Supportive care and airway protection
›Non antibiotic measures
›Oxygen therapy
›Nasal cannula titration to SpO2 target
›HFNC for moderate to severe hypoxemia
›Airway clearance
›Suctioning of secretions
›Chest physiotherapy consideration
›Aspiration prevention
›Head of bed elevation
›NPO until swallow safety clarified
›If particulate aspiration with obstruction concern, bronchoscopy
›Large volume food aspiration
›Persistent lobar collapse
›When to use antibiotics
›Aspiration pneumonia
›Fever and leukocytosis with infiltrate
›Symptoms developing over 24 to 72 hours
›Aspiration pneumonitis
›Supportive care first
›Antibiotics if no improvement within 48 hours or infection features
›ACEP Level C recommendation
›Anaerobic coverage indications
›Lung abscess
›Cavitation on imaging
›Putrid sputum
›Empyema
›Loculated pleural fluid
›Pleural drainage requirement
›Severe periodontal disease with aspiration
›Foul breath and poor dentition
›Necrotizing infection concern
›Standard inpatient coverage
›Ampicillin sulbactam IV
›3 g IV every 6 hours
›Renal adjustment when impaired
›Ceftriaxone IV plus metronidazole
›Ceftriaxone 2 g IV daily
›Metronidazole 500 mg IV every 8 hours
›Piperacillin tazobactam IV for severe illness or pseudomonas risk
›4.5 g IV every 6 hours
›Extended infusion per local protocol
›MRSA coverage when risk factors present
›Vancomycin IV
›15 to 20 mg/kg IV every 8 to 12 hours
›Trough or AUC guided monitoring per protocol
›Linezolid IV or PO
›600 mg every 12 hours
›Platelet monitoring with prolonged use
›If severe beta lactam allergy
›Levofloxacin IV plus metronidazole
›Levofloxacin 750 mg IV daily
›Metronidazole 500 mg IV every 8 hours
›Moxifloxacin IV or PO
›400 mg daily
›QT prolongation risk review
›Oral options when stable
›Amoxicillin clavulanate PO
›875 mg PO every 12 hours
›Alternative 500 mg PO every 8 hours
›Clindamycin PO when anaerobic coverage needed and beta lactam allergy
›300 to 450 mg PO every 6 to 8 hours
›High C difficile risk counseling
›Levofloxacin PO plus metronidazole when needed
›Levofloxacin 750 mg PO daily
›Metronidazole 500 mg PO every 8 hours
Duration and reassessment
›Duration targets
›Uncomplicated aspiration pneumonia
›5 to 7 days if clinical response
›Afebrile and improving oxygenation
›Lung abscess or necrotizing infection
›3 to 6 weeks common range
›Imaging guided response assessment
›Response checkpoints
›48 to 72 hour clinical improvement expectation
›Falling fever curve
›Reduced oxygen requirement
›If deterioration or no improvement, broaden evaluation
›CT chest for abscess or empyema
›Alternative diagnosis reassessment
Adjuncts and complication management
›Bronchospasm
›Inhaled bronchodilator
›Salbutamol 2.5 mg nebulized PRN
›MDI with spacer alternative
›Steroids only for comorbid asthma or COPD indication
›Avoid routine steroids for pneumonia
›ACEP Level C recommendation
›Pleural effusion and empyema
›Diagnostic thoracentesis when moderate to large effusion
›pH and glucose and LDH analysis
›Gram stain and culture
›Chest tube drainage when empyema
›Loculation management plan
›Surgical consult consideration