Community-acquired pneumonia at the IMT (Internal Medicine Training) clinical station is answered by scoring it and then acting to a clock. NICE NG250, which replaced NG138 on 2 September 2025, recommends CURB65 in hospital, a chest X-ray within 4 hours of presentation, and antibiotics within 4 hours of presentation.

Key takeaways

  • NICE NG138 has been updated and replaced by NICE NG250, 'Pneumonia in adults: diagnosis and management', published on 2 September 2025, and NG250 is the guideline to cite.
  • CURB65 gives one point each for confusion, urea over 7 mmol per litre, respiratory rate of 30 breaths per minute or more, blood pressure with a diastolic of 60 mmHg or less or a systolic below 90 mmHg, and age 65 or more.
  • NICE NG250 groups CURB65 as 0 or 1 low risk with less than 3% mortality, 2 intermediate at 3% to 15%, and 3 to 5 high risk at more than 15%.
  • Place of care follows the score: inpatient care at 3 or more with critical care referral if appropriate, a virtual ward, same-day emergency care unit, hospital at home or inpatient care at 2, and discharge home with primary care follow-up at 0 or 1.
  • NICE NG250 sets two four-hour targets: processes to allow diagnosis including chest X-ray within 4 hours of presentation, and antibiotic treatment started within 4 hours of presentation.
  • For adults, stop antibiotics after 5 days unless microbiology suggests longer or the person is not clinically stable, and consider a corticosteroid for 4 to 7 days in high-severity pneumonia in hospital.

How do you recognise community-acquired pneumonia in the scenario?

Community-acquired pneumonia presents as fever, cough, sputum, pleuritic chest pain and breathlessness with focal chest signs, and in older patients as confusion or a fall with none of the classic features.

The station usually pairs it with a NEWS2 score, so say early that you would assess for sepsis alongside pneumonia rather than treating the two as alternatives.

NICE NG250 says the antibiotic choice for community-acquired pneumonia takes account of disease severity, the risk of complications, local resistance and surveillance data, recent antibiotic use and recent microbiological results.

What does the A to E assessment and the first hour look like?

The first hour of community-acquired pneumonia is an A to E assessment, oxygen titrated to target, fluids, cultures where indicated, and the CURB65 score calculated so the antibiotic and the place of care can both be decided.

  • Airway and breathing: respiratory rate, saturations, controlled oxygen, and a chest X-ray requested within the 4-hour window NICE NG250 sets
  • Circulation: blood pressure, perfusion, intravenous access, fluids, and a urea as part of the score rather than as an afterthought
  • Disability: conscious level and a check for new confusion, which is a scoring item and not a soft sign
  • Antibiotics: started as soon as possible after the diagnosis is made, and within 4 hours of presentation to hospital
  • Sepsis: if sepsis is suspected, NICE NG250 says to follow the antibiotic recommendations in the NICE sepsis guidelines rather than the pneumonia table

However, the score is not the whole decision. NICE NG250 asks you to use clinical judgement together with CURB65, bearing in mind that comorbidities or pregnancy can affect it.

Which investigations does community-acquired pneumonia need?

The investigation that confirms community-acquired pneumonia is the chest X-ray, and NICE NG250 asks for processes that allow diagnosis, including chest X-ray, within 4 hours of presentation to hospital.

  • Lung ultrasound is recognised for rapid point-of-care diagnosis in a sick or deteriorating person, where an alternative diagnosis such as heart failure is possible, and for investigating pleural complications
  • Consider a baseline C-reactive protein on admission for adults with community-acquired pneumonia
  • Do not routinely offer microbiological tests to adults with low-severity community-acquired pneumonia
  • For moderate or high severity, consider blood cultures where there are clinical indications such as suspected sepsis, sputum cultures, pneumococcal urinary antigen to support de-escalation, and legionella urinary antigen if there are risk factors
  • If there is clinical concern about treatment failure, consider measuring C-reactive protein or procalcitonin 3 or 4 days after starting treatment

What is CURB-65, and what does each band change?

CURB65 is the hospital severity score in community-acquired pneumonia, and NICE NG250 prints one point for each of five prognostic features.

  • Confusion, defined as an abbreviated Mental Test score of 8 or less, or new disorientation in person, place or time
  • Raised blood urea nitrogen, over 7 mmol per litre
  • Raised respiratory rate, 30 breaths per minute or more
  • Low blood pressure, diastolic 60 mmHg or less, or systolic less than 90 mmHg
  • Age 65 years or more

The bands are the part candidates leave out. A score of 0 or 1 is low risk with a mortality of less than 3%, a score of 2 is intermediate at 3% to 15%, and 3 to 5 is high risk at more than 15%.

Place of care follows. NICE NG250 says to consider inpatient care at 3 or more, with referral to critical care if appropriate; a virtual ward, same-day emergency care unit, hospital at home service or inpatient care at 2; and discharge home with referral to primary care and safety netting at 0 or 1.

In primary care the score is CRB65, which drops the urea. NICE NG250 says to consider referral to hospital at a CRB65 of 2 or more, and primary care-led services with safety netting at 0.

What is the definitive management of community-acquired pneumonia?

Definitive management of community-acquired pneumonia is a severity-matched antibiotic for 5 days, oxygen and fluids, a corticosteroid in the high-severity group, and an early review of the intravenous route.

  • Low severity: amoxicillin 500 mg three times a day for 5 days, with doxycycline 200 mg on day one then 100 mg once a day, or clarithromycin 500 mg twice a day, as alternatives
  • Moderate severity: amoxicillin 500 mg three times a day for 5 days, with clarithromycin 500 mg twice a day added if atypical pathogens are suspected
  • High severity: co-amoxiclav 500/125 mg three times a day orally or 1.2 g three times a day intravenously for 5 days, with clarithromycin 500 mg twice a day, and levofloxacin 500 mg twice a day as the penicillin-allergy alternative
  • Give oral antibiotics first line if the person can take them and the severity does not require the intravenous route, and review intravenous antibiotics by 48 hours with a view to switching
  • For high-severity community-acquired pneumonia in hospital, NICE NG250 says to consider a corticosteroid in addition to antibiotics for 4 to 7 days or until discharge if sooner, starting with intravenous hydrocortisone where suitable

The stopping rule is worth saying precisely. NICE NG250 says to stop antibiotics after 5 days in adults unless microbiology suggests a longer course, or the person is not clinically stable.

It defines instability as a fever in the past 48 hours, or more than one of a systolic blood pressure below 90 mmHg, a heart rate above 100, a respiratory rate above 24, or saturations below 90% on room air.

When and to whom do you escalate community-acquired pneumonia?

Escalate community-acquired pneumonia to critical care when the CURB65 score is 3 or more and the patient is not responding, because NICE NG250 pairs inpatient care at that score with referral to critical care services if appropriate.

For respiratory failure where standard oxygen is not meeting the target, NICE NG250 says to consider a trial of high-flow nasal oxygen, based on multidisciplinary consensus, clinical trajectory and what the person can tolerate.

It also asks that the location for non-invasive respiratory support takes account of the risk of failure, any advance directive or treatment escalation plan, and the clinical trajectory, which is the ceilings conversation in guideline language.

How do you hand over community-acquired pneumonia in one minute?

The community-acquired pneumonia handover uses SBAR with the CURB65 score and the observations in the first sentence, because the score is the receiving team's triage.

Situation: an 81 year old with three days of cough and fever, confused, urea 9.4, respiratory rate 32, blood pressure 88 over 54. Background: independent at home, no previous admissions this year.

Assessment: high-severity community-acquired pneumonia, CURB65 of 5, right basal consolidation on chest X-ray taken within the hour. Recommendation: co-amoxiclav and clarithromycin given within 4 hours of arrival, blood cultures sent, please review for critical care and for a corticosteroid.

What does the panel listen for in a pneumonia answer?

The panel listens for the five CURB65 items with their actual thresholds, the score bands linked to a place of care, the two four-hour targets, and the 5-day stopping rule.

In practice they also mark whether you know the guideline changed, because most revision material still cites NG138. The internalmedicineinterview bank of 361 questions across 56 scenarios, with AI-marked spoken practice, drills the current numbers against the clock.

What are the common mistakes in a pneumonia station?

  • Quoting CURB65 without the thresholds, so urea over 7 and a respiratory rate of 30 or more never get said
  • Using CURB65 in primary care, where the score is CRB65 and the urea is not available
  • Treating the score as the decision rather than using clinical judgement alongside it
  • Defaulting to a 7-day course when NICE NG250 says to stop at 5 days unless the person is unstable or microbiology says otherwise
  • Missing the corticosteroid recommendation for high-severity pneumonia in hospital, which is new in NG250
  • Ordering a routine follow-up chest X-ray, when NG250 says not to offer one routinely and to consider it at 6 weeks only in defined groups

How this comes up at the IMT interview

Community-acquired pneumonia maps onto all three parts of the IMT clinical station. Investigations and diagnosis is the chest X-ray, the urea and the CURB65 score; management is severity-matched antibiotics within 4 hours, oxygen, fluids and the steroid decision; and communication is explaining the recovery timeline, which NICE NG250 sets out week by week.

The handover minute is where the score, the observations and the antibiotic already given get said in order, followed by a request for critical care review with a time attached.