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COVID-19 rapid Nice guideline summary: Managing pneumonia in adults

Nice has published rapid guidelines for the care of patients with suspected and confirmed cases of COVID-19

Unplanned learning

Where new recommendations in this guideline cover existing Nice guidelines for pneumonia, the new recommendations are to be followed during the pandemic.

It may be useful to print this summary as a resource for your pharmacy team – PDF available here.


When physical examination and other ways of making an objective diagnosis are not possible, clinical diagnosis of community-acquired pneumonia (CAP) in adults can be informed by clinical signs or symptoms such as:

  • body temperature greater than 38°C
  • heart rate above 100 beats per minute
  • confusion that is new
  • respiratory rate higher than 20 breaths per minute.

Patients with a more severe illness need to be referred to a medical practitioner.

More severe illness can be indicated by:

  • blue lips or face
  • coughing up blood
  • severe shortness of breath or breathing difficulty at rest
  • fainting or collapse
  • mottled skin or feeling cold and clammy
  • new confusion
  • difficult to rouse
  • little or no urine output.
Symptoms of viral COVID-19 pneumonia and bacterial pneumonia

Differentiating between bacterial pneumonia and viral COVID-19 pneumonia is difficult in primary care. Bacterial pneumonia may be primary or secondary to COVID-19. During the current pandemic, patients presenting with pneumonia symptoms are more likely to have viral COVID-19 pneumonia given the increasing prevalence of the virus.

Viral COVID-19 pneumonia  Bacterial pneumonia

Severe muscle pain

Rapid deterioration of condition after a few days of symptoms

Sense of smell has been lost

No history of typical COVID-19 symptoms

Breathlessness with no associated chest pain when breathing

Sharp or stabbing chest pain when breathing

History of exposure to a confirmed or suspected case of COVID-19

Purulent sputum

Has typical COVID-19 symptoms that have been present for around a week



Refer patients who are more likely to develop severe pneumonia to a medical practitioner. This group includes: elderly, people with comorbidities, impaired immunity, a reduced ability to cough or the production of clear phlegm and those that are frail.

Drug treatment

Do not use antibiotics if the symptoms are mild or to manage viral COVID-19 pneumonia because they are not effective and may contribute to Clostridiodes difficile infection and antimicrobial resistance. Oral antibiotics can be used for people who are able, or wish, to be treated in the community where:

  • the cause is likely to be bacterial
  • symptoms are concerning and the cause is unclear
  • they are at high risk of complications (eg elderly or frail, have a comorbidity such as immunosuppression, significant heart or lung disease, or they usually suffer from severe illness after a lung infection).

Antibiotic treatment should be started as soon as possible, while taking into consideration other methods to minimise face-to-face contact and delivery of medicines during the pandemic. Suitable measures include, use of electronic prescriptions, telephone or video counselling and pharmacy delivery, postal or drive-through pick-up for collection of medication.

Antibiotic treatment (if indicated):

Step 1: Doxycycline 200mg on day 1, then 100mg daily for 4 days (5-day course in total) (do not use during pregnancy)

Step 2: Alternatively, amoxicillin 500mg 3 times a day for a total of 5 days

In more severe disease and penicillin allergy or pregnancy, or if an atypical pathogen is suspected, refer to Nice antimicrobial prescribing guideline on community-acquired pneumonia.

Advise all patients, whether they are taking an antibiotic or not, to seek medical help if there is any worsening of symptoms or no improvement in symptoms as expected.

This summary is intended as a quick resource for pharmacy teams on the Nice COVID-19 rapid guideline: Managing suspected or confirmed pneumonia in adults in the community. For more detailed information, please see the full guideline here.

Other sources of useful information include:


National Institute for health Care and Excellence (2020) COVID-19 rapid guideline: Managing suspected or confirmed pneumonia in adults in the community. Nice guideline (NG165).

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