Are steroids recommended for treatment of aspiration pneumonia?

Steroids are NOT Recommended for Treatment of Aspiration Pneumonia

Steroids are not recommended in the treatment of aspiration pneumonia. 1

Evidence Against Steroid Use in Aspiration Pneumonia

• The American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA) guidelines strongly recommend against routinely using corticosteroids in adults with nonsevere community-acquired pneumonia (CAP) (strong recommendation, high quality of evidence) 1
• The ATS/IDSA also suggests not routinely using corticosteroids in adults with severe CAP (conditional recommendation, moderate quality of evidence) 1
• European guidelines explicitly state that "steroids are not recommended in the treatment of pneumonia" 1
• Despite one promising controlled trial, two meta-analyses show that steroids cannot be recommended in the treatment of patients with CAP 1
• Animal studies have found no benefit of steroids in foodstuff-induced aspiration pneumonia, with no significant differences in mortality, blood gases, hemodynamics, or histological findings 2

Recommended Treatment Approach for Aspiration Pneumonia

First-Line Antibiotic Options

• Beta-lactam/beta-lactamase inhibitors (amoxicillin/clavulanate, ampicillin/sulbactam) are recommended as first-line treatment 3, 4
• Clindamycin is an alternative option, particularly for patients with penicillin allergies 3, 4
• Moxifloxacin can be used as monotherapy in appropriate patients 3, 4

Treatment Based on Clinical Setting

• For outpatient or hospital ward patients admitted from home:
  • Oral or IV beta-lactam/beta-lactamase inhibitor OR
  • Clindamycin 3
• For ICU patients or those admitted from nursing homes:
  • Clindamycin plus cephalosporin OR
  • Cephalosporin plus metronidazole 3

Duration of Treatment

• Treatment should generally not exceed 8 days in patients who respond adequately 3
• In uncomplicated cases, 7-10 days of antibiotics is typically sufficient 4
• For complications like necrotizing pneumonia or lung abscess, prolonged therapy (14-21 days or longer) may be necessary 4

Monitoring Treatment Response

• Response should be monitored using simple clinical criteria, including:
  • Body temperature
  • Respiratory parameters
  • Hemodynamic status 1, 3
• C-reactive protein should be measured on days 1 and 3-4, especially in patients with unfavorable clinical parameters 3

Additional Recommended Therapies

• Early mobilization is recommended for all patients 1, 3
• Low molecular weight heparin should be given to patients with acute respiratory failure 1, 3
• Non-invasive ventilation can be considered, particularly in patients with COPD and ARDS 1, 3

Common Pitfalls and Caveats

• Avoid unnecessary anaerobic coverage - the ATS/IDSA recommends against routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected 3
• While one small Japanese study from 1995 suggested benefit from low-dose methylprednisolone in aspiration pneumonia 5, this finding has not been supported by larger, more recent studies or incorporated into clinical guidelines
• Anaerobes are no longer considered the predominant microbes isolated in aspiration pneumonia; modern microbiology shows mixed cultures including aerobes 6
• Aspiration pneumonia patients experience greater morbidity and mortality than those with community-acquired pneumonia, highlighting the importance of appropriate antibiotic selection 6

In conclusion, current evidence and guidelines do not support the use of steroids in the treatment of aspiration pneumonia. The mainstay of treatment remains appropriate antibiotic therapy targeting the likely pathogens, along with supportive care measures.