Clinical update

Antimicrobial prescribing guidance for pneumonia in children and young people

Two new guidelines on pneumonia set out a prescribing strategy aiming to optimise the use of antibiotics and reduce resistance to them

Two new guidelines on pneumonia set out a prescribing strategy aiming to optimise the use of antibiotics and reduce resistance to them

Picture shows a frontal X-ray of the chest of a young girl with bacterial pneumonia (grainy white areas) in the lungs. Two new guidelines on pneumonia set out prescribing strategy that aims to optimise the use of antibiotics and reduce resistance to them.
Picture: Science Photo Library

Essential information

Hospital-acquired pneumonia is pneumonia that has developed 48 hours or more after hospital admission and was not incubating at the time of admission. It is caused by microorganisms acquired in hospital, most commonly Streptococcus pneumoniae.

Community-acquired pneumonia is contracted outside of hospital and is usually caused by bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa. In the UK about 220,000 people are diagnosed with pneumonia each year, according to the British Lung Foundation. Both types of pneumonia can be life-threatening.

What’s new?

The National Institute for Health and Care Excellence (NICE) and Public Health England (PHE) has published antimicrobial prescribing guidance on community-acquired and hospital-acquired pneumonia in adults, children and babies aged 72 hours and over.

These two guidelines set out an antimicrobial prescribing strategy that aims to optimise antibiotic use and reduce antibiotic resistance.

They state that antibiotic treatment should be started as soon as possible, no more than four hours after diagnosis, and within one hour if sepsis is suspected.

The guidance stresses the importance of healthcare staff using clinical judgement in assessing the severity of symptoms in children in the community and in hospital.

It sets out the recommended antibiotics to use for each patient. Further recommendations include a limited role for levofloxacin, which follows a warning by the Medicines and Healthcare products Regulatory Agency (MHRA) to restrict the use of fluoroquinolone antibiotics.

Signs and symptoms

British Thoracic Society guidelines state that bacterial pneumonia should be considered in children when there is persistent or repetitive fever greater than 38.5°C together with chest recession and a raised respiratory rate.

Other symptoms of pneumonia include a cough, difficulty breathing, feeling generally unwell, sweating and shivering, and loss of appetite.

Picture shows a young girl having her temperature taken. Two new guidelines on pneumonia set out prescribing strategy that aims to optimise the use of antibiotics and reduce resistance to them.
Picture: Alamy

Causes and risk factors

Pneumonia is a form of acute respiratory infection that affects the lungs. When someone has pneumonia the small sacs in the lungs called alveoli, which usually fill with air, instead fill with pus and fluid. This makes breathing painful and limits oxygen intake, according to the World Health Organization.

Babies and very young children and children whose immune systems are compromised or have pre-existing illnesses, such as symptomatic human immunodeficiency virus (HIV) infections and measles, are at higher risk.

Environmental factors including indoor air pollution and parental smoking increase risk.

What prescribing advice does the guidance give?

For community-acquired pneumonia

When choosing an antibiotic take account of:

  • The severity of signs and symptoms in children and young people.
  • The risk of complications, for example a relevant co-morbidity, such as severe lung disease or immunosuppression.
  • Local antimicrobial resistance and surveillance data, such as influenza and Mycoplasma pneumoniae infection rates.
  • Recent antibiotic use.
  • Previous microbiological results, including colonisation with multi-drug resistant bacteria.

For hospital-acquired pneumonia

Consider following the NICE guideline on community-acquired pneumonia for choice of antibiotic if symptoms start within 3-5 days of admission and the patient is not at higher risk of resistance.

When choosing an antibiotic take account of:

  • The severity of symptoms and signs, which should be based on clinical judgement.
  • Number of days in hospital before onset of symptoms.
  • The risk of developing complications, for example if the person has a relevant co-morbidity, such as severe lung disease or immunosuppression.
  • Local hospital and ward-based antimicrobial resistance data.
  • Recent antibiotic use.
  • Recent microbiological results, including colonisation with multi-drug resistant bacteria.
  • Recent contact with health or social care setting before current admission.
  • The risk of adverse effects with broad spectrum antibiotics, including Clostridium difficile infection.
  • Give oral antibiotics as first-line therapy if possible.

What are the concerns about antimicrobial resistance?

Between 2013 and 2017, drug-resistant infections increased by 35% in England, PHE data shows.

Earlier this year, NICE reviewed evidence that people are on average being prescribed unnecessarily long courses of antibiotics that could lead to antibiotic resistance.

NICE has published a suite of antimicrobial guidelines which aim to advise and ensure that antibiotics remain an effective treatment for future generations. The guidance stresses that, where possible, what is prescribed should be the shortest antibiotic course that is effective.

Expert comment

Picture of Wendy Preston, RCN head of nursing practice comments on new guidelines on pneumonia that set out an antimicrobial prescribing strategy aimed at optimising the use of antibiotics and reducing resistance to them.RCN head of nursing practice Wendy Preston

‘If antibiotics are used inappropriately their impact on bacteria is affected due to resistance. This means that when people need treatment for infections their effect will be reduced or they will be ineffective.

‘Pneumonia can be difficult to diagnose, particularly in the community, and antibiotics can often be prescribed just in case. However, antibiotics don’t work on the viruses that cause many respiratory infections, such as upper respiratory tract infection.

‘This guidance can support nurses to advise patients on strategies that can reduce antimicrobial resistance, such as completing antibiotic courses when prescribed.

‘When prescribing, local antibiotics guidance should be used as it is part of the plan to reduce resistance. Adhering to the appropriate length of course is also essential, for example five days instead of seven.’


Erin Dean is a freelance health writer


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