Clinical Commander

Back to dossier
pulm.aspiration-pneumonia.core.v1PRODUCTION
pulm.aspiration-pneumonia.core.v1

Aspiration Pneumonia

pulmonologyacutesubacuteadult
Hard-required inputs
0 / 7
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

THE PIVOT — classify aspiration PNEUMONITIS (chemical/Mendelson: abrupt onset hours after a witnessed acid/gastric event, infiltrate evolving and improving, fever early and resolving, RESPONDS WITHOUT ANTIBIOTICS in 24-48 h; severe acid load → ARDS) vs aspiration PNEUMONIA (bacterial: subacute >24-48 h, persistent/late fever + leukocytosis, fixed dependent-segment infiltrate, REQUIRES ANTIBIOTICS) (Marik NEJM 2001 PMID 11228282; Mandell & Niederman NEJM 2019 PMID 30763196)

Inputs
1
Actions
0
Advance rule
Set
Advance when

Pneumonitis-vs-pneumonia working classification assigned with timing/fever-curve rationale

Patient inputs (15)

Age stratifies severity and antibiotic dosing

Hypoxemia and severity grading

Bacterial superinfection vs chemical pneumonitis time course

Tachypnea + work-of-breathing severity

Septic shock screening; CURB-65 element

Dependent-lobe infiltrate confirms pneumonia vs uncomplicated pneumonitis

eGFR for renal-dosed antibiotics

Lung abscess, empyema, foreign body aspiration, cavitation

Witnessed acid/gastric aspiration event timestamp anchors the pneumonitis-vs-pneumonia clock (Marik NEJM 2001 PMID 11228282)

Risk substrate (stroke, dementia, intoxication, recent extubation, NG/PEG tube) — drives secondary prevention (Mandell 2019 PMID 30763196)

Severe periodontal disease/putrid sputum/abscess is now the ONLY routine indication for anaerobic coverage (Metlay ATS/IDSA 2019 PMID 31573350; Bartlett 2013 PMID 23398871)

Hospital-acquired aspiration → broaden coverage to gram-negatives + Pseudomonas

Hours-after-event abrupt + improving = pneumonitis; >24-48 h with persistent fever/leukocytosis = bacterial pneumonia (Marik 2001 PMID 11228282; Mandell NEJM 2019 PMID 30763196)

Leukocytosis/bandemia for bacterial pneumonia

Sepsis severity

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningmassive_acid_aspiration_ards_mendelson
    Large-volume acid aspiration with rapidly progressive bilateral infiltrates + hypoxemia (P/F ≤300) within hours — Mendelson syndrome evolving to ARDS
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningseptic_shock_in_aspiration
    Vasopressor requirement OR lactate ≥4 OR SBP <90 unresponsive to fluids in aspiration pneumonia (ATS/IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelung_abscess
    Cavitating consolidation OR loculated lesion ≥2 cm with air-fluid level on CT — one of the FEW remaining indications for anaerobic coverage (Mandell NEJM 2019 PMID 30763196; Bartlett 2013 PMID 23398871)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereempyema
    Pleural fluid pH <7.20 OR pus on thoracentesis OR loculated pleural collection with sepsis (ATS/IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereforeign_body_aspiration_concern
    Witnessed choking event with persistent unilateral wheeze, persistent atelectasis, or post-obstructive pneumonia (Marik 2001)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehospital_acquired_or_post_extubation
    Aspiration occurring ≥48 h after hospital admission, post-extubation aspiration, or vent-associated pneumonia (IDSA/ATS 2016 HAP/VAP)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_aspiration_pneumonia
    Second episode within 12 months in patient with chronic dysphagia substrate (DeLegge 2002)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpneumonitis_resolving_stop_antibiotics
    Witnessed acid/gastric aspiration, abrupt onset, infiltrate evolving/improving, afebrile with falling/normal WBC at 48 h — chemical pneumonitis confirmed by trajectory
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

DISPOSITIONoptionalDrives disposition
Loading…

Recommended regimen

Aspiration: when-to-treat fork + empirical antibiotics WITHOUT routine anaerobic coverage (Metlay ATS/IDSA 2019 PMID 31573350; Mandell NEJM 2019 PMID 30763196; Marik NEJM 2001 PMID 11228282)
axis: aspiration_empirics_by_settingstep pneumonitis_observe_no_antibiotics - Aspiration PNEUMONITIS (chemical/Mendelson) — observe, NO antibiotics, DEPRESCRIBE if started
Selected step "Aspiration PNEUMONITIS (chemical/Mendelson) — observe, NO antibiotics, DEPRESCRIBE if started" — Witnessed acid/gastric aspiration, abrupt onset within hours, infiltrate (if any) evolving/improving, NO persistent fever or leukocytosis at 48 h, clinical improvement — chemical injury, sterile
  • oxygen
    first line
    oxygen
    1–6 L/min NC titrated • inhaled • continuous PRN to SpO2 ≥92%
    triggers: hypoxia
    Supportive only — chemical pneumonitis typically resolves in 24–48 h; antibiotics do NOT alter the course of pure pneumonitis and select resistance / C. difficile (Marik NEJM 2001 PMID 11228282; Mandell NEJM 2019 PMID 30763196). RxCUI RxNav-confirmed 2026-05-16.
    rxcui 7806

outpatient playbook — drug actions (3)

  1. 1. amoxicillin-clavulanate
    875/125 mg PO BID • PO • q12h × 5–7 days
    trigger: Mild community aspiration pneumonia
    Standard outpatient regimen
  2. 2. clindamycin
    300–450 mg PO QID • PO • q6h × 5–7 days
    trigger: Penicillin allergy + anaerobic concern
    Alternative covering anaerobes
  3. 3. moxifloxacin
    400 mg PO daily • PO • daily × 5–7 days
    trigger: Penicillin allergy + ambiguous coverage
    FQ with anaerobic coverage

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Witnessed aspiration / choking event; Cough, fever, dyspnea after dysphagia/altered LOC; Dependent-lobe infiltrate (RLL, posterior segments) on CXR/CT.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Aspiration Pneumonia** (pulm.aspiration-pneumonia.core.v1).
Phenotype framing: Aspiration pneumonitis vs aspiration pneumonia (THE pivot) vs CAP (no aspiration substrate) vs HAP/VAP (≥48 h hospitalised → pulm.hospital-acquired-pneumonia-non-covid.v1) vs ARDS (Mendelson can cause it → pulm.ards.core.v1) vs PE (pleuritic, hypoxia disproportionate to infiltrate → pulm.pe.core.v1) vs lung abscess/empyema vs sepsis from another source (id.sepsis.core.v1)
Scope: THE PIVOT — classify aspiration PNEUMONITIS (chemical/Mendelson: abrupt onset hours after a witnessed acid/gastric event, infiltrate evolving and improving, fever early and resolving, RESPONDS WITHOUT ANTIBIOTICS in 24-48 h; severe acid load → ARDS) vs aspiration PNEUMONIA (bacterial: subacute >24-48 h, persistent/late fever + leukocytosis, fixed dependent-segment infiltrate, REQUIRES ANTIBIOTICS) (Marik NEJM 2001 PMID 11228282; Mandell & Niederman NEJM 2019 PMID 30763196)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Aspiration: when-to-treat fork + empirical antibiotics WITHOUT routine anaerobic coverage (Metlay ATS/IDSA 2019 PMID 31573350; Mandell NEJM 2019 PMID 30763196; Marik NEJM 2001 PMID 11228282)** — step "Aspiration PNEUMONITIS (chemical/Mendelson) — observe, NO antibiotics, DEPRESCRIBE if started".
1. oxygen 1–6 L/min NC titrated inhaled continuous PRN to SpO2 ≥92% (oxygen, first line) — Supportive only — chemical pneumonitis typically resolves in 24–48 h; antibiotics do NOT alter the course of pure pneumonitis and select resistance / C. difficile (Marik NEJM 2001 PMID 11228282; Mandell NEJM 2019 PMID 30763196). RxCUI RxNav-confirmed 2026-05-16.

Setting playbook (outpatient) — Mild community aspiration pneumonia in ambulatory adult — short-course oral antibiotics + speech-swallow follow-up + aspiration-prevention bundle
2. amoxicillin-clavulanate 875/125 mg PO BID PO q12h × 5–7 days — Mild community aspiration pneumonia (Standard outpatient regimen)
3. clindamycin 300–450 mg PO QID PO q6h × 5–7 days — Penicillin allergy + anaerobic concern (Alternative covering anaerobes)
4. moxifloxacin 400 mg PO daily PO daily × 5–7 days — Penicillin allergy + ambiguous coverage (FQ with anaerobic coverage)

Non-pharmacologic actions:
- Diet modification per swallow screen
- Head-of-bed elevation post-meals
- Oral hygiene 2×/day
- Avoid sedatives where possible
- Vaccination update

AVOID / contraindication checks:
- DO NOT add routine anaerobic coverage for uncomplicated aspiration pneumonia — only for lung abscess/empyema/necrotizing/severe periodontal disease (Metlay ATS/IDSA 2019 PMID 31573350)
- Do not treat pure chemical pneumonitis with antibiotics — observe and deprescribe if started (Marik NEJM 2001 PMID 11228282; Mandell NEJM 2019 PMID 30763196)
- Clindamycin highest C difficile risk among aspiration agents counsel patients (Bartlett 2013 PMID 23398871)
- Fluoroquinolone tendon aortic QT neuropathy warning reserve for β lactam allergy (ATS/IDSA 2019 PMID 31573350)
- Metronidazole alcohol disulfiram like reaction counsel; peripheral neuropathy with prolonged use (Bartlett 2013 PMID 23398871)
- Vancomycin AUC target 400 600 avoid AKI nephrotoxicity (ATS HAP/VAP 2016)
- Linezolid serotonin syndrome with SSRI/MAOI; myelosuppression beyond 14 days (ATS HAP/VAP 2016)
- Renal dose adjust pip tazo, cefepime, meropenem, vancomycin by CrCl; hepatic adjust metronidazole in severe hepatic impairment

Monitoring

Regimen monitoring:
- reclassify pneumonitis-vs-pneumonia at 48 h — STOP antibiotics if pneumonitis resolved (Marik NEJM 2001 PMID 11228282)
- clinical response at 48-72h then de-escalate / narrow per culture (Metlay ATS/IDSA 2019 PMID 31573350)
- duration 5 to 7 days for uncomplicated pneumonia (Mandell NEJM 2019 PMID 30763196)
- duration 3 weeks+ to radiographic resolution for lung abscess, 4-6 weeks if slow (Bartlett 2013 PMID 23398871)
- CrCl-guided dose adjustment pip-tazo/cefepime/meropenem/vancomycin (ATS HAP/VAP 2016)
- speech-swallow eval pre discharge + dysphagia secondary prevention (Sherman/Martino JAHA 2021 PMID 34096328)
- aspiration-prevention bundle post discharge — oral care, diet modification, HOB elevation, sedative deprescribing (Mandell NEJM 2019 PMID 30763196)

Setting (outpatient) monitoring:
- 48-72 h follow-up call/visit (ATS/IDSA 2019)
- CXR at 6 weeks if smoker / age ≥50 (ATS/IDSA 2019)

Follow-up plan: Secondary prevention bundle — speech-language pathology swallow rehab, diet/texture modification, oral-hygiene programme, head-of-bed elevation, sedative/anticholinergic deprescribing, vaccination, goals-of-care discussion for recurrent aspiration (PEG does NOT eliminate aspiration risk) (Mandell 2019 PMID 30763196; Sherman/Martino JAHA 2021 PMID 34096328)
- Close-out criterion: Aspiration-prevention + secondary-prevention bundle in place

Monitoring phase: Clinical response at 48-72 h (de-escalate / stop antibiotics if pneumonitis confirmed by resolution); repeat imaging only if non-resolving (then CT for abscess/empyema); swallow re-evaluation pre-discharge

Disposition

Current setting: outpatient — Mild community aspiration pneumonia in ambulatory adult — short-course oral antibiotics + speech-swallow follow-up + aspiration-prevention bundle

Disposition criteria:
- Continue outpatient if symptoms improving by 72 h (ATS/IDSA 2019)
- Refer to ED if not improving (ATS/IDSA 2019)

Escalation triggers (move to higher acuity):
- Worsening dyspnea / hypoxia → ED (ATS/IDSA 2019)
- Fever ≥72 h → ED (ATS/IDSA 2019)
- Recurrent aspiration → outpatient swallow rehab (DeLegge 2002)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Large-volume acid aspiration with rapidly progressive bilateral infiltrates + hypoxemia (P/F ≤300) within hours — Mendelson syndrome evolving to ARDS
- [LIFE_THREATENING] Vasopressor requirement OR lactate ≥4 OR SBP <90 unresponsive to fluids in aspiration pneumonia (ATS/IDSA 2019)
- [SEVERE] Cavitating consolidation OR loculated lesion ≥2 cm with air-fluid level on CT — one of the FEW remaining indications for anaerobic coverage (Mandell NEJM 2019 PMID 30763196; Bartlett 2013 PMID 23398871)

Citations

- Marik NEJM 2001 pneumonitis-vs-pneumonia framework (PMID 11228282) + Mandell & Niederman NEJM 2019 aspiration review (PMID 30763196) + ATS/IDSA 2019 CAP guideline — recommends AGAINST routine anaerobic coverage (Metlay PMID 31573350) + ATS 2025 CAP short-course overlap + ATS HAP/VAP 2016 (nosocomial) [PMID:11228282](https://pubmed.ncbi.nlm.nih.gov/11228282/)
- Cited evidence (PMID 30763196) [PMID:30763196](https://pubmed.ncbi.nlm.nih.gov/30763196/)
- Cited evidence (PMID 31573350) [PMID:31573350](https://pubmed.ncbi.nlm.nih.gov/31573350/)
- Cited evidence (PMID 23398871) [PMID:23398871](https://pubmed.ncbi.nlm.nih.gov/23398871/)
- Cited evidence (PMID 34096328) [PMID:34096328](https://pubmed.ncbi.nlm.nih.gov/34096328/)

Last reconciled with current guidelines: 2026-05-16.
References
  • Marik NEJM 2001 pneumonitis-vs-pneumonia framework (PMID 11228282) + Mandell & Niederman NEJM 2019 aspiration review (PMID 30763196) + ATS/IDSA 2019 CAP guideline — recommends AGAINST routine anaerobic coverage (Metlay PMID 31573350) + ATS 2025 CAP short-course overlap + ATS HAP/VAP 2016 (nosocomial) — PMID:11228282
  • Cited evidence (PMID 30763196) — PMID:30763196
  • Cited evidence (PMID 31573350) — PMID:31573350
  • Cited evidence (PMID 23398871) — PMID:23398871
  • Cited evidence (PMID 34096328) — PMID:34096328