Summary of antimicrobial guidance

Lower Respiratory Tract Infection text summaries

Please refer to the user guide and principles of treatment when using the antimicrobial prescribing guidance summaries.

COVID-19

Antibiotics should not be used for preventing or treating COVID-19 unless there is clinical suspicion of additional bacterial co-infection.

Do not use azithromycin to treat COVID-19.

Do not use doxycycline to treat COVID-19 in the community.

Do not offer an antibiotic for preventing secondary bacterial pneumonia in people with COVID-19.

If a person in the community has suspected or confirmed secondary bacterial pneumonia, start antibiotic treatment as soon as possible, see community-acquired pneumonia for choices.

In hospital, start empirical antibiotics if there is clinical suspicion of a secondary bacterial infection in people with COVID-19, see hospital-acquired pneumonia for choices. Start antibiotics as soon as possible after establishing a diagnosis of secondary bacterial pneumonia, and certainly within 4 hours. Start treatment within 1 hour if the person has suspected sepsis and meets any of the high-risk criteria for this outlined in the NICE guideline on sepsis.

For detailed information, see the NICE guideline on managing COVID-19.

Section last updated: December 2021

Acute Exacerbation of COPD

Many exacerbations are not caused by bacterial infections so will not respond to antibiotics.

Consider an antibiotic, but only after taking into account severity of symptoms (particularly sputum colour changes and increases in volume or thickness), need for hospitalisation, previous exacerbations, hospitalisations and risk of complications, previous sputum culture and susceptibility results, and risk of resistance with repeated courses.

Some people at risk of exacerbations may have antibiotics to keep at home as part of their exacerbation action plan.

First choice adult:

amoxicillin 500mg TDS (see BNF for severe infection) for 5 days

doxycycline 200mg on day 1, then 100mg OD (see BNF for severe infection) for 5 days

clarithromycin 500mg BD for 5 days

Second choice adult: use alternative first choice

Alternative choice adult (if person at higher risk of treatment failure):

co-amoxiclav 500/125mg TDS for 5 days

co-trimoxazole 960mg BD for 5 days

levofloxacin (only if other alternative choice antibiotics are unsuitable with specialist advice) 500mg OD for 5 days.

See the MHRA January 2024 advice on restrictions and precautions for using fluoroquinolone antibiotics because of the risk of disabling and potentially long-lasting or irreversible side effects. Fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate.

IV antibiotics: see the guidance visual summary

For detailed information, see the guidance visual summary or https://www.nice.org.uk/guidance/ng115

NICE

Section last updated September 2024

Acute Exacerbation of Bronchiectasis (Non-Cystic Fibrosis)

Send a sputum sample for culture and susceptibility testing.

Offer an antibiotic.

When choosing an antibiotic, take account of severity of symptoms and risk of treatment failure. People who may be at higher risk of treatment failure include people who’ve had repeated courses of antibiotics, a previous sputum culture with resistant or atypical bacteria, or a higher risk of developing complications.

Course length is based on severity of bronchiectasis, exacerbation history, severity of exacerbation symptoms, previous culture and susceptibility results, and response to treatment.

Do not routinely offer antibiotic prophylaxis to prevent exacerbations.

Seek specialist advice for preventing exacerbations in people with repeated acute exacerbations. This may include a trial of antibiotic prophylaxis after a discussion of the possible benefits and harms, and the need for regular review.

First choice empirical treatment adult:

amoxicillin (preferred if pregnant) 500mg TDS for 7 to 14 days

doxycycline (not in under 12s) 200mg on day 1, then 100mg OD for 7 to 14 days

clarithromycin 500mg BD for 7 to 14 days

Alternative choice (if person is at higher risk of treatment failure) empirical treatment adult:

co-amoxiclav 500/125mg TDS for 7 to 14 days

levofloxacin (adults only: with specialist advice if con-amoxiclav cannot be used: consider safety issues) 500mg OD or BD 7 to 14 days

levofloxacin (adults only: only if con-amoxiclav is unsuitable; with specialist advice) 500mg OD or BD 7 to 14 days

IV antibiotics: see the guidance visual summary

When current susceptibility data available: choose antibiotics accordingly

For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng117/

NICE

Section last updated September 2024

Acute Cough

Some people may wish to try honey (in over 1s), the herbal medicine pelargonium (in over 12s), cough medicines containing the expectorant guaifenesin (in over 12s) or cough medicines containing cough suppressants, except codeine, (in over 12s). These self-care treatments have limited evidence for the relief of cough symptoms.

Acute cough with upper respiratory tract infection: no antibiotic.

Acute bronchitis: no routine antibiotic.

Acute cough and higher risk of complications (at face-to-face examination): immediate or back-up antibiotic.

Acute cough and systemically very unwell (at face-to-face examination): immediate antibiotic.

Higher risk of complications includes people with pre-existing comorbidity; young children born prematurely; people over 65 with 2 or more of, or over 80 with 1 or more of: hospitalisation in previous year, type 1 or 2 diabetes, history of congestive heart failure, current use of oral corticosteroids.

Do not offer a mucolytic, an oral or inhaled bronchodilator, or an oral or inhaled corticosteroid unless otherwise indicated.

First choice adults:

doxycycline 200mg day1, then 100mg OD for 5 days

Alternative first choice adults:

amoxicillin (preferred if pregnant) 500mg TDS for 5 days

clarithromycin 250mg to 500mg BD for 5 days

erythromycin (if macrolide needed in pregnancy; consider benefit/harm) 250mg to 500mg QDS or 500mg to 1000mg BD for 5 days

First choice children:

amoxicillin for 5 days

Alternative first choice children:

clarithromycin for 5 days

erythromycin for 5 days

doxycycline (not in under 12s) for 5 days

For information on children’s dosage or for detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng120

NICE

Section last updated Feb 2019

Hospital-Acquired Pneumonia

If symptoms or signs of pneumonia start within 48 hours of hospital admission, see community acquired pneumonia.

Offer an antibiotic. Start treatment as soon as possible after diagnosis, within 4 hours (within 1 hour if sepsis suspected and person meets any high-risk criteria – see the NICE guideline on sepsis).

When choosing an antibiotic, take account of severity of symptoms or signs, number of days in hospital before onset of symptoms, risk of developing complications, local hospital and ward-based antimicrobial resistance data, recent antibiotic use and microbiological results, recent contact with a health or social care setting before current admission, and risk of adverse effects with broad spectrum antibiotics.

No validated severity assessment tools are available. Assess severity of symptoms or signs based on clinical judgement.

Higher risk of resistance includes relevant comorbidity (such as severe lung disease or immunosuppression), recent use of broad-spectrum antibiotics, colonisation with multi-drug resistant bacteria, and recent contact with health and social care settings before current admission.

If symptoms or signs of pneumonia start within days 3 to 5 of hospital admission in people not at higher risk of resistance, consider following community acquired pneumonia for choice of antibiotic.

First choice adults and children (non-severe and not higher risk of resistance):

co-amoxiclav for adults 500/125mg TDS for 5 days then review

co-amoxiclav for children see the guidance visual summary for children’s dosage

Alternative first choice adults (non-severe and not higher risk of resistance):

choice based on specialist microbiological advice and local resistance data

Options include:

doxycycline 200mg on day 1, then 100mg OD for 5 days then review

cefalexin (caution in penicillin allergy) 500 mg BD or TDS (can increase to 1 to 1.5g TDS or QDS for 5 days then review

co-trimoxazole 960mg BD for 5 days then review

levofloxacin (only if switching from IV levofloxacin with specialist advice;) 500mg OD or BD for 5 days then review

Children alternative first choice (non-severe and not higher risk of resistance): clarithromycin

other options may be suitable based on specialist microbiological advice and local resistance data

see the guidance visual summary for children’s dosage

For first choice IV antibiotics (severe or higher risk of resistance) and antibiotics to be added if suspected or confirmed MRSA infection see visual summary.

For detailed information see the guidance visual summary or https://www.nice.org.uk/guidance/ng139

NICE

Section last updated September 2024

Community-Acquired Pneumonia

Assess severity in adults based on clinical judgement and guided by a mortality risk score (CRB65 or CURB65) when these scores can be calculated:

low severity – CRB65 0 or CURB65 0 or 1
moderate severity – CRB65 1 or 2 or CURB65 2
high severity – CRB65 3 or 4 or CURB65 3 to 5.

1 point for each parameter: confusion, urea (>7 mmol/l), respiratory rate ≥30/min, low systolic (<90 mm Hg) or diastolic (≤60 mm Hg) blood pressure, age ≥65.

Assess severity in children based on clinical judgement.

When choosing an antibiotic, take account of severity, risk of complications, local antimicrobial resistance and surveillance data, recent antibiotic use, and microbiological results.

First choice (low severity in adults or non-severe in children):

amoxicillin for adults 500mg TDS (higher doses can be used, see BNF) for 5 days