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High-severity community-acquired pneumonia — MRCEM SBA MCQ

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EasyInfection and sepsisHigh-severity community-acquired pneumoniaMRCEM SBA

A 72-year-old man presents to the emergency department with three days of fever, productive cough and repeated vomiting. Chest X-ray shows new right lower-lobe consolidation. He is alert, with a respiratory rate of 32/min, blood pressure of 118/72 mmHg and oxygen saturation of 96% on 2 L/min oxygen via nasal cannula, having been 91% on air. His blood urea is 8.4 mmol/L. He cannot retain oral medicines. He has no antibiotic allergy, and there is no history suggesting resistant organisms. Which initial antibiotic and place-of-care plan is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Intravenous co-amoxiclav plus intravenous clarithromycin; inpatient care.

This is confirmed community-acquired pneumonia. His CURB65 score is 3: one point each for age at least 65 years, respiratory rate at least 30/min and urea above 7 mmol/L. Together with his oxygen requirement, this supports high-severity disease and inpatient care. NICE recommends co-amoxiclav with clarithromycin as first-line treatment for high-severity community-acquired pneumonia. Repeated vomiting makes intravenous treatment the appropriate initial route; antibiotics should be started promptly. A uses a low-severity regimen and a route he cannot retain. B provides co-amoxiclav but omits the recommended clarithromycin. C selects appropriate antibiotics, but his current response to low-flow oxygen and maintained blood pressure do not establish a need for critical care admission; escalation should be reconsidered if he deteriorates. D selects the recommended drugs and inpatient setting, but not a usable route in this patient. His oxygenation and clinical course require reassessment after treatment begins. For high-severity pneumonia in hospital, NICE also advises considering a corticosteroid alongside antibiotics.

Reference: NICE NG250: Pneumonia: diagnosis and management — recommendations (2 September 2025) — https://www.nice.org.uk/guidance/NG250/chapter/recommendations NICE NG250: Pneumonia: diagnosis and management — table 1 and antibiotic recommendations (2 September 2025) — https://www.nice.org.uk/guidance/NG250/chapter/recommendations NICE NG250: Pneumonia: diagnosis and management — corticosteroid treatment in hospital (2 September 2025) — https://www.nice.org.uk/guidance/NG250/chapter/recommendations