By Dean L. Winslow, MD, FACP, FIDSA
Professor of Medicine, Division of General Medical Disciplines, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine
Dr. Winslow reports no financial relationships relevant to this field of study.
SYNOPSIS: Researchers compared outcomes in patients with aspiration pneumonitis who received prophylactic antibiotics during the first two days after macro-aspiration to patients who received only supportive care during this time. Among the 200 patients meeting the acute aspiration pneumonitis case definition, antimicrobial prophylaxis was not associated with improvement in mortality. However, patients receiving prophylactic antibiotics required more frequent escalation of antibiotics and received more days of antibiotics than those who were managed initially with supportive care alone.
SOURCE: Dragan V, Wei L, Elligsen M, et al. Prophylactic antimicrobial therapy for acute aspiration pneumonitis. Clin Infect Dis 2018;67:513-518.
The authors of this paper report on a retrospective cohort study conducted in Toronto of a large number of patients. The authors evaluated outcomes for patients with aspiration pneumonitis who received prophylactic antibiotics compared to those who received supportive care only in the first two days after the observed aspiration event. The primary outcome was in-hospital 30-day mortality. The secondary outcomes were transfer to critical care, antimicrobial therapy received between day 3-14 after aspiration, escalation of antibiotic therapy, and antibiotic-free days.
Of the 1,483 patient charts reviewed by investigators, 200 met the acute aspiration pneumonitis case definition. Thirty-eight percent received prophylactic antimicrobials and 62% received just supportive care in the first two days after the macroaspiration event. After investigators adjusted for patient-level predictors, they found that antimicrobial prophylaxis was not shown to improve 30-day mortality or prevent transfer to the intensive care unit (ICU). However, patients who received early prophylactic antimicrobials subsequently underwent antibiotic therapy escalation more frequently (8% vs. 1%; P = 0.002) and had fewer days free of antibiotics (7.5 vs. 10.9; P < 0.0001).
During the last five years since I have been working full time at our university hospital and our excellent VA (where I receive my own medical care), I have been attending more on the inpatient medicine service than I have on the infectious disease consult service, and have had the opportunity of seeing day-to-day clinical decision-making in a university hospital up close. Probably at least once each week, I’ll overhear a resident sign out something to the effect: “Patient X vomited and aspirated last night, was a bit wheezy, so I covered him/her with vancomycin and piperacillin-tazobactam.” I often challenge the residents by asking where they learned that “covering” patients after aspiration with broad-spectrum antibiotics is a good idea. The answer I often receive is, “This is standard of care.” Additionally, a few days later, I’ll hear them say, “Patient X has been on vancomycin and piperacillin-tazobactam for empiric coverage for aspiration for four days and his WBC went from 6,000 to 10,000 last night, so we empirically broadened coverage to meropenem.” Again, I’ll often challenge that decision, too. Now, I have a good article to forward to the house staff that I hope will reassure them that it is OK to withhold empiric antibiotics after aspiration.