eMedicine Specialties > Pulmonology > Aspiration and Atelectasis
Pneumonia, Aspiration: Treatment & Medication
Updated: Aug 7, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Chemical pneumonia: Treatment should include maintenance of airways and clearance of secretions with tracheal suctioning, oxygen supplementation, mechanical ventilation if the patient is unable to maintain adequate oxygenation, early use of positive end-expiratory pressure (PEEP), and administration of intravenous fluids. Routine use of corticosteroids is not indicated. Early prophylactic use of antibiotics is controversial because no evidence indicates that bacterial infection plays a role in the initial events. Bacterial pneumonia (BP) that may occur later (eg, days after the aspiration event) as a complication of chemical pneumonia (CP) should be treated with appropriate antibiotics.
- Bacterial pneumonia: Antibiotics are the mainstay of treatment. The choice of antibiotics and duration of treatment depend on the suspected or proven causative organisms. Most commonly in community-acquired BP, the causative organisms are indigenous oral flora. These are predominantly anaerobes (eg, Bacteroides species, Fusobacterium species, Peptostreptococcus species) and streptococci. In nosocomial BP (ie, aspiration in the hospital), in addition to the usual oral flora pathogens such as Staphylococcus aureus, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas species may be involved.
Surgical Care
No role for surgical care exists, except in cases with complications.
Consultations
- Pulmonologist - For bronchoscopy when obstruction is suspected in patients with CP or in ruling out a neoplasm in BP cases
- Intensivist (critical care) - For severe CP if hypoxemia is severe and ventilatory support is anticipated
- Thoracic surgeon - For anaerobic BP with complications, eg, closed tube drainage of an empyema, open tube drainage, and decortication
Diet
In patients with stroke or other risk factors for aspiration, a comprehensive swallowing evaluation is recommended. A speech and language therapist can perform this bedside evaluation and, if abnormalities are found, can teach the patient compensatory strategies with soft or pureed foods.
Medication
Antibiotics are usually not necessary unless an infection develops.
Chemical pneumonia
Antibiotics are not routinely indicated for patients with CP. If pneumonia occurs days after the aspiration event, antibiotics are indicated. As noted earlier, various organisms are causative. Therefore, choosing antibiotics based on organisms cultured from sputum, tracheal aspirates, or aspirate obtained through a protected catheter by bronchoscopy rather than empirically is more appropriate. The choice of antibiotics is also dictated by the severity of the pneumonia, patient-related risk factors (eg, malnutrition, comorbid illnesses) and intervention-related factors (eg, prior use of antibiotics, corticosteroids, cytotoxic agents, endotracheal tube), and the duration of hospitalization.
As examples, dual treatment involving a carefully chosen second-generation cephalosporin or nonpseudomonal third-generation cephalosporin and clindamycin, aztreonam, or fluoroquinolones is appropriate in many cases. However, in severe pneumonia occurring many days after initiation of mechanical ventilation, the probability of resistant organisms, including Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant S aureus is increased, and, therefore, antibiotic treatment should be broader and aggressive; the choices include ciprofloxacin, quinolones, aminoglycoside with antipseudomonal penicillin, ceftazidime, imipenem, and vancomycin.
Bacterial pneumonia
In BP, clindamycin is the antibiotic of choice. Alternatives to clindamycin include amoxicillin with clavulanate (Augmentin) and metronidazole (Flagyl). Metronidazole used alone is not recommended because of a high failure rate. Similarly, macrolides, cephalosporins, and fluoroquinolones are additional alternatives that are not recommended as first-line agents because they are not well studied.
Antibiotics
Antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Clindamycin (Cleocin)
Available in parenteral form (ie, clindamycin phosphate) and oral form (ie, clindamycin hydrochloride). Oral clindamycin is absorbed rapidly and almost completely and is not appreciably altered by the presence of food in the stomach. Appropriate serum levels are reached and sustained for at least 6 h following an oral dose. No significant levels are attained in the cerebrospinal fluid. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
600 mg IV q8h; continue treatment with 300 mg PO q6h; doses as high as 4800 mg qd have been used in life-threatening severe infections
Pediatric
8-20 mg/kg/d PO as hydrochloride and 8-25 mg/kg/d as palmitate divided tid/qid
20-40 mg/kg/d IV/IM equally divided tid/qid
Use the higher dose for more severe infections
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin
Documented hypersensitivity; regional enteritis, ulcerative colitis, pseudomembranous colitis; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment is necessary in renal insufficiency; associated with severe and possibly fatal colitis; if diarrhea develops during the course of treatment, clindamycin should be stopped
Amoxicillin/clavulanate potassium (Augmentin)
Combines a semisynthetic antibiotic (ie, amoxicillin) and a beta-lactamase inhibitor (ie, clavulanate potassium) and provides for an extended spectrum of coverage to include bacteria resistant to amoxicillin and other beta-lactam antibiotics. It is well absorbed from the gastrointestinal tract and can be administered without regard to the time of a meal. The half-life of oral Augmentin is 1-1.3 h. Augmentin has good tissue penetration but does not enter the cerebrospinal fluid. Drug combination treats bacteria resistant to beta-lactam antibiotics.
Adult
500 mg q12h PO or 875 mg PO q12h in severe infections
Pediatric
<3 months: Not established
>3 months: Base dosing protocol on amoxicillin content
<40 kilograms: 20-40 mg/kg/d PO divided bid; do not use 250-mg tab until child weighs >40 kg
>40 kilograms: Administer as in adults
Probenecid decreases renal tubular secretion and may result in prolonged and high level of amoxicillin; concurrent use of allopurinol substantially increases incidence of skin rashes; coadministration with warfarin or heparin increases risk of bleeding
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause antibiotic-associated diarrhea and because this is associated with pseudomembranous colitis, stop administration of the drug if diarrhea occurs; hepatic dysfunction manifested by rise in liver enzymes may occur; increased incidence of erythematous skin rash in patients with infectious mononucleosis who are administered ampicillin
More on Pneumonia, Aspiration |
| Overview: Pneumonia, Aspiration |
| Differential Diagnoses & Workup: Pneumonia, Aspiration |
 Treatment & Medication: Pneumonia, Aspiration |
| Follow-up: Pneumonia, Aspiration |
| Multimedia: Pneumonia, Aspiration |
| References |
| Further Reading |
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References
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[Guideline] Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. Oct 2008;29 Suppl 1:S31-40. [Medline].
[Guideline] Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. Mar 26 2004;53:1-36. [Medline].
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van Westerloo DJ, Knapp S, van't Veer C, Buurman WA, de Vos AF, Florquin S. Aspiration pneumonitis primes the host for an exaggerated inflammatory response during pneumonia. Crit Care Med. Aug 2005;33(8):1770-8. [Medline].
Varkey B, Kutty K. Pulmonary aspiration syndromes. In: Kochar's Concise Textbook of Medicine. Baltimore, Md:. Lippincott Williams & Wilkins;1998:902-906.
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Further Reading
Clinical guidelines
Coffin SE, Klompas M, Classen D, Arias KM, Podgorny K, Anderson DJ, Burstin H, Calfee DP, Dubberke ER, Fraser V, Gerding DN, Griffin FA, Gross P, Kaye KS, Lo E, Marschall J, Mermel LA, Nicolle L, Pegues DA, Perl TM, Saint S, Salgado CD, Weinstein RA, Wise R, Yokoe DS. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol 2008 Oct;29 Suppl 1:S31-40. 2
Tablan OC, Anderson LJ, Besser R, Bridges C, Hajjeh R. Guidelines for preventing health-care--associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep 2004 Mar 26;53(RR-3):1-36. 3
Keywords
aspiration pneumonia, Mendelson syndrome, chemical pneumonitis, anaerobic bacterial pneumonia, chemical pneumonia, CP, aspiration of gastric acid, bacterial pneumonia, BP, aspiration of bacteria from oral and pharyngeal areas, exogenous lipoid pneumonia, aspiration of oil, aspiration of a foreign body, acute respiratory emergency, parenchymal inflammatory reaction, community-acquired pneumonia, CAP, nosocomial pneumonia, acute respiratory distress syndrome, ARDS
