eMedicine Specialties > Emergency Medicine > Pulmonary

Pneumonia, Aspiration: Treatment & Medication

Author: Anand Swaminathan, MD, Chief Resident Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Coauthor(s): Sassan Naderi, MD, Staff Physician, Department of Emergency Medicine, North Shore/Long Island Jewish Health System, Albert Einstein College of Medicine
Contributor Information and Disclosures

Updated: May 5, 2009

Treatment

Prehospital Care

Prehospital care should focus on stabilizing the patient's airway, breathing, and circulation.

  • In patients found with signs of gastric aspiration (ie, vomitus) suctioning of the upper airway may remove a significant amount of aspirate or potential aspirate.
  • Intubation should be considered in any patient who is unable to protect his or her airway. The ability of paramedics to provide this intervention depends on the level of training. In addition, EMTs trained in intubation may choose to intubate patients with poor gag reflex prior to aspiration.
  • Oxygen supplementation
  • Cardiac monitoring and pulse oximetry
  • Intravenous catheter placement and intravenous fluids as indicated

Emergency Department Care

Emergency department care should start with stabilizing the patient's airway, breathing, and circulation.

  • Oropharyngeal/tracheal suctioning may be indicated to further remove aspirate.
  • Reassess the need for intubation on a frequent basis depending on oxygenation, patient's mental status, signs of increased work of breathing, or impending respiratory failure.
  • Continue supplemental oxygenation as needed.
  • Continue cardiac monitoring and pulse oximetry.
  • Provide continued supportive care with intravenous fluids and electrolyte replacement.
  • Antibiotic therapy
    • Aspiration pneumonia: Antibiotics are always indicated.
    • Aspiration pneumonitis
      • Prophylactic antibiotics are not recommended in most cases.
      • In addition, those patients with recent aspiration, fever, and leukocytosis should not be treated even in the presence of a pulmonary infiltrate due to the risk of development of resistant organisms.
      • When to use antibiotics: (1) Pneumonitis fails to resolve within 48 hours. (2) Patients with small-bowel obstruction–lower; bacteria may colonize gastric contents. (3) Antibiotics should be considered for patients on antacids due to the potential for gastric colonization.
  • Antibiotic choice
    • Patients without a toxic appearance
      • Cover typical community-acquired pathogens.
      • Ceftriaxone plus azithromycin, levofloxacin, or moxifloxacin are appropriate options.
    • Patients with a toxic appearance or who were recently hospitalized  
      • Although community-acquired pathogens are still the most common, gram-negative bacteria including Pseudomonas aeruginosa and Klebsiella pneumoniae as well as methicillin-resistant Staphylococcus aureus must be covered as well.
      • Piperacillin/tazobactam or imipenem/cilastatin plus vancomycin would be appropriate.
      • Add clindamycin for purulent sputum.
  • Corticosteroids
    • Historically corticosteroids have been used in the treatment of aspiration pneumonitis, but randomized control studies have been unable to demonstrate a benefit to using high-dose corticosteroids.
    • Patients with septic shock that requires vasoactive substances to maintain blood pressure should receive stress-dose steroids.

Consultations

  • Pulmonary/critical care specialist in severe cases of respiratory failure requiring ventilatory support
  • Infectious disease specialist for advice about proper antibiotic therapy

Medication

The antibiotics of choice should be tailored to the setting in which the aspiration occurred (community vs nosocomial); however, antibiotic agents with activity against gram-negative organisms as well as gram-positive organisms is usually required.

Microbiological evidence indicates that empiric coverage of anaerobes is not indicated unless the patient presents with putrid sputum, severe oropharyngeal disease, or evidence of lung abscess or necrotizing pneumonia on chest radiograph or CT scan.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Azithromycin (Zithromax)

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.

Adult

500 mg IV q24h for 3 d, then 500 mg/d PO for 7-10 d

Pediatric

<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function or prolonged QT intervals
This medication should not be used alone in patients with aspiration pneumonia but in conjunction with a third-generation cephalosporin.


Moxifloxacin (Avelox)

Inhibits the A subunits of DNA gyrase, resulting in inhibition of bacterial DNA replication and transcription. Indicated for community-acquired pneumonia, including multi–drug-resistant S pneumoniae.

Adult

400 mg PO/IV qd

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, electrolyte supplements reduce absorption; loop diuretics, probenecid, cimetidine increase serum levels; NSAIDs enhance CNS stimulating effect
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT); ferrous sulfate decreases bioavailability (administer moxifloxacin 4 h prior or 8 h following ferrous sulfate); coadministration with drugs that prolong QTc interval (quinidine, procainamide, amiodarone, sotalol, erythromycin, tricyclic antidepressants) increase risk of life-threatening arrhythmia

Documented hypersensitivity; known QT prolongation, concurrent administration of drugs that cause QT prolongation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); superinfections may occur with prolonged or repeated antibiotic therapy; fluoroquinolones have induced seizures in CNS disorders and caused tendinitis or tendon rupture


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to one or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of bacterial cell wall. Bacteria eventually lyse due to the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases, both penicillinase and cephalosporinase, of gram-negative and gram-positive bacteria. Approximately 33-67% of dose excreted unchanged in urine, and remainder secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins, and binding has been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.

Adult

1-2 g IV qd or divided bid; not to exceed 4 g/d

Pediatric

<7 days: Not established
>7 days to 6 months: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
>6 months: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Documented hypersensitivity; hyperbilirubinemic neonates, particularly those who are premature

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Therapy should continue for a period of at least 10 d or until resolution of the clinical picture; adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breastfeeding women; may displace bilirubin from albumin-binding sites, increasing the risk of kernicterus; caution with gallbladder, biliary tract, liver, or pancreatic disease or in patients with history of colitis or penicillin hypersensitivity


Ampicillin and sulbactam (Unasyn)

Drug combination of beta-lactamase inhibitor with ampicillin. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms.

Adult

1.5 (1 g ampicillin + 0.5 g sulbactam) to 3 g (2 g ampicillin + 1 g sulbactam) IV/IM q6h; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Pediatric

<3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300 mg Unasyn) IV divided q6h
>12 years: Administer as in adults; not to exceed 4 g/d sulbactam or 8 g/d ampicillin

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Therapy should continue for a period of at least 10 d or until resolution of the clinical picture; adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction


Piperacillin and tazobactam sodium (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication.

Adult

3.375 g (piperacillin 3 g and tazobactam 0.375 g) IV q6h

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Tetracyclines may decrease effects of piperacillin; high concentrations of piperacillin may physically inactivate aminoglycosides if administered in same IV line; effects when administered concurrently with aminoglycosides are synergistic; probenecid may increase penicillin levels; high-dose parenteral penicillins may result in increased risk of bleeding

Documented hypersensitivity; severe pneumonia, bacteremia, pericarditis, emphysema, meningitis, and purulent or septic arthritis should not be treated with an oral penicillin during the acute stage

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Therapy should continue for a period of at least 10 d or until resolution of the clinical picture; perform CBCs prior to initiation of therapy and at least weekly during therapy; monitor for liver function abnormalities by measuring AST and ALT levels during therapy; exercise caution in patients with hepatic insufficiencies; perform urinalysis, and BUN and creatinine determinations during therapy and adjust dose if values become elevated; monitor blood levels to avoid possible neurotoxic reactions


Imipenem and cilastatin (Primaxin)

For treatment of multiple-organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

Adult

Base initial dose on severity of infection, and administer in equally divided doses; dose may range from 500 mg to 1 g IV for maximum of 3-4 g/d; alternatively, 500-750 mg q12h IM or intra-abdominally

Pediatric

<12 years: Not established; 15-25 mg/kg/dose IV q6h suggested for >3 mo
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to exceed 4 g/d

Coadministration with cyclosporine may increase CNS side effects of both agents; coadministration with ganciclovir may result in generalized seizures

Documented hypersensitivity; known hypersensitivity to amide local anesthetics; children with CNS infections (increased seizure risk); children <30 kg with renal impairment (lack of data)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Therapy should continue for a period of at least 10 d or until resolution of clinical symptoms observed; adjust dose in renal insufficiency (adult adjustments); avoid use in children <12 y with CNS infections; caution with history of seizures, hypersensitivity to penicillins, cephalosporins, or other beta-lactam antibiotics
CrCl (mL/min) 80-50: 0.5 g q6-8h
CrCl 50-10: 0.5 g q8-12h
Hemodialysis (HD): 0.25-0.5 g after HD, then q12h


Amoxicillin and clavulanate (Augmentin, Augmentin XR)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.
Good alternative antibiotic for patients allergic or intolerant to the macrolide class. Usually is well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. Half-life of oral dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.
For children >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable-tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Adult

875 mg PO q12h or 500 mg PO q8h

Pediatric

<3 months: 125 mg/5 mL PO susp based on amoxicillin; 30 mg/kg/d divided bid for 7-10 d
>3 months: if using 200 mg/5 mL or 400 mg/5 mL susp, 45 mg/kg/d PO q12h; if using 125 mg/5 mL or 250 mg/5 mL susp, 40 mg/kg/d PO q8h for 7-10 d
>40 kg: Administer as in adults

Coadministration with warfarin or heparin increases risk of bleeding; may act synergistically against selected microorganisms when coadministered with aminoglycosides; coadministration with allopurinol may increase incidence of amoxicillin rash; may decrease efficacy of oral contraceptives when administered concomitantly

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Therapy should continue for a period of at least 10 d or until resolution of clinical symptoms observed
Hepatic impairment may occur with prolonged treatment in the elderly; diarrhea may occur; adjust dose in renal impairment; cross allergy may occur with other beta-lactams and cephalosporins


Levofloxacin (Levaquin)

Used to treat community-acquired pneumonia caused by S aureus, S pneumoniae (including penicillin-resistant strains), H influenzae, H parainfluenzae, Klebsiella pneumoniae, M catarrhalis, Chlamydia pneumoniae, Legionella pneumophila, or M pneumoniae. Fluoroquinolones should be used empirically in patients likely to develop exacerbation due to resistant organisms to other antibiotics. Rapidly becoming a popular choice in pneumonia. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Agent acts by inhibition of DNA gyrase activity. PO form has bioavailability that reportedly is 99%.

Adult

750 mg IV qd

Pediatric

<18 years: Not recommended
>18 years: Administer as in adults

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; levofloxacin reduces therapeutic effects of phenytoin; probenecid may increase levofloxacin serum concentrations

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Therapy should continue for a period of at least 10 d or until resolution of clinical symptoms observed
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
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).

Adult

600 mg IV q6-8h; 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 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; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Therapy should continue for a period of at least 10 d or until resolution of clinical symptoms observed; for use when suspicious of anaerobic infection; use in conjunction with antibiotic that covers both gram-positive and gram-negative organisms
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile


Amikacin (Amikin)

Irreversibly binds to 30S subunit of bacterial ribosomes; blocks recognition step in protein synthesis; causes growth inhibition. For gram-negative bacterial coverage of infections resistant to gentamicin and tobramycin. Effective against P aeruginosa.
Use patient's IBW for dosage calculation. The same principles of drug monitoring for gentamicin apply to amikacin.

Adult

5 mg/kg IV q8h; use patient's IBW for dose calculation

Pediatric

Administer as in adults

Coadministration with other aminoglycosides, penicillins, cephalosporins, and amphotericin B increases nephrotoxicity; enhances effects of neuromuscular blocking agents; causes respiratory depression; irreversible hearing loss may occur with coadministration of loop diuretics

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Not intended for long-term therapy; caution in patients with renal failure (not on dialysis), hypocalcemia, myasthenia gravis, and conditions that depress neuromuscular transmission; adjust dose based on creatinine clearance; follow trough values to guide therapy and avoid toxicity


Vancomycin (Vancocin)

Potent antibiotic against gram-positive organisms and active against Enterococcus species. Useful in the treatment of septicemia and skin structure infections. Indicated for use in patients who cannot receive or who have infections that fail to respond to penicillins and cephalosporins or infections with resistant staphylococci. For abdominal penetrating injuries, it is combined with an agent active against enteric flora and/or anaerobes. Used with gentamicin for prophylaxis in patients who are allergic to penicillin and undergoing GI or genitourinary procedures.
To avoid toxicity, assay vancomycin trough levels after third dose drawn 0.5 h prior to next dose; use CrCl value to adjust dose in patients with renal impairment.

Adult

500 mg to 2 g/d IV divided tid/qid

Pediatric

40 mg/kg/d IV divided tid/qid

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Therapy should continue for a period of at least 10 days or until resolution of the clinical picture
Caution in renal failure, neutropenia; red man syndrome is caused by too rapid IV infusion (dose given over a few min) but rarely happens when dose given IV over 2 h administration or as PO or IP administration; red man syndrome is not an allergic reaction; adjust dose based on creatinine clearance; follow trough values to guide therapy and avoid toxicity

More on Pneumonia, Aspiration

Overview: Pneumonia, Aspiration
Differential Diagnoses & Workup: Pneumonia, Aspiration
Treatment & Medication: Pneumonia, Aspiration
Follow-up: Pneumonia, Aspiration
Multimedia: Pneumonia, Aspiration
References
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References

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  8. Mier L, Dreyfuss D, Darchy B. Is penicillin G an adequate initial treatment for aspiration pneumonia? A prospective evaluation using a protected specimen brush and quantitative cultures. Intensive Care Med. 1993;19(5):279-84. [Medline].

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Further Reading

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Contributor Information and Disclosures

Author

Anand Swaminathan, MD, Chief Resident Physician, Department of Emergency Medicine, New York University/Bellevue Hospital Center
Anand Swaminathan, MD is a member of the following medical societies: American Academy of Emergency Medicine, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Sassan Naderi, MD, Staff Physician, Department of Emergency Medicine, North Shore/Long Island Jewish Health System, Albert Einstein College of Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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