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QCO 320210

REVIEW

CURRENT
OPINION Aspiration pneumonia and pneumonitis: a spectrum
of infectious/noninfectious diseases affecting
the lung
Sarah Neill a,b and Nathan Dean a,b

Purpose of review
Our purpose is to describe aspiration pneumonia/pneumonitis as a spectrum of infectious/noninfectious
diseases affecting the lung. We summarize diagnosis, risk factors, treatment, and strategies for prevention
of aspiration.
Recent findings
Aspiration is present in normal individuals, and disease manifestation depends on the chemical
Downloaded from http://journals.lww.com/co-infectiousdiseases by BhDMf5ePHKbH4TTImqenVDJivV4JHtPRGerRZXnrdXP3npWmEdTfLdQcb1df/Dn/ on 01/24/2019

characteristics, frequency, and volume of inoculum. Anaerobes, though present, are no longer the
predominant microbes isolated in aspiration pneumonia. Targets for preventing aspiration including
improved oral hygiene and positional feeding have had mixed results. Patients diagnosed by clinicians
with aspiration pneumonia experience greater morbidity and mortality than patients with community-
acquired pneumonia.
Summary
Aspiration pneumonia and pneumonitis are part of the pneumonia continuum and share similarities in
pathophysiology, microbiology, and treatment. Modern microbiology demonstrates that the lung is not
sterile, and isolates in aspiration pneumonia frequently include aerobes or mixed cultures. Treatment for
aspiration pneumonia should include antibiotic coverage for oral anaerobes, aerobes associated with
community-acquired pneumonia, and resistant organisms depending on appropriate clinical context.
Additional studies targeting prevention of aspiration and investigating the increased morbidity and
mortality associated with aspiration pneumonia are warranted.
Keywords
anaerobes, aspiration pneumonia, aspiration pneumonitis, community-acquired pneumonia, pneumonitis

INTRODUCTION LUNG MICROBIOME

Aspiration is defined as the entry of gastric or
oropharyngeal contents into the larynx and lower
respiratory tract. The frequency, volume, and char-
acteristics of the inoculum interact with host
defenses and can manifest as a spectrum of pulmo-
nary disease including aspiration pneumonia, pneu-
monitis, pulmonary abscess, and airway obstruction
[1]. Despite recognition of these clinical pheno-
types, aspiration pneumonia/pneumonitis lack a
consistent clinical definition or diagnostic criteria.
Rather than distinguishable entities, aspiration
pneumonia and pneumonitis are more likely one
end of the pneumonia and aspiration spectrum. In
this review, we discuss proposed pathophysiology,
clinical characteristics, methods of prevention, and
treatment recommendations.
Reviewing aspiration pathophysiology begins with
new understandings of the lung microbiome. The
lung environment below the larynx was classically
thought to be sterile, and therefore bacteria recov-
ered in culture confirmed a pathologic presence.
This understanding remained for many years
a
Section of Pulmonary and Critical Care Medicine, Intermountain Medical
Center, Murray and bDivision of Pulmonary and Critical Care Medicine,
University of Utah Health, Salt Lake City, Utah, USA
Correspondence to Sarah Neill, MD, MPH, University of Utah, Division of
Pulmonary and Critical Care Medicine, 26N. 1900 E, 701 Wintrobe, Salt
Lake City, UT 84132, USA. Tel: +1 512 971 7176;
e-mail: Sarah.Neill@hsc.utah.edu
Curr Opin Infect Dis 2019, 32:000–000
DOI:10.1097/QCO.0000000000000524

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Respiratory infections
KEY POINTS
 Aspiration is present in normal individuals;
development of clinically significant disease is
dependent on the characteristic of the inoculum and
whether host responses are overwhelmed.
 Isolates from aspiration pneumonia are commonly
polymicrobial and include aerobes associated with
community-acquired pneumonia and oral anaerobes.
 Patients with witnessed aspiration events should not
receive prophylactic antibiotics.
 Broad spectrum antibiotic coverage should be restricted
to those patients at risk for multidrug-
resistant organisms.
 Aspiration pneumonia is associated with increased
morbidity and mortality compared with community-
acquired pneumonia.
because of the technically challenging nature of
sampling the lung microbiome and the low lung
biomass (10–100 bacterial cells per 1000 human
cells). A primary issue was that sampling distal air-
ways requires passage through the microbiome-rich
pharynx via nose or mouth, contaminating speci-
mens. However, with protected brush specimens
and confirmatory testing using serial dilutions,
researchers were able to reliably sample flora from
the lower respiratory tract without pharyngeal con-
tamination. The development of culture-indepen-
dent techniques helped identify members of the
lung microbiome, despite the low biomass. The
most commonly employed technique utilizes
high-throughput sequencing of the amplicons of
the 16s rRNA, which is a highly conserved locus
in the bacterial genome. The 16s rRNA is then
compared with a known database of bacterial spe-
cies; diversity and relative abundance of particular
&
species is then extrapolated [2 ]. Modern studies
using this sequence-based technique show that
the lung constantly undergoes microbe immigra-
tion and elimination through host defenses [3].
CLINICAL PRESENTATION AND RISK
FACTORS
Aspiration pneumonia is characterized by witnessed
or suspected aspiration and cough, fever, shortness
of breath in the presence of a new alveolar infiltrate
seen on computed tomography (CT) scan or chest
radiograph secondary to an infectious cause. Aspi-
ration pneumonitis has a similar presentation but
has no infectious cause, though secondary superin-
fection can occur. The difficulty in differentiating
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between aspiration pneumonia and pneumonitis
leads to provider bias for an underlying infection
&&
and results in overprescribing of antibiotics [4 ].
Airway obstruction results from the aspiration of
large particles (food or other foreign bodies) and
can partially or completely obstruct the trachea or
bronchi. The most commonly affected segments of
the lungs are those subject to gravitational flow in
upright or supine individuals; the superior segments
of the lower lobes and posterior segments of the
upper lobes in a recumbent patient, contrasted with
the basal segments of the lower lobes in upright
patients [5].
Of patients with community-acquired pneumo-
nia (CAP), 7–24% are designated as aspiration pneu-
monia by clinicians [6]. Patients admitted to the
hospital with aspiration pneumonia are older
(median age 74 years in one study) and have more
comorbidities including heart failure, liver disease,
and cerebrovascular accidents than their nonaspira-
tion pneumonia counterparts [7,8]. Residency in a
continuing care facility (CCF) was associated with
aspiration pneumonia (30 vs. 10%) compared with
those diagnosed with CAP [6]. Other risk factors
associated with aspiration include altered mental
status, dysphagia, impaired gastrointestinal motil-
ity, and neurological disorders.
Altered mental status is caused by a heteroge-
neous group of disorders including hypoglycemia,
seizures, alcohol intoxication, or illicit drug abuse,
all of which increased risk of aspiration. Acute alco-
hol intoxication decreases sensorium and causes
respiratory depression, decreased airway sensitivity,
and decreased ciliary clearance leading to aspiration
and development of pneumonia [8]. Opioids also
cause decreased mental status and increased risk of
disease. A nested case controlled study looking at
use of opioids and risk of pneumococcal disease
[73.9% of cases (n ¼ 911) were invasive pneumonia]
found that opioid users had increased adjusted odds
ratio (aOR, 1.62; 95% CI 1.36–1.92) after controlling
for other known risk factors. Opioids also impair
host defenses by disrupting phagocyte proliferation,
decreasing activity of the innate immune system,
and cytokine expression as seen in animal studies
&
[9 ]. Medications given in the hospital setting for
acute delirium or management of dementia have
also been associated with aspiration pneumonia
after adjustment for patient characteristics. Patients
with antipsychotic exposure (atypical and typical)
had increased risk for aspiration pneumonia (OR
&
3.9; 95% CI 3.2–4.8) [10 ].
Dysphagia/impaired gastric motility and pneu-
monia is commonly found in stroke patients and
other neurological disorders (Parkinson disease,
dementia, multiple sclerosis). Location of the stroke
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(cerebral, cerebellar, or brainstem) is associated with
various impairments of swallowing physiology.
Identification of dysphagia in the poststroke popu-
lation depends greatly on the method of diagnosis
with the highest prevalence by videofluoroscopy
(64–78%) compared with clinician testing (30–
55%). Meta-analysis of acute stroke and dysphagia
showed a much higher relative risk (RR) of develop-
ing pneumonia compared with their counterparts
without dysphagia (RR 3.17; 95% CI 2.07–4.87) [11].
However, dysphagia as a risk factor is confounded by
age, medications, and comorbid conditions. Studies
of Alzheimer patients on neuroleptic medications
demonstrate significant delay in their swallowing
reflux, making them more vulnerable to aspiration
and development of pneumonia (OR 3.1; 95% CI
1.46–6.69) [12].
PATHOPHYSIOLOGY
Volume, frequency, chemical characteristics, and
size of particles factor into the development of
aspiration pneumonia, pneumonitis, and airway
obstruction, which results in a wide spectrum of
disease. Natural defenses against aspiration include
glottis closure, cough reflex, mucociliary clearance,
&
and resident alveolar macrophages [2 ,3]. Aspiration
in otherwise healthy individuals was first recognized
in the anesthesia literature [13,14]. Experiments
where nontoxic blue azo dye was ingested prior to
surgery determined whether or not aspiration had
occurred. The dye was detected by bronchoscopy
prior to the end of surgery in 75% of patients where
aspiration was suspected, but was also found in
19.6% of patients where aspiration/regurgitation
had not been suspected [14]. High risk of aspiration
at the time of anesthesia was attributed to early
anesthetic techniques, which led to the description
of chemical pneumonitis (Mendelson’s syndrome)
[13,14]. Mendelson assembled a case series of 61
obstetric patients with witnessed aspiration and
described the clinical syndrome as respiratory dis-
tress, cyanosis, and single/bilateral lower lobe infil-
trates within 2 h. He remarked that despite severity
of initial presentation, young otherwise healthy
obstetrical patients typically had resolution of their
symptoms and infiltrates within 7 days without
antibiotics [15]. Gleeson et al. [16] demonstrated
aspiration in normal individuals by identifying
ingested radiolabeled dye in lung parenchyma in
50% of healthy young men after undergoing poly-
somnography. Quantities of dye were typically
between 0.01 and 0.2 ml and did not result in clini-
cally significant consequences. The variable clinical
presentation seen in small volume (microaspiration)
and large volume (macroaspiration) demonstrates
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Aspiration pneumonia and pneumonitis Neill and Dean
that volume of inoculum contributes to severity of
the disease.
The chemical nature of the aspirate also affects
clinical manifestations of aspiration. Studies where
dilutions of hydrochloric acid were instilled into the
trachea of anesthetized rabbits demonstrated that a
pH below 2.5 produced a significant, nonspecific
injury pattern including de-epithelialization of the
bronchial mucosa, pulmonary edema, hemorrhage,
and a neutrophilic cellular infiltrate. In contrast,
instilled acid with pH above 2.5 had similar histo-
logic findings as the control group where water was
instilled into the trachea [17]. Animal studies into
the mediators associated with acid-induced lung
injury revealed that both complement and inflam-
matory cytokines (IL-8, TNF-alpha) are increased in
response to injury [18–20]. Aspirated lipids, such as
mineral oil used for chronic constipation, can also
cause a significant inflammatory response present-
ing with low-grade fever and dyspnea in the acute
setting or as lipoid pneumonia in chronic aspiration
[21].
Chronicity and frequency of aspiration events
contribute to the development of pneumonia by
denuding the epithelium and increasing bacterial
load. In the absence of infection, recurrent
aspiration contributes to the development and
&
progression of idiopathic pulmonary fibrosis [2 ].
Development of clinically evident disease results
from overwhelming the host responses (alveolar
macrophages and mucociliary clearance [3]).
PREVENTION
Interventions to prevent aspiration have targeted
delivery of nutrition, patient position during feed-
ing, and oral hygiene. Patients with dysphagia often
require tube feeding for nutrition. Studies have
looked at relative risks and benefits of different
modalities (gastrostomy tube feeding vs. nasogastric
tube feeding) and location (gastrostomy vs. jejunos-
tomy) but showed similar incidence of aspiration
pneumonia between methods and locations [22,23].
Avoiding high gastric residual volumes in patients
with delayed gastric emptying may reduce aspira-
tion. However, a low residual volume (<150 ml) was
present in 23% of aspiration events so no consistent
relationship between residual volumes and aspira-
tion could be identified [24,25].
Initial studies showed improved oral hygiene
decreased lower respiratory tract infections in
high-risk nursing home populations [26]. This find-
ing was not reproducible and meta-analysis showed
unclear benefit, which led to investigation of bun-
&
dled interventions [27,28 ]. A cluster-randomized
trial of combining chlorhexidine rinses, oral
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brushings, and upright feedings unfortunately did
not show significant reduction in the incidence of
radiographically confirmed pneumonia or lower
respiratory tract infection compared with the nurs-
ing home residents receiving usual care [29].
MICROBIOLOGY
The role of anaerobes in aspiration pneumonia was
reported in the 1970s in 70 patients where cultures
‘devoid of oropharyngeal flora were collected,’
including transtracheal aspirates, pleural fluid,
and blood cultures. The predominant organisms
isolated were Bacteroides melaninogenicus and Fuso-
bacterium nucleatum [30]. Hospitalized patients had a
higher rate of Staphylococcus aureus and Gram-nega-
tive bacilli isolation. Eighty-seven percent of the
study patients had anaerobes isolated [31].
Recent studies of aspiration pneumonia show
less recovery of anaerobes and increases in aerobic
bacteria. In 2005, a study of pulmonary abscesses
identified Klebsiella pneumoniae as the most com-
monly isolated bacteria followed by Streptococcus
milleri group. Invasive samples in this study
included percutaneous transthoracic aspiration of
the abscess, blood cultures, surgical specimens, and
pleural fluid cultures. Of the 90 culture positive
cases, 18 (20%) only grew anaerobes. Patients with
pure anaerobe cultures were more likely to have
subacute or chronic presentation (duration of symp-
toms prior to diagnosis >30 days) than other culture
positive patients (72 vs. 43%; P < .05) [31]. In
another study, bronchoalveolar lavage samples were
collected from intubated patients with suspected
aspiration within 6 h of admission. Pneumonia
was defined as the isolation of at least one patho-
genic bacteria at 104 CFU/ml. Culture confirmed
the bacterial cause in 32 of 65 cases. The predomi-
nant bacterial species identified were S. aureus (n ¼ 6)
and Escherichia coli (n ¼ 6). Anaerobic species includ-
ing Fusobacterium spp. and Prevotella spp. were iso-
lated in one and six cases, respectively [32]. The
decrease in anaerobes isolated in more recent studies
might represent a consequence of changes in sam-
pling, antibiotic practices, and host features. Fewer
dental caries (fluoridated water), improved dental
hygiene (decreased anaerobe biomass), access to
emergency care, and frequent outpatient antibiotics
could prevent the subacute presentations that favor
anaerobic infection.
TREATMENT
Treatment for aspiration pneumonitis has not sig-
nificantly changed since it was first described by
Mendelson in the 1950s. Clinical care is supportive
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and consists of suctioning to clear the airway,
oxygen to correct hypoxemia, and support with
mechanical ventilation if needed. Aspiration of
large particles resulting in partial or complete
obstruction of bronchial segments may require
bronchoscopy to clear the obstruction. Corticoste-
roids have not improved outcomes in aspiration
pneumonitis [33]. Prophylactic antibiotics in the
setting of aspiration is common practice with 78%
of critical care respondents prescribing antibiotics at
the time of a macroaspiration event in one survey
[34]. Dragan et al. analyzed a retrospective cohort of
patients with aspiration pneumonitis and compared
individuals who received antibiotics within the
first 2 days after macroaspiration compared with
supportive care. Of the patients who received pro-
phylactic antibiotics (n ¼ 76, 38%), there was no
improvement in mortality (OR, 0.9; 95% CI 0.4–
1.7 P ¼ 0.7), no less escalation of care (5 vs. 6%;
P ¼ 0.7), but more frequent escalation of antibiotics
(8 vs. 1%; P ¼ 0.002) compared with the supportive
&&
care group [4 ]. Prospective study of patients intu-
bated for coma (Glasgow Coma Scale score 8)
showed that antibiotic cessation in individuals with
suspected aspiration and negative bronchoscopic
cultures was nearly always effective (31 of 33
&&
patients) [35 ]. Prophylactic use of antibiotics in
aspiration pneumonitis is not recommended as it
does not improve outcomes and may drive resistance.
Early guidelines for the treatment of anaerobic
pleuropulmonary infections in the 1970s recom-
mended penicillin therapy. As penicillinase-produc-
ing bacterial strains became more frequent, other
agents were required. Comparative effectiveness of
clindamycin and metronidazole was studied and
found that clindamycin monotherapy had a higher
cure rate for pleuropulmonary disease, likely
because anaerobic streptococci are not susceptible
to metronidazole [36]. Clindamycin monotherapy
has fallen out of favor given risk of C. difficile infec-
tions, although studies comparing beta-lactam/
beta-lactamase inhibitor, clindamycin, and carba-
penems showed similar adverse events [37]. Current
guidelines favor parenteral beta-lactam/beta-lacta-
mase inhibitors in severely ill patients with transi-
tion to similar oral therapy once stable. Individuals
with penicillin allergy who tolerate cephalosporins
can be treated with a combination of third-genera-
tion cephalosporin and metronidazole. Individuals
at risk for multidrug-resistant organisms should
receive broad spectrum coverage [5]. However,
CAP therapy, such as ceftriaxone and azithromycin
can be used in patients with aspiration pneumonia
as they are effective in vitro against oral anaerobes
and the aerobic bacteria commonly isolated in the
studies cited earlier.
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QCO 320210
MORBIDITY AND MORTALITY
Diagnosis of aspiration is associated with increased
morbidity and mortality. Retrospective review per-
formed by Lanspa et al. showed that patients with a
diagnosis of aspiration pneumonia were more likely
to need admission to the hospital (99 vs. 58%;
n ¼ 628), require ICU care (38 vs. 14%), and had
higher Charlson comorbidity index (3 vs. 1) com-
pared with patients with CAP [38]. Meta-analysis of
69 129 patients found that aspiration increased risk
of in-hospital mortality (RR, 3.62; 95% CI 2.65–
4.96; P < 0.00001; I2 ¼ 86%) [39]. Individuals with
aspiration pneumonia also had higher 30-day mor-
tality (RR 3.57; 95% CI 2.18–5.86; P < 0.001;
I2 ¼ 85%) [39].
CONCLUSION
Aspiration pneumonia is not a distinct clinical phe-
nomenon as it shares similar pathophysiology,
microbiology, diagnosis, and treatment as CAP. It
does represent one end of the pneumonia spectrum
associated with significant morbidity and mortality
beyond what is seen in CAP. The association of
greater severity of illness and comorbidities may
signal that diagnosis of aspiration pneumonia is a
surrogate for declining overall health.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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