Recommendations
Key Recommendations
During periods of high COVID-19 prevalence, consider all patients with cough, fever, or other suggestive symptoms to have COVID-19 until proven otherwise. For management of patients with suspected or confirmed COVID-19 pneumonia, see Coronavirus disease 2019 (COVID-19).
Pneumonia due to COVID-19 is not covered in this topic.
Appropriate antibiotics should be initiated as soon as possible to treat the infection and prevent development of complications such as empyema and lung abscess formation. The airways should be well suctioned for those with endotracheal tubes or tracheostomy. It is also important to correct any underlying problems that precipitated the aspiration. For example, if a patient aspirated due to intolerance for nasogastric tube feeding, then tube feedings should be discontinued. If dysphagia is a concern, the patient should be kept nil per os (NPO) and a swallowing assessment should be organized.[12][43]
Nonpharmacologic measures include oxygen, management of hypotension, and therapy for acute respiratory distress syndrome and septic shock if they ensue.
There are no established criteria to determine hospital admission or level of care, and the decision needs to be based on clinical presentation. Intravenous antibiotics are usually administered to a hospitalized patient. An intensive care unit (ICU) admission is justified by patient intubation, hypotension, or altered mental status. Pneumonia severity scores, which are used to triage patients for hospital or ICU admission, do not work as well or at all for patients with aspiration pneumonia.[4][10]
Antibiotic therapy
With the exception of anaerobic pleuropulmonary syndrome (a later presentation of cavitary pneumonia or empyema associated with prior loss of consciousness and poor dental hygiene), empiric treatment for aspiration pneumonia does not require coverage for anaerobic organisms.[7] Similarly, no additional anaerobic antimicrobial coverage is warranted for patients with dysphagia or aspiration associated with stroke.[44]
Empiric therapy for aspiration pneumonia is the same as that for non-aspiration pneumonia (community-acquired, hospital-acquired, or ventilator-associated). There are no recent data on the importance of needing to cover anaerobes during presumptive therapy of aspiration pneumonia.[45] Despite the paucity of data, and the recommendation by international societies against administration of empiric anaerobic coverage, many clinicians continue to administer antibiotics with anaerobic coverage.[10]
Patients who aspirate with an endotracheal tube or who have been hospitalized for more than 48 hours may be colonized with nosocomial organisms and require coverage for pathogens common in hospital-acquired or ventilator-associated pneumonia, such as gram-negative rods and Staphylococcus aureus.
In the presence of infection, antibiotics should be continued for at least 5 days in a patient who responds promptly and longer if highly resistant pathogens such as Pseudomonas aeruginosa are isolated, or if the patient fails to improve. Once culture results are known, antibiotic treatment is tailored to sensitivity results.
Risk of a resistant organism is proportional to the number of prior infections and previous exposure to antibiotics. Patients who live in an environment where many different types of antibiotics may have been used (e.g., nursing homes) are also at higher risk for resistant organisms.[10]
There are insufficient numbers of prospective randomized studies for aspiration pneumonia in the healthcare setting. To a large extent, the therapy of aspiration pneumonia has to be individualized depending on host factors, risk factors for multidrug-resistant pathogens, institutional antibiotic formularies, and severity of encountered pneumonia.
See Community-acquired pneumonia in adults (non COVID-19) and Hospital-acquired pneumonia (non COVID-19) for more detailed treatment information.
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