A lower respiratory tract infection on the ward becomes community-acquired pneumonia when there are focal chest signs or consolidation, and its severity is set by CURB-65: one point each for confusion, urea over 7 mmol/L, respiratory rate 30 or more, low blood pressure and age 65 or over. NICE's pneumonia guideline NG250, published in September 2025 and replacing NG138 and CG191, uses the score with clinical judgement to choose the place of care and the antibiotic, and asks for the first dose within 4 hours of presentation. For a CT1 anaesthetics candidate the station is about scoring, sepsis recognition and knowing which patient belongs in critical care.

Key takeaways

  • CURB-65 in hospital scores confusion (abbreviated Mental Test 8 or less, or new disorientation), urea over 7 mmol/L, respiratory rate 30 or more, diastolic blood pressure 60 or less or systolic under 90, and age 65 or over.
  • NICE NG250 stratifies mortality risk as 0 to 1 low (under 3 per cent), 2 intermediate (3 to 15 per cent) and 3 to 5 high (over 15 per cent), and says to use clinical judgement together with the score.
  • Place of care under NG250: inpatient care with referral to critical care if appropriate at 3 or more; virtual ward, same-day emergency care, hospital at home or inpatient care at 2; discharge with safety-netting at 0 or 1.
  • Antibiotics start as soon as possible after diagnosis and within 4 hours of presentation to hospital; diagnosis including the chest X-ray should be possible within 4 hours.
  • First-line antibiotics are amoxicillin 500 mg three times a day for 5 days in low severity, amoxicillin with clarithromycin if atypicals are suspected in moderate severity, and co-amoxiclav with clarithromycin in high severity.
  • NG250 now says to consider a corticosteroid, starting with intravenous hydrocortisone, for 4 to 7 days or until discharge in adults with high-severity pneumonia in hospital.

How do you recognise pneumonia on the ward?

You recognise pneumonia from cough, fever, breathlessness and new focal chest signs, confirmed by consolidation on a chest X-ray, and you distinguish it from a simple lower respiratory tract infection by those focal signs, a raised respiratory rate, low saturations or illness severity.

NG250 defines a clinical diagnosis of community-acquired pneumonia as symptoms and signs of lower respiratory tract infection in someone the clinician thinks likely to have pneumonia in the absence of a chest X-ray, for example because of focal chest signs, an increased respiratory rate, low oxygen saturations or illness severity.

The distinction that matters on the ward is community-acquired versus hospital-acquired. NG250 says symptoms starting within 48 hours of admission are treated as community-acquired; later than that the antibiotic choice changes and the resistance risk rises.

In practice, the presentation that reaches the anaesthetic CT1 is the septic patient: tachypnoeic, hypotensive, confused, with an oxygen requirement climbing over an afternoon. Pneumonia is the commonest source of sepsis you will be called to.

What is the A to E and first-hour management of pneumonia?

The first hour of pneumonia is oxygen to target, cultures and bloods including urea, a chest X-ray, a CURB-65 score, and antibiotics by severity, all inside the 4-hour window NG250 sets and much faster if the patient is septic.

Airway and breathing

  • Oxygen titrated to an SpO2 of 94 to 98 per cent, or 88 to 92 per cent if at risk of hypercapnic respiratory failure, per the BTS emergency oxygen guideline.
  • Respiratory rate counted for a full minute, because 30 or more is a CURB-65 point and a NEWS2 trigger.
  • A chest X-ray, which NG250 wants available so that diagnosis can be made within 4 hours of presentation.
  • A blood gas if saturations are low or the patient is tiring.

Circulation, disability and exposure

  • Blood pressure, because a diastolic of 60 or less or a systolic under 90 scores a point. Intravenous access and fluid resuscitation if shocked.
  • Bloods including urea, full blood count, CRP and lactate. NG250 says microbiological tests are not routine in low severity but should be considered in moderate and high severity.
  • An abbreviated Mental Test or a check for new disorientation, which is the confusion criterion.
  • Age, comorbidities and pregnancy, which NG250 says can affect how the score should be read.

What is the CURB-65 score, and how does NICE use it?

CURB-65 is a five-point hospital mortality score for community-acquired pneumonia: confusion, urea over 7 mmol/L, respiratory rate 30 or more, blood pressure with a diastolic of 60 or less or a systolic under 90, and age 65 or over, each scoring one point.

According to NICE NG250, a score of 0 or 1 is low risk with a mortality under 3 per cent, 2 is intermediate at 3 to 15 per cent, and 3 to 5 is high at over 15 per cent. In primary care the CRB-65 drops the urea.

NG250 is careful to separate mortality risk from disease severity. It says clinical judgement should always be used, because a patient with a low score but unusually low saturations, pleural complications or several comorbidities may still have moderate or high-severity disease.

The score then drives place of care. NG250 says to consider inpatient care with critical care referral where appropriate at 3 or more; a virtual ward, same-day emergency care unit, hospital at home or inpatient care at 2; and discharge with primary care follow-up and safety-netting at 0 or 1.

What is the definitive management of pneumonia?

Definitive management of pneumonia is the right antibiotic for the severity, oral where possible, reviewed at 48 hours if intravenous, for a 5-day course in adults, with a corticosteroid considered in high-severity disease and clear expectations set for recovery.

Antibiotics by severity

  • Low severity: amoxicillin 500 mg three times a day for 5 days. Alternatives for penicillin allergy or suspected atypicals are doxycycline 200 mg on day one then 100 mg daily for 4 days, or clarithromycin 500 mg twice a day for 5 days.
  • Moderate severity: amoxicillin 500 mg three times a day for 5 days, with clarithromycin 500 mg twice a day if atypical pathogens are suspected. Doxycycline or clarithromycin alone for penicillin allergy.
  • High severity: co-amoxiclav 500/125 mg three times a day orally or 1.2 g three times a day intravenously, with clarithromycin 500 mg twice a day, for 5 days. Levofloxacin 500 mg twice a day for penicillin allergy, with a microbiologist consulted if a fluoroquinolone is inappropriate.
  • Erythromycin replaces clarithromycin in pregnancy.

Route, review and steroids

NG250 says to give oral antibiotics first line if the person can take them and severity does not need the intravenous route, and to review intravenous antibiotics by 48 hours with a switch to oral where possible.

The 2025 addition is steroid. NG250 recommends considering a corticosteroid, in addition to antibiotics, for adults with high-severity community-acquired pneumonia in hospital, for 4 to 7 days or until discharge, starting with intravenous hydrocortisone, with the MHRA warning about combining steroids with fluoroquinolones noted.

When do you escalate pneumonia, and who do you call?

You escalate pneumonia at a CURB-65 of 3 or more, at a NEWS2 of 5 or more, or at any sign of septic shock or respiratory failure, and you call the medical registrar and critical care outreach together, because NG250 says to consider critical care referral at that score.

The Royal College of Physicians' NEWS2 chart sets the ward triggers: a total of 5 or more is the urgent-response threshold, needing urgent assessment by a clinician competent in acutely ill patients, and 7 or more is the emergency-response threshold, needing a team with critical care competencies including advanced airway skills and consideration of level 2 or 3 care.

As the anaesthetic CT1 you are that airway skill. The patient you are called to is hypoxic on high-flow oxygen, tiring, and acidotic. Say what you would assess: the work of breathing, the gas, the lactate, the trend, and whether the ceiling of care has been discussed.

However, escalation is also about the patient who scores low but looks wrong. NG250's own rationale says the score does not always match severity. A young patient with a CURB-65 of 1 and saturations of 88 per cent needs a registrar now.

What is the human-factors and reflective-practice angle in pneumonia?

The human-factors angle in pneumonia is the score used as a substitute for looking: a CURB-65 calculated from the notes, with the confusion box unticked because nobody asked the ten questions and the respiratory rate copied from the last set of observations.

A good answer says you count the rate yourself, ask the Mental Test questions yourself, and look at the urea rather than the CRP. The score is only as good as its five inputs.

Reflective practice at the station wants an example. Most candidates have a patient whose antibiotic was late, or whose score was low and who was on critical care by the morning. Describe what was missed, what you changed, and how you now hand over a pneumonia with its score and its trend.

Working under pressure is the 4-hour clock running against a queue of patients. Show how you would prioritise: the septic patient gets the antibiotic before the X-ray is reported, and the ward sister knows which patient you will return to first.

What are the common mistakes candidates make with pneumonia and CURB-65?

The commonest mistake with CURB-65 at interview is quoting the wrong thresholds: urea over 7, respiratory rate 30 or more, diastolic 60 or less or systolic under 90, age 65 or over. The second is treating the score as the whole assessment.

  • Citing NG138 or CG191. Both were replaced by NG250 on 2 September 2025.
  • Giving intravenous antibiotics to everyone. NG250 says oral first line if the patient can take them and the severity allows.
  • Missing the atypical cover. Clarithromycin is added in moderate severity when atypicals are suspected and is standard in high severity.
  • Forgetting the 48-hour intravenous review and the 5-day course.
  • Not knowing that high-severity pneumonia now has a steroid recommendation.
  • Discharging on the score alone. NG250 says clinical judgement, comorbidities and pregnancy all modify it.

How this comes up at the CT1 anaesthetics interview

Pneumonia comes up at the CT1 anaesthetics interview as a septic ward patient or a deteriorating admission in the clinical judgement station, which ANRO marks on clinical judgement and decision making, reflective practice and working under pressure.

Clinical judgement is the score, the severity and the antibiotic. Decision making is the moment the patient crosses from ward to critical care, and whether the ceiling has been agreed. Reflective practice is the late antibiotic you remember. Working under pressure is the 4-hour target against a full take.

Expect the panel to give a low score and bad saturations, then ask whether you would discharge. The anaestheticinterview bank builds its scenarios on that turn, and its AI-marked spoken practice scores whether you say the score is not the patient.