectasis or COPD), or have a history of severe illness following previous lung infection.

4.8.

When starting antibiotic treatment, the first-choice oral antibiotic is:

• doxycycline 200 mg on the first day, then 100 mg once a day for 4 days (5-day course in total); doxycycline should not be used in pregnancy
• alternative: amoxicillin 500 mg 3 times a day for 5 days.

Doxycycline is preferred because it has a broader spectrum of cover than amoxicillin, particularly against Mycoplasma pneumoniae and Staphylococcus aureus, which are more likely to be secondary bacterial causes of pneumonia during the COVID-19 pandemic. [amended 23 April 2020]

4.9.

Do not routinely use dual antibiotics.

4.10.

For choice of antibiotics in penicillin allergy, pregnancy and more severe disease, or if atypical pathogens are likely, see the recommendations on choice of antibiotic in the NICE antimicrobial prescribing guideline on community-acquired pneumonia.

4.11.

Start antibiotic treatment as soon as possible, taking into account any different methods needed to deliver medicines to patients during the COVID-19 pandemic (see recommendation 1.3).

Oral corticosteroids

4.12.

Do not routinely offer a corticosteroid unless the patient has other conditions for which these are indicated, such as asthma or COPD.

Safety netting and review

4.13.

Advise patients to seek medical help without delay if their symptoms do not improve as expected or worsen rapidly or significantly, whether they are taking an antibiotic or not (see recommendation 1.1 and recommendation 3.4).

4.14.

On reassessment, reconsider whether the patient has symptoms and signs of more severe illness (see recommendation 3.4) and whether to admit to hospital (see recommendation 4.2).

Minor changes since publication

2 September 2020: We added a link to NHS England’s guide to pulse oximetry to recommendation 3.6.

19 August 2020: We made a small change to the second bullet point of recommendation 4.3 to indicate that the disadvantages of hospital admission are uncertain.

26 May 2020: We updated the list of symptoms in recommendation 1.1 to include loss of smell or taste in line with current government advice.

4 May 2020: We removed the cross-reference to the NICE guideline on pneumonia in adults from recommendation 3.5 because the recommendations in that guideline do not apply during the COVID-19 pandemic.