Aspiration pneumonia

@AdamRodmanMD observed that Metronidazole was commonly given for aspiration PNA.

I suggested a poll and @gbosslet approved. Later, I decided to to add this simple thread

If you have a a concern for aspiration PNA, what’s your next step?

Currently, it is well know that all of us aspirate (Some more than others). These are called micro and macro aspirations. But what is behind the practice of treating aspiration pneumonia?

Snoring Old Man GIF

Aspiration pneumonia was originally reported in 1890’s, but it was in the 1920’s when Smith was able to find that synergism between multiple bacteria (including G-/anaerobes) was key for developing lung abscess in animals. @AdamRodmanMD any access to these original papers?

With progressive evolution of antibiotic therapy and microbiology methods more data was found about aspirations in humans. So what happened next? #LaboratoryMedicine

Dexter Lab GIF

It was seen that anaerobes were a common cause for oral infections( for example: gingivitis). In the 80’s it was proposed that patients with severe dental pathology are at higher risk for these infections in the setting of persistent aspiration episodes.

Now, remember that aspiration episode? It can still have transient symptoms that resolve over the course of 24 hrs. But what do the guidelines actually say?

Ohreally Sarcasm GIF

for that answer we can go to the 2019 guidelines for CAP from @atscommunity. Question 10: In the Inpatient Setting, Should Patients with Suspected Aspiration Pneumonia Receive Additional Anaerobic Coverage beyond Standard Empiric Treatment for CAP?

The recommendation reads: “we suggest not routinely adding anaerobic coverage for suspected aspiration pneumonia unless lung abscess or empyema is suspected.” (conditional recommendation with very low quality of evidence) but suggests that more research should be done.

So, next time you are concerned about aspiration

Not so fast. You should still cover for common CAP organisms. Remember that Metronidazole does not have activity for strep, and although it can be used, you would still need strep coverage. So: why give 2 meds when you can give 1?

So, next time someone is at risk remember your common oral bugs: peptostreptococcus, bacteroides and fusobacterium, but also your CAP bugs. Use clindamycin or ampicillin/sulbactam for simplified regimens and if needed, you can scalate to include quinolones and carbapenem

but before we close, since this is the season, will give a #TipForNewDoctors No data suggests that tubes (ng, og, peg, post pyloric, etc) reduce the risk of aspiration episodes.

I’ll ask some of the experts to weight in, or if they have any other comments @maddog1066 @gbosslet @ChrisCarrollMD (for peds) @laxswamy.

@AdamRodmanMD, I’ll get back to you with the data, but definitely would like to see what others report as practice in their centers 😃

If you want references and further discussion! Looking forward to hear everyone. #MedEd

Originally tweeted by Enrique Pacheco (@EPachecoMD) on 16 August, 2020.

Leave a Reply