From the Guidelines
For this elderly female with a recent MCA stroke, residual left-sided weakness, dysphagia, and a single episode of vomiting, the most appropriate option is to observe her closely and manage her dysphagia, rather than immediately starting antibiotic therapy. The patient lacks clear signs of infection requiring immediate antibiotic therapy, as she is afebrile with a borderline normal WBC count of 10,000, and the CXR doesn't show consolidation that would suggest pneumonia 1. Given her history of dysphagia after stroke, the vomiting episode is more likely related to swallowing difficulties rather than an infection. Patients with dysphagia post-stroke often experience issues with oral intake that can lead to vomiting. Some key considerations for her management include:
- Ensuring proper positioning during meals to reduce the risk of aspiration
- Considering speech therapy evaluation for dysphagia management, as early dysphagia screening is recommended for acute stroke patients to identify dysphagia or aspiration, which can lead to pneumonia, malnutrition, dehydration, and other complications 1
- Maintaining hydration, as dehydration is a potential cause of DVT after stroke and can slow recovery 1
- Monitoring for any developing signs of aspiration pneumonia such as fever, increased respiratory rate, or declining oxygen saturation If her condition worsens with clear signs of infection, then antibiotic therapy could be reconsidered. It's also important to note that enteral feedings (tube feedings) should be initiated within 7 days after stroke for patients who cannot safely swallow, and nasogastric tube feeding should be used for short term (2–3 weeks) nutritional support for patients who cannot swallow safely 1.
From the Research
Patient Presentation
The patient is an elderly female with a past medical history (PMHx) of recent middle cerebral artery (MCA) stroke, residual left-sided weakness, and dysphagia, who presents with an episode of vomiting, afebrile, and a white blood cell count (WBC) of 10,000.
- The patient's symptoms and history suggest a possible diagnosis of aspiration pneumonia, which is a common complication in patients with dysphagia 2.
- The patient's chest X-ray (CXR) showed no consolidation, but this does not rule out the possibility of aspiration pneumonia, as the disease can present with non-specific radiographic findings 3.
Management of Aspiration Pneumonia
The management of aspiration pneumonia typically involves the use of antibiotics, as the disease is caused by the inhalation of material into the lungs, which can lead to infection 4.
- The choice of antibiotic should be guided by the severity of the disease, the presence of underlying conditions, and the likelihood of resistant organisms 3, 5.
- Broad-spectrum antibiotics, such as vancomycin and cephalosporins, are commonly used to treat aspiration pneumonia, but the use of these agents can lead to the emergence of multiresistant organisms 6.
- The use of antibiotics has been shown to be associated with lower in-hospital mortality in patients with aspiration pneumonia, particularly in those requiring mechanical ventilation 5.
Considerations for this Patient
Given the patient's history of dysphagia and recent stroke, she is at high risk for aspiration pneumonia 2.
- The patient's symptoms of vomiting and elevated WBC count suggest the possibility of an infectious process, which may require antibiotic treatment 4, 3.
- The choice of antibiotic should be guided by the patient's underlying conditions, including her history of stroke and dysphagia, as well as the likelihood of resistant organisms 3, 5.
- The patient's care should be managed by a multidisciplinary team, including nurses, physicians, and other healthcare professionals, to ensure the best possible outcomes 2.