NICE issues antimicrobial prescribing guidance for pneumonia
As part of its antimicrobial prescribing series, NICE and Public Health England (PHE) have published new guidelines on the treatment of community-acquired (NG138) and hospital-acquired (NG139) pneumonia in adults and children. The two guidelines outline antimicrobial prescribing strategies for pneumonia that aim to optimise antibiotic use and minimise resistance.
In December 2014, NICE published a full clinical guideline on the diagnosis and management of pneumonia in adults (CG191); some of the recommendations on antibiotic therapy have now been removed from this guidance and replaced by the recommendations in the new antimicrobial prescribing guidance, but the remainder of the advice still stands and both sets of guidance should be used together.
Community-acquired pneumonia is defined as an infection contracted outside the hospital setting, and can be caused by several different pathogens (bacteria or viruses), with Streptococcus pneumoniae bacteria being the most common. Hospital-acquired pneumonia is defined as an infection that develops 48 hours or more after hospital admission and is not incubating at the time of admission; if symptoms have started before this, the guideline on community-acquired pneumonia should be followed. Hospital-acquired pneumonia has a worse prognosis than community-acquired; the most common micro-organisms acquired in the hospital environment are Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA) and other non-pseudomonal Gram-negative bacteria.
In both community-acquired and hospital-acquired pneumonia, NICE recommends that antibiotic therapy should be offered within four hours of establishing a diagnosis. The choice of antibiotic should be guided by the age of the patient, whether the infection is community- or hospital-acquired, the severity of the symptoms, the risk of complications and the risk of antibiotic resistance. Oral antibiotics should be offered first-line if possible; however, IV antibiotics may be required if symptoms are severe or there is higher risk of resistance. IV antibiotics should be reviewed by 48 hours, and consideration given to switching to oral antibiotics if possible. The choice of antibiotic therapy should be reviewed when the results of microbiological testing are available, and changed if necessary according to the results, using a narrower spectrum antibiotic if appropriate. Specialist advice should be sought if symptoms do not improve with antibiotic therapy, or in the case of multi-drug resistance.
The two sets of guidance are each complemented by a three-page visual summary, featuring a treatment algorithm and tables to guide antibiotic choice and dosing in both adults and children.