From the Guidelines
For aspiration pneumonia, I recommend empiric antibiotic coverage with a regimen that targets both anaerobic and aerobic organisms, specifically using a combination of clindamycin and a cephalosporin, or alternatively, using moxifloxacin, as these regimens have been shown to be effective in recent guidelines 1. The choice of antibiotic regimen should be guided by the severity of illness, patient risk factors, and local resistance patterns.
- For patients admitted from home, oral or intravenous beta-lactam/beta-lactamase inhibitors, such as ampicillin-sulbactam, or clindamycin can be used 1.
- For patients admitted from a nursing home or requiring ICU care, a combination of clindamycin and a cephalosporin, or moxifloxacin can be considered 1.
- The treatment duration should typically be 5-7 days, but may extend to 14 days for complicated cases or immunocompromised patients.
- It is essential to assess clinical response after 48-72 hours to determine if the regimen is effective and adjust as needed. Aspiration pneumonia often involves mixed flora from the oropharynx, including anaerobes, gram-negative bacilli, and streptococci, and the chosen antibiotic regimen should reflect this. Additionally, addressing underlying conditions that led to aspiration, such as dysphagia, and considering preventive measures like elevation of the head of bed and proper oral care can help prevent recurrence 1.
From the Research
Coverage for Aspiration Pneumonia
The coverage for aspiration pneumonia varies based on the site of acquisition, risk for multidrug-resistant (MDR) organisms, and severity of illness 2.
- For community-acquired aspiration pneumonia (CAAP) without severe illness and no risk for MDR organisms or Pseudomonas aeruginosa (PA), standard inpatient community-acquired pneumonia therapy covering anaerobes is recommended 2.
- For CAAP with risk factors for MDR pathogens, septic shock, need for intensive care unit (ICU) admission, or mechanical ventilation, broader coverage against anaerobes, methicillin-resistant Staphylococcus aureus (MRSA), and PA is considered 2.
- For severe aspiration pneumonia originating in a long-term care facility or healthcare-associated aspiration pneumonia (HCAAP) with one or more risk factors for MDR organisms, similar treatment is recommended 2.
- For HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation, double coverage for PA in addition to coverage for MRSA and anaerobes is recommended 2.
Antibiotic Treatment
The most common empirical treatment of aspiration pneumonia is the administration of broad-spectrum antibiotics 3.
- Tazobactam/piperacillin (TAZ/PIPC) is as effective and safe as imipenem/cilastatin (IPM/CS) in the treatment of moderate-to-severe aspiration pneumonia 4.
- In patients with gram-positive bacterial infection, TAZ/PIPC was more effective at the end of treatment 4.
- The therapeutic choices should be expanded to cover multi-drug resistant Gram-negative bacteria in selected cases of aspiration pneumonia 3.
Transition to Oral Antibiotics
For patients with healthcare-associated pneumonia, transitioning from broad-spectrum intravenous antibiotics to narrow-spectrum oral antibiotics may be safe once clinical stability is achieved, even without a microbiological diagnosis 5.
- There were no statistically significant differences in 30-day readmission or 30-day all-cause mortality between narrow and broad oral antibiotic groups 5.