Correspondence

Aspiration Pneumonia

N Engl J Med 2001; 344:1868-1870June 14, 2001

Article

To the Editor:

We disagree with Marik (March 1 issue)1 about the bacteriology of aspiration pneumonia and his therapeutic recommendations. Marik contends that anaerobes are seldom involved in aspiration pneumonia, on the basis of both our results2 and his results.3 This may not be true for two reasons. In both studies, anaerobic conditions were not preserved during transport, which precludes optimal recovery of oxygen-sensitive anaerobes,4 and in our study the patients were routinely given penicillin G before sampling with a protected specimen brush was performed. Marik rightly points out that the range of potentially offending organisms is broad, and he proposes that levofloxacin should be administered as the first-line antibiotic in most instances and as a broad-spectrum regimen in all cases. This approach results in both undertreatment and overtreatment of aspiration pneumonia and is not cost effective. Levofloxacin has poor antianaerobic properties and is not a first-line antipneumococcal drug. We retrieved substantial concentrations of Streptococcus pneumoniae from several patients with community-acquired aspiration pneumonia.2

Marik also overlooks the therapeutic implications of the distinction between community-acquired and hospital-acquired episodes. The usual oropharyngeal flora is most likely involved in community-acquired cases, and treatment with penicillin G is probably sufficient.2 Hospital-acquired aspiration pneumonia often occurs in very sick patients with modified oral flora5 and abnormalities of the gastrointestinal tract that favor the proliferation of gram-negative rods.2 No empirical therapy is secure in such cases. It is wiser to base the treatment on the results of quantitative cultures of samples obtained with a protected specimen brush.2 Pending culture results, an extended-spectrum penicillin (with or without a β-lactamase inhibitor) is probably a more appropriate treatment than levofloxacin.

Didier Dreyfuss, M.D.
Laurence Mier, M.D.
Hôpital Louis Mourier, 92700 Colombes, France

5 References

1. 1

   Marik PE. Aspiration pneumonitis and aspiration pneumonia. N Engl J Med 2001;344:665-671
   Full Text | Web of Science | Medline

2. 2

   Mier L, Dreyfuss D, Darchy B, et al. 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;19:279-284
   CrossRef | Web of Science | Medline

3. 3

   Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999;115:178-183
   CrossRef | Web of Science | Medline

4. 4

   Dore P, Robert R, Grollier G, et al. Incidence of anaerobes in ventilator-associated pneumonia with use of a protected specimen brush. Am J Respir Crit Care Med 1996;153:1292-1298
   Web of Science | Medline

5. 5

   Johanson WG, Pierce AK, Sanford JP. Changing pharyngeal bacterial flora of hospitalized patients: emergence of gram-negative bacilli. N Engl J Med 1969;281:1137-1140
   Full Text | Web of Science | Medline

To the Editor:

Marik's review article on aspiration pneumonitis and pneumonia refers to the lack of data favoring gastrostomy over nasogastric-tube feeding to prevent aspiration pneumonia. We believe it is important to emphasize that for patients with neurogenic dysphagia, neither type of tube feeding has been shown to be superior to careful hand feeding.1 In fact, there are considerable data to the contrary.1,2

Marik states that an evaluation of swallowing that includes either videofluoroscopy or endoscopy “is required” to identify patients at risk for aspiration. Although he acknowledges that even healthy adults aspirate oropharyngeal secretions during sleep, it should also be noted that studies of swallowing are only weakly predictive of pneumonia and that feeding tubes do not lower the risk. In the study by Croghan and colleagues3 that Marik cites, the outcomes in nursing home patients who underwent an evaluation of swallowing were poor regardless of the results of the evaluation or subsequent intervention.

Thomas E. Finucane, M.D.
Colleen Christmas, M.D.
Johns Hopkins Geriatrics Center, Baltimore, MD 21224

3 References

1. 1

   Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-1370
   CrossRef | Web of Science | Medline

2. 2

   Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348:1421-1424[Erratum, Lancet 1997;349:364.]
   CrossRef | Web of Science | Medline

3. 3

   Croghan JE, Burke EM, Caplan S, Denman S. Pilot study of 12-month outcomes of nursing home patients with aspiration on videofluoroscopy. Dysphagia 1994;9:141-146
   CrossRef | Medline

To the Editor:

In his comprehensive survey of the aspiration syndromes, Marik describes various strategies that are widely used to minimize aspiration. Two of these are tucking the chin and turning the head while eating. These strategies belong with other “traditional” approaches and have recently been shown not to be as useful as previously assumed. Tucking the chin, in particular, may be contraindicated, since it tends to interfere with the superior and anterior movement of the hyoid that is essential for the opening of the upper esophageal sphincter.1,2 This failure of hyoid movement is very common in patients with dysphagia after stroke and in patients with movement disorders.

Turning the head should be used to minimize aspiration only if it is certain that the epiglottis is descending bilaterally. If there is unilateral failure of epiglottic descent, the vallecula on the affected side will not open.3 If the head is turned to the contralateral side, the only route for the bolus to follow is effectively blocked. This condition, which is not uncommon, can be identified only by an anteroposterior view in a videofluoroscopic examination of swallowing.

Irene Campbell-Taylor, Ph.D.
Surrey Place Centre, Toronto, ON M2V 2C2, Canada

3 References

1. 1

   Bulow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia 1999;14:67-72
   CrossRef | Web of Science | Medline

2. 2

   Perlman AL, Grayhack JP, Booth BM. The relationship of vallecular residue to oral involvement, reduced hyoid elevation, and epiglottic function. J Speech Hear Res 1992;35:734-741
   Medline

3. 3

   Vandaele DJ, Perlman AL, Cassell MD. Intrinsic fibre architecture and attachments of the human epiglottis and their contributions to the mechanism of deglutition. J Anat 1995;186:1-15
   Web of Science | Medline

Author/Editor Response

Dr. Marik replies:

To the Editor: This important issue is controversial, but I believe that the role of anaerobic bacteria in aspiration pneumonia has been overemphasized, with very few supporting data. Indeed, the widespread use of antimicrobial agents with antianaerobic activity is based entirely on three studies from the early 1970s.1-3 The usefulness of the studies is limited by methodologic problems, and the patients are not representative of those seen today. It is notoriously difficult to isolate anaerobes, but in our series we were unable to isolate any pathogenic anaerobic bacteria, despite diligent precautions.4 Almost all bacterial pneumonias are caused by the patients' aspiration of colonized oropharyngeal secretions (which contain anaerobic bacteria). We do not routinely treat these patients with antibiotics that are active against anaerobes. Our anaerobic flora play an important part in resistance to colonization, and the excessive use of antibiotics with activity against anaerobes has a role in the acquisition and persistence of vancomycin-resistant enterococci and Clostridium difficile.5,6

In my article, I pointed out that the choice of antibiotics in patients with aspiration pneumonia should be based on the likely colonizing organisms and that this is largely determined by the setting in which the aspiration occurs (i.e., whether it is community acquired or hospital acquired). Dreyfuss and Mier argue that levofloxacin should not be used as first-line therapy for community-acquired aspiration pneumonia because the drug has poor antianaerobic activity and is not a first-line antipneumococcal agent. They correctly point out that S. pneumoniae is an important pathogen in community-acquired aspiration pneumonia. However, in the United States, as in many other countries, strains of S. pneumoniae that are resistant to penicillin have become an important problem, and penicillin G can no longer be considered first-line therapy in patients infected with this organism. In the United States, pneumococci that are resistant to quinolones are still rare. The fact that levofloxacin has poor antianaerobic activity may be a therapeutic advantage. Manzella et al. reported that 16 percent of patients with community-acquired pneumonia treated with ceftriaxone became colonized with vancomycin-resistant enterococci, as compared with none of those treated with levofloxacin.7 I do agree that the treatment of hospital-acquired aspiration should be guided by the results of quantitative culture of samples obtained with a protected specimen brush.

Finucane and Christmas are correct in stating that feeding tubes do not protect against aspiration pneumonia, which remains the commonest cause of death in patients with neurogenic dysphagia. The optimal route of feeding for these patients remains unclear. I agree with Campbell-Taylor's comments. Patients with neurogenic dysphagia should be evaluated and treated by health professionals with expertise in this area.

Paul Marik, M.D.
Mercy Hospital of Pittsburgh, Pittsburgh, PA 15219-5166

7 References

1. 1

   Bartlett JG, Gorbach SL, Feinegold SM. The bacteriology of aspiration pneumonia. Am J Med 1974;56:202-207
   CrossRef | Web of Science | Medline

2. 2

   Lorber B, Swenson RM. Bacteriology of aspiration pneumonia: a prospective study of community- and hospital-acquired cases. Ann Intern Med 1974;81:329-331
   Web of Science | Medline

3. 3

   Cesar L, Gonzalez C, Calia FM. Bacteriologic flora of aspiration-induced pulmonary infections. Arch Intern Med 1975;135:711-714
   CrossRef | Web of Science | Medline

4. 4

   Marik PE, Careau P. The role of anaerobes in patients with ventilator-associated pneumonia and aspiration pneumonia: a prospective study. Chest 1999;115:178-183
   CrossRef | Web of Science | Medline

5. 5

   Donskey CJ, Chowdhry TK, Hecker MT, et al. Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. N Engl J Med 2000;343:1925-1932
   Full Text | Web of Science | Medline

6. 6

   Quale J, Landman D, Saurina G, Atwood E, DiTore V, Patel K. Manipulation of a hospital antimicrobial formulary to control an outbreak of vancomycin-resistant enterococci. Clin Infect Dis 1996;23:1020-1025
   CrossRef | Web of Science | Medline

7. 7

   Manzella J, Benenson R, Pellerin G, et al. Choice of antibiotic and risk of colonization with vancomycin-resistant Enterococcus among patients admitted for treatment of community-acquired pneumonia. Infect Control Hosp Epidemiol 2000;21:789-791
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Julie M. Hauer. (2007) Respiratory Symptom Management in a Child with Severe Neurologic Impairment. Journal of Palliative Medicine 10:5, 1201-1207
   CrossRef

2. 2

   Thibaud d???Escrivan, Benoit Guery. (2005) Prevention and Treatment of Aspiration Pneumonia in Intensive Care Units. Treatments in Respiratory Medicine 4:5, 317-324
   CrossRef