Is penicillin G an adequate initial treatment for aspiration pneumonia?
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To evaluate the bacteriology of early aspiration pneumonia using a protected specimen brush and quantitative culture techniques, and whether penicillin G is adequate as initial treatment pending culture results.
Patients and methods
52 patients (of which 45 required mechanical ventilation) meeting usual clinical criteria for aspiration pneumonia were prospectively included. On admission, patients were given intravenous penicillin G and a protected specimen brush was performed ≤48 h after.
Cultures of the brush were negative (<103 CFU/ml) in 33 patients (1 had blood cultures positive withS. pneumoniae) and positive (≥103 CFU/ml) forS. pneumoniae in 2 patients. Seventeen patients had a positive culture (≥103 CFU/ml) for at least one penicillin G resistant microorganism, with a total of 20 organisms (S. aureus: 6;H. influenzae: 2;Enterobacteriaceae: 8;P. aeruginosa: 3;C. albicans: 1). In 4 of these patients, a penicillin-sensitive pathogen was also recovered in significant concentrations (S. pneumoniae: 2;Streptococcus sp.: 2). These 17 patients with a resistant pathogen did not differ from the 35 other patients with respect to need for ventilatory support and mortality rate. By contrast, they were older (61.1±21.9 vs 42.9±18.8 years;p<0.005) and required longer mechanical ventilation (6.1±4.6 vs. 3.5±2.7 days;p<0.03) and hospitalization (11.2±8.8 vs. 6.7±4.7 days;p<0.02). Of 17 patients 12 with penicillin G resistant organisms versus 0/35 without, were in-hospital patients and/or had a digestive disorder (p<0.001).
The broad range of offending organisms seen in early aspiration pneumonia precludes use of any single empiric regimen, making protected specimen brush mandatory in many patients. Nevertheless, the involvement ofS. pneumoniae in a notable proportion of our patients suggests that routine penicillin prophylaxis after early aspiration (at least in most patients with community-acquired aspiration) is warranted given the potential severity of pneumococcal sepsis in such patients.
Key wordsAspiration pneumonia Protected specimen brush Antibiotics
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