Community-acquired Aspiration Pneumonia Research Articles

Anaerobic Antibiotic Coverage in Aspiration Pneumonia and the Associated Benefits and Harms: A Retrospective Cohort Study

BackgroundAntibiotics with extended anaerobic coverage are commonly used to treat aspiration pneumonia, which is not recommended by current guidelines. Research questionIn patients admitted to hospital for community-acquired aspiration pneumonia, is there a difference between antibiotic therapy with limited anaerobic coverage (LAC) versus antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis? MethodsWe conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada from January 1, 2015 to January 1, 2022. Patients were included if the physician diagnosed the patient with aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy within 48 hours of admission. Patients were then categorized into LAC group if they received ceftriaxone, cefotaxime or levofloxacin. Patients were in the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause mortality in hospital. Secondary outcomes included incident C. difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors. ResultsThere were 2,683 and 1,316 patients in the LAC and EAC group respectively. In hospital, 814 (30.3%) and 422 (32.1%) patients in the LAC and EAC group died respectively. C. difficile colitis occurred in 5 or less (≤0.2%) and 11 to 15 (0.8% to 1.1%) patients in the LAC and EAC group respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI 0.3% to 1.7%) for C. difficile colitis. InterpretationExtended anaerobic coverage is likely unnecessary in aspiration pneumonia because it is associated with no additional mortality benefit, only an increased risk of C. difficile colitis.

Aspirasyon Pnömonisi ile Yoğun Bakım Ünitesine Yatan Geriatrik Hastalarda Erken Mortalite Belirteçleri

Aim In the geriatric group, aspiration pneumonia is one of the most common causes of Intensive Care Unit admission. Multiple comorbidities related with systemic diseases, as well as dementia, fraility and difficulty in swallowing or protecting the airway may all contribute the development of the AP in the geriatric age. Furthermore, many other variables may influence the outcome of this patient group. In this study, it is aimed to determine the parameters that may have an effect on the intensive care mortality. Materials and Methods 221 patients aged ≥ 80 years who were admitted to the third level ICU with the diagnosis of aspiration pneumonia were retrospectively analyzed. They were divided into two groups according to the 28-day outcome (survived-nonsurvived). The admission levels of arterial blood Ph and pCO2 and lactate , blood urea, creatinine, potassium (K) and sodium (Na) levels, APACHE II, Glaskow Coma Scale (GCS), modified shock index (MSI) and the aspiration pneumonia's source ( community-acquired aspiration pneumonia (CA-AP) or healthcare-associated aspiration pneumonia (HCA-AP) )were recorded.The effects of these variables on 28-day mortality were analyzed. Results The presence of HCA-AP, GCS and APACHEII scores were found to be significantly correlated between the two groups. ROC analysis were done for those variables and cutoff points werecalculated. Logistic regression analysis indicated that APACHEII (>22.5,AUC:0.812,P=0.00) and GCS (<9, AUC:0.730, P=0.00) as the most prominentin dependent predictors of mortality (p<0,05, odds ratio 7.68, 3.23 respectively) with the presence of HCA-AP. Conclusion Although many variables are significant in predicting the first 28 days of mortality in ICU admission of geriatric patients with aspiration pneumonia, the presence of HCA-AP, high hospitalization APACHE II score and low GCS score were significant independent variables.

1300. Comparison of Narrow vs. Broad Spectrum Antibiotics for Treatment of Community-acquired Aspiration Pneumonia

Abstract Background Aspiration pneumonia (aspPNA) accounts for 5-15% of pneumonia admissions. Despite the absence of risk factors for organisms such as methicillin-resistant S. aureus (MRSA) or Pseudomonas aeruginosa (PsA), broad-spectrum (BS) antibiotics active against these pathogens are frequently prescribed. We compared outcomes of patients receiving narrow-spectrum (NS) versus BS antibiotics for aspPNA. Methods This is a retrospective cohort study of hospitalized patients started on antibiotics for aspPNA upon admission from 1/1/2019 to 12/31/2019. The BS cohort included patients prescribed antibiotics with activity against PsA or MRSA and were on BS antibiotics for > 50% duration of therapy regardless of de-escalation. The primary endpoint was clinical response, defined as resolved, improved, no change, or worsened. Secondary endpoints included 30-day all-cause mortality, duration of therapy, 30-day C. difficile infection, and length of stay. Outcomes were assessed using logistic regression with antibiotic group as a fixed effect, and all analyses were conducted using R v. 4.0.3. Results A total of N=95 patients were included in the study, 35 in the NS and 60 in the BS groups. Clinical response was similar in distribution between groups (p > 0.3). 30-day all-cause mortality was lower in the NS (11.4%) as compared to the BS group (33.3%) (OR 0.26; 95% CI 0.09- 0.81; p < 0.04). There were no differences for the secondary endpoints including median duration of therapy (4 [IQR 2.5] days vs. 6 [IQR 6] days, p> 0.2), 30-day C. difficile infection (0% vs 6.7%, p > 0.3), and median length of stay (6 [IQR 5] days vs. 7 [IQR 8.5] days, p > 0.2) in NS vs. BS groups, respectively. A positive blood or respiratory culture was isolated in 37% (35/95) patients. Enteric organisms were the most prevalent bacteria isolated (20%), followed by methicillin susceptible S. aureus (8%), and Streptococcus spp (7%). MRSA and PsA were detected in 2% and 3% of patients, respectively. Conclusion There is no difference in efficacy between NS and BS antibiotics for aspPNA. Microbiologic data confirm the low incidence of PsA or MRSA causing aspPNA despite high empiric prescribing of antibiotics active against these pathogens. These results support the ongoing need for targeted antibiotic stewardship initiatives for aspPNA. Disclosures All Authors: No reported disclosures

Prognostic factors in patients hospitalized with community-acquired aspiration pneumonia

IntroductionPatients with aspiration pneumonia (AP) exhibit higher mortality than those with non-AP. However, data regarding predictors of short-term prognosis in patients with community-acquired AP are limited. MethodsPatients hospitalized with community-acquired pneumonia (CAP) were retrospectively classified into aspiration pneumonia (AP) and non-AP groups. The AP patients were further divided into nonsurvivors and survivors by 30-day mortality, and various clinical variables were compared between the groups. ResultsOf 1249 CAP patients, 254 (20.3%) were classified into the AP group, of whom 76 patients (29.9%) died within 30 days. CURB-65, pneumonia severity index (PSI), and Infectious Diseases Society of America/American Thoracic Society criteria for severe CAP (SCAP) showed only modest prognostic performance for the prediction of 30-day mortality (c-statistics, 0.635, 0.647, and 0.681, respectively). Along with the PSI and SCAP, Eastern Cooperative Oncology Group performance status (ECOG-PS) and blood biomarkers, including, N-terminal of prohormone brain natriuretic peptide (NT-proBNP) and albumin, were independent predictors of 30-day mortality. In models based on clinical prediction rules, including CURB-65, PSI, and SCAP, the addition of ECOG-PS further improved their c-statistics compared to the clinical prediction rules alone. In the four combinations based on SCAP, ECOG-PS, and two blood biomarkers (NT-proBNP and albumin), the c-statistics further increased to reach approximately 0.8. ConclusionsCURB-65, PSI, and SCAP exhibited only modest discriminatory power in predicting the 30-day mortality of patients with community-acquired AP. The addition of performance status and blood biomarkers, including NT-proBNP and albumin, further increased prognostic performance, showing good predictive accuracy in the SCAP-based model.

Aspiration Pneumonia in Older Adults.

Aspiration pneumonia refers to an infection of the lung parenchyma in an individual that has inhaled a bolus of endogenous flora that overwhelms the natural defenses of the respiratory system. While there are not universally agreed upon criteria, the diagnosis can be made in patients with the appropriate risk factors and clinical scenario, in addition to a radiographic or an ultrasonographic image of pneumonia in the typical dependent lung segment. Treatment options for aspiration pneumonia vary based on the site of acquisition (community-acquired aspiration pneumonia [CAAP] versus healthcare-associated aspiration pneumonia [HCAAP]), the risk for multidrug-resistant (MDR) organisms, and severity of illness. Hospitalized CAAP patients without severe illness and with no risk for MDR organisms or Pseudomonas aeruginosa (PA) can be treated with standard inpatient community-acquired pneumonia therapy covering anaerobes. Patients with CAAP and either of the following-risk factors for MDR pathogens, septic shock, need for an intensive care unit (ICU) admission, or mechanical ventilation-can be considered for broader coverage against anaerobes, methicillin-resistant Staphylococcus aureus (MRSA), and PA. Severe aspiration pneumonia that originates in a long-term care facility or HCAAP with one or more risk factors for MDR organisms should be considered for similar treatment. HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation should receive double coverage for PA in addition to coverage for MRSA and anaerobes. Multiple gaps in current understanding and management of aspiration pneumonia require future research, with a particular focus on antibiotic stewardship.

P86 Do We Need A Specific Guideline For The Management Of Aspiration Pneumonia (ap)?

Introduction and objectives Aspiration-related pneumonia accounts for 10–15% of cases hospitalised with community acquired pneumonia. Guideline-directed pathways for the diagnosis and management of AP are lacking in detail (BTS/ATS/IDSA). The local practice of assessing patients admitted with primary diagnosis of AP and outcome was evaluated in a large tertiary hospital in the UK. Methods A retrospective cohort study that reviewed the case notes of 34 consecutive patients admitted to hospital with a high likelihood for a diagnosis of community acquired aspiration pneumonia (CAAP). Aspiration risk assessment on admission, appropriate antimicrobial therapy, dietetic and Speech and Language Therapy (SALT) team input, airway assessment, length of hospital stay and mortality were included in the data analysis. Results A crude risk assessment for aspiration was performed in all patients on admission. An aspiration event was witnessed in 35% of cases. Pre-existing neurological pathology was the predominant risk factor (70%). Appropriate antimicrobial therapy was commenced within 4 h of admission in 14 (58%) cases. Airway assessment by a SALT team was performed in 4 patients within 48 h of admission. None of the patients underwent video fluoroscopy. An initial dietetic review within 72 h of admission was observed in 6 patients (18%). Median hospital stay was 8 days and in hospital mortality was 41%. Conclusion The study demonstrates a significant inconsistency in the initial management of patients hospitalised with AP. The lack of early intervention by SALT and dietetic services and routine video fluoroscopy use in the majority of patients is of concern. A specific guideline with an evidence based diagnostic pathwayand managementis needed for patients at high risk for AP.

Microbiology and prognostic factors of hospital- and community-acquired aspiration pneumonia in respiratory intensive care unit

Incidence of aspiration pneumonia in hospital-acquired pneumonia and community-acquired pneumonia is high; however, many features of this disease remain imprecise. Our objective was to characterize the microbial etiology and their antibiotic resistance and to determine the prognostic factors in aspiration pneumonia among patients admitted to a respiratory intensive care unit (RICU). A prospective survey was conducted in 112 patients exhibiting hospital-or community-acquired aspiration pneumonia in the RICU of a provincial general hospital from 2010-2012. Bronchoalveolar lavage sampling was collected, and then followed by standard culture and drug-sensitive test. Risk factors were analyzed by multivariate logistic analysis. One hundred twenty-eight strains were isolated in 94 patients, gram-negative bacilli (57.8%) was the predominant cultured microorganism, followed by fungus (28.9%) and gram-positive cocci (13.3%). The 5 main isolated bacteria demonstrated high and multiantibiotic resistance. The crude overall mortality was 43.8%, 50%, and 40%, respectively, in hospital- and community-acquired aspiration pneumonia group. Multivariate logistic analysis identified age older than 65 years, use of inotropic support, and ineffective initial therapy as independent risk factors of poor outcome. The predominant pathogenic bacteria of aspiration pneumonia in patients admitted to an RICU were antibiotic-resistant bacteria, and effective initial supportive management secured better prognosis.

Mortality, morbidity, and disease severity of patients with aspiration pneumonia

Aspiration pneumonia is a common syndrome, although less well characterized than other pneumonia syndromes. We describe a large population of patients with aspiration pneumonia. In this retrospective population study, we queried the electronic medical records at a tertiary-care, university-affiliated hospital from 1996 to 2006. Patients were initially identified by International Classification of Diseases, 9th Revision code 507.x; subsequent physician chart review excluded patients with aspiration pneumonitis and those without a confirmatory radiograph. Patients with community-acquired aspiration pneumonia were compared to a contemporaneous population of community-acquired pneumonia (CAP) patients. We compared CURB-65 (a clinical prediction rule based on Confusion, Uremia, Respiratory rate, Blood Pressure, and age)-predicted mortality with actual 30-day mortality. We identified 628 patients with aspiration pneumonia, of which 510 were community-acquired. Median age was 77 years, with 30-day mortality of 21%. Compared to CAP patients, patients with community-acquired aspiration pneumonia had more frequent inpatient admission (99% vs 58%) and intensive care unit admission (38% vs 14%), higher Charlson comorbidity index (3 vs 1), and higher prevalence of do not resuscitate/intubate orders (24% vs 11%). CURB-65 predicted mortality poorly in aspiration pneumonia patients (area under the curve, 0.66). Patients with community-acquired aspiration pneumonia are older, have more comorbidities, and demonstrate higher mortality than CAP patients, even after adjustment for age and comorbidities. CURB-65 poorly predicts mortality in this population.

A Comparison Between Time to Clinical Stability in Community-Acquired Aspiration Pneumonia and Community-Acquired Pneumonia

SESSION TYPE: Pneumonia Morbidity and Mortality

A comparison between time to clinical stability in community-acquired aspiration pneumonia and community-acquired pneumonia

Antimicrobial therapy has been the main stay of therapy of community-acquired aspiration pneumonia (CAAP), but the duration of treatment has not been established. The objective of this study was to describe the time to reach clinical stability in patients with aspiration pneumonia compared to community-acquired pneumonia (CAP). A retrospective case control study at two university affiliated centers encompassing 329 consecutive patients admitted with CAAP and 329 consecutive patients with CAP was conducted between 2007 and 2011. While the median time to stability for patients with CAP was distributed around a median of 4 days, there was a bimodal distribution for time to clinical stability in patients with CAAP with dual peaks at days 2 and 5, respectively. CAAP patients who required more than 2 days to achieve clinical stability had a higher mortality rate compared to those with 2 days or less [odds ratio (OR) 5.95, 95% CI 2.85-12.4], and a longer hospital stay (6.6 ± 5.8 vs. 3.9 ± 1.2 days; p < 0.001). None of the CAAP patients who achieved clinical stability in 2 days or less was transferred to a higher level of care. In a multivariate analysis, time to clinical stability was found to be an independent predictor of outcome in patients with CAAP (OR 2.59, 95% CI 2.02-3.32). Normalization of vital signs in aspiration pneumonia follows a distinct pattern from that of patients with CAP. Time to achieve clinical stability may assist in identifying CAAP patients who are likely to require a shorter hospital stay and a shorter course of antimicrobial therapy.

Tazobactam/piperacillin for moderate-to-severe pneumonia in patients with risk for aspiration: Comparison with imipenem/cilastatin

Background Treatment of aspiration pneumonia is becoming an important issue due to aging of populations worldwide. Effectiveness of tazobactam/piperacillin (TAZ/PIPC) in aspiration pneumonia is not clear. Purpose To compare clinical efficacy between TAZ/PIPC (1:4 compound) and imipenem/cilastatin (IPM/CS) in patients with moderate-to-severe aspiration pneumonia. Patients and methods In this open-label, randomized study either TAZ/PIPC 5 g or IPM/CS 1 g was intravenously administered every 12 h to patients with moderate-to-severe community-acquired aspiration pneumonia or nursing home-acquired pneumonia with risk for aspiration pneumonia for average 11 days. The primary outcome was clinical response rate at the end of treatment (EOT) in validated per-protocol (VPP) population. Secondary outcomes were clinical response during treatment (days 4 and 7) and at the end of study (EOS) in VPP population, and survival at day 30 in modified intention-to-treat (MITT) population. Results There was no difference between the groups in primary or secondary outcome. However, significantly faster improvement as measured by axillary temperature ( p < 0.05) and WBC count ( p = 0.01) was observed under TAZ/PIPC treatment. In patients with gram-positive bacterial infection, TAZ/PIPC was more effective at EOT in VPP population ( p = 0.03). Conclusion TAZ/PIPC is as effective and safe as IPM/CS in the treatment of moderate- to-severe aspiration pneumonia.

Studies of Respiratory Tract Infection in Nursing Home Residents: What Are We Learning?

Studies of Respiratory Tract Infection in Nursing Home Residents: What Are We Learning?

Differences in the Features of Aspiration Pneumonia According to Site of Acquisition: Community or Continuing Care Facility

To determine the prevalence of aspiration pneumonia and to compare the features and risk factors for this entity in patients from continuing care facilities (CCFs) and the community who were admitted to the hospital with pneumonia. Prospective population-based study. Six hospitals in Capital Health Region (Edmonton), Alberta, Canada. One thousand nine hundred forty-six adults admitted with pneumonia. Patients were stratified by their residence as community or CCF. Aspiration pneumonia prevalence; risk factors; and outcomes such as mortality, length of stay, and intensive care unit admission rates. Ten percent of those with community-acquired pneumonia (CAP) had aspirated, compared with 30% of those with CCF-acquired pneumonia. Those with community-acquired aspiration pneumonia (CAAP) and those with CCF-acquired aspiration pneumonia (CCF-AP) were younger, more likely to go to ICU, and more likely to require mechanical ventilation and had a longer length of stay and a higher mortality rate than nonaspirators. The risk factors for aspiration differed; for those with CAAP, impaired consciousness due to alcohol, drugs, or hepatic failure predominated, whereas 72% of those with CCF-AP had neurological disease that resulted in dysphagia. Eighty percent were treated with antibiotics effective against anaerobic bacteria. Aspiration pneumonia is common in patients with both CAP and CCF-acquired pneumonia. The risk factors differ, and there is a high mortality rate. Neurological disease dominates as the predisposing factor toward aspiration pneumonia in people in CCFs.

Microbiological Diagnostic and Antibiotic Management of Community Aquired and Nosocomial Pneumonias in Intensive Care Units in Germany

Pneumonien sind die häufigsten nosokomialen Infektionen bei kritisch kranken Patienten und ursächlich verantwortlich für bis zu 50 % des gesamten Antibiotikaverbrauchs auf Intensivstationen [1]. Adäquate mikrobiologische Diagnostik und Antibiotikatherapie verbessern das klinische Outcome von Patienten mit beatmungsassoziierter Pneumonie [2] [3] und vermindern die Wahrscheinlichkeit für eine Infektion mit multiresistenten Erregern [4].

SEVERE COMMUNITY-ACQUIRED PNEUMONIA

Community-acquired pneumonia (CAP) is likely to be severe in the very elderly, and clinically significant in those with hepatic/ renal insufficiency, cardiopulmonary disease, or, impaired host defenses. Pathogens in mild, moderately severe, and severe CAP are the same. These pathogens determine prognosis, complications, and duration of therapy. Empiric antimicrobial therapy should be based on likely pathogens, not severity of illness which affects the potency but not spectrum of antibiotic selected.

Community-acquired aspiration pneumonia in intensive care units. Epidemiological and prognosis data.

Over a 9-yr period, among 505 patients exhibiting severe community-acquired pneumonia and admitted into a total of six medical ICUs in the north of France, we collected 116 patients (23%) meeting the usual criteria for aspiration pneumonia. Main medical grounds of ICU admission were respiratory distress in 54 patients and neurological disturbances in 62 patients. The main underlying risk factor for aspiration pneumonia was drug overdose (39%). Mechanical ventilation was required for 73 patients. Initial shock was present in 15 patients. Pulmonary involvement was bilateral in 27 patients. There were 94 aerobic organisms isolated from 70 patients (60%), the most frequent being gram-negative bacilli (n = 38), Staphyloccus spp. (n = 27) and Streptococcus pneumoniae (n = 22). Overall mortality was 22%, but only 11 (11%) deaths were directly or indirectly related to aspiration pneumonia. Stepwise multivariate analysis identified four independent predictors of mortality: ineffective initial antimicrobial therapy (p = 0.0001), positive initial blood culture (p = 0.0001), hospital-acquired lower respiratory tract superinfections (p = 0.0054), and use of inotropic support (p = 0.0078). The importance of prevention of hospital-acquired superinfections and permanent optimization of our antimicrobial strategies warranting efficacy of the initial antimicrobial therapy is underlined.

Antibiotic policies in Dutch hospitals for the treatment of pneumonia.

The guidelines used in Dutch hospitals for the treatment of pneumonia as described in antibiotic formularies are described. A total of 42 formularies were examined. Amoxycillin was the most frequently used agent in the treatment of community-acquired pneumonia and a wide variety of drugs was used for the treatment of nosocomial pneumonia, of which cefuroxime, alone or in combination with an aminoglycoside, was used most often. Benzylpenicillin was the most frequently used drug in community-acquired aspiration pneumonia; this drug, in combination with an aminoglycoside, was also the drug of choice in hospital-acquired aspiration pneumonia. Treatment of pneumonias with known or presumed pathogens was also surveyed and the most usual drugs of choice were benzylpenicillin for pneumococci, flucloxacillin for staphylococci, amoxycillin for Haemophilus influenzae, cefuroxime for Enterobacteriaceae (cefuroxime), cotrimoxazole for Pneumocystis carinii, doxycycline and erythromycin for Mycoplasma pneumoniae and erythromycin for Legionella pneumophila. Relatively wide variations in dosage guidelines were observed for benzylpenicillin and amoxycillin. Only a few formularies gave guidelines for the duration of treatment.

Campylobacter fetus Associated with Pulmonary Abscess and Empyema

An unusual case of community-acquired necrotizing aspiration pneumonia with pulmonary abscess and empyema associated with Campylobacter fetus (formerly Vibrio fetus) in mixed culture is reported. This microaerophilic gram-negative curved bacillus has been increasingly associated with human disease. Unlike most pathogens associated with community-acquired aspiration pneumonia, this organism is usually resistant to penicillin. Infection associated with this organism is characteristically relapsing in nature and requires protracted antimicrobial therapy.

Bacteriology of aspiration pneumonia. A prospective study of community- and hospital-acquired cases.

We prospectively studied 24 cases of community-acquired aspiration pneumonia and 23 cases of hospital-acquired aspiration pneumonia, with special attention to their microbiology. Specimens were obtained by transtracheal aspiration or thoracentesis and were processed with appropriate anaerobic and standard bacteriologic methods. Quantitative cultures were done, and numbers of 106/ml or greater were considered significant. Anaerobic bacteria were isolated from 21 of 24 community-acquired infections and, in 13 cases, were the only isolates. In the hospital-acquired infections anaerobes were found in 8 of 23 cases and were the only isolates in 2 cases. Gram-negative facultative anaerobes and aerobes were common in the hospital-acquired infections. Community- and hospital-acquired aspiration pneumonias are bacteriologically different. The causative organisms reflect the oropharyngeal flora, and the anaerobic bacteria seem to be important pathogens in both community- and hospital-acquired cases.