UNASSIGNED: The role of preoperative pharmacological prophylaxis in preventing aspiration pneumonitis under general anesthesia (GA) in patients at low risk of aspiration pneumonitis is still under debate. We addressed the need for routine pharmacological aspiration prophylaxis in at-risk population by assessing the change in gastric volume using ultrasound with and without pharmacological acid aspiration prophylaxis.
UNASSIGNED: A single-center, randomized double-blinded trial, with 200 adult patients scheduled for elective surgical procedures under GA, were randomized into a prophylaxis group, in which the patients received oral famotidine and metoclopramide, and a no prophylaxis group, in which the patients did not receive any prophylaxis. Gastric volume derived from preinduction measurement of gastric antral volume by ultrasound, postinduction gastric pH, and incidences of aspiration pneumonitis were compared. Bland-Altman plot was used to determine the level of agreement between measured gastric volume and ultrasonography based on calculated gastric volume.
UNASSIGNED: The gastric antral cross-sectional area (CSA) and volume in the no prophylaxis group (3.12 cm2 and 20.11 ml, respectively) were comparable to the prophylaxis group (2.56 cm2 and 19.67 ml, respectively) (P-values 0.97 and 0.63, respectively). Although there was a statistically significant decrease in gastric pH in the no prophylaxis group (P-value 0.01), it was not clinically significant to increase the risk of aspiration pneumonitis based on Roberts and Shirley criteria (P-value 0.39).
UNASSIGNED: In an adequately fasted low-risk population, the amount of residual gastric volume was similar and below the aspiration threshold, regardless of the aspiration prophylaxis status.

BACKGROUND: Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined.
METHODS: We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration.
RESULTS: Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as \"possible pulmonary aspiration\" by anaesthetists, revealed that this adverse event did not occur in the cohort.
CONCLUSIONS: In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation.

OBJECTIVE: The purpose of the study is to assess if daily use of hypnotics increases mortality, aspiration pneumonia and hip fracture among relatively healthy individuals aged 75 years or older who lead independent lives in the community.
METHODS: Of the adults aged 75 years or older residing in Hokkaido prefecture of Japan (n = 705,538), those who did not meet several exclusion criteria were eligible for generating propensity score-matched cohorts (n = 214,723). Exclusion criteria included co-prescribed medications acting on the central nervous system, diagnoses of malignant neoplasm, dementia, depression, etc. We compared 33,095 participants who were prescribed hypnotics for daily use (hypnotic group) with a propensity score-matched cohort without a prescription (control group). Participants were followed for more than 42 months.
RESULTS: During the 42-month follow-up period, the incidence of the three outcome measures in the hypnotics group was significantly higher than that in the control group (aspiration pneumonia p < 0.001, hip fracture p = 0.007, and all-cause mortality p < 0.001). Sensitivity analyses utilizing inverse probability weighting demonstrated hazard ratios of 1.083 [1.023-1.146] for mortality, 1.117 [1.014-1.230] for aspiration pneumonia, and 1.720 [1.559-1.897] for hip fracture. Meanwhile, the attribute risk differences were 2.7, 1.5, and 1.0 per 1000 patient-years, respectively.
CONCLUSIONS: Although daily use of hypnotics increased the risk of three events, their attribute risk differences were fewer than 3.0 per 1000 patient-years. The results will help provide guidance on whether it is reasonable to prescribe hypnotics to geriatric population aged 75 or older leading independent lives in the community.
BACKGROUND: UMIN-CTR UMIN000048398.

OBJECTIVE: Aspiration pneumonia (AP) has significant incidence and impact on mortality. However, data about clinical diagnosis criteria are scarce. We aimed to evaluate according to predefined criteria the prevalence of true AP and its impact on antibiotic stewardship.
METHODS: Retrospective study of patients whose main diagnosis was AP hospitalized at Amiens University Hospital in 2018. We first defined diagnostic criteria of certainty for pneumonia and aspiration. AP was then classified according to degree of certainty.
RESULTS: Among 862 cases of AP, its diagnosis was certain, likely, probably in excess, certainly in excess or absent in 2 % (n = 17), 3 % (n = 26), 50.5 % (n = 433), 23.1 % (n = 198) and 21.4 % (n = 183) respectively. Irrelevant use of amoxicillin-clavulanic acid and metronidazole was found in 27 % and 13 % of cases, respectively.
CONCLUSIONS: The diagnosis of AP is frequently excessive, and diagnostic tools are urgently needed to improve antibiotic stewardship.

There is little evidence regarding the long-term prognosis of patients with aspiration pneumonia. This study aimed to investigate post-discharge survival time and prognostic factors in older patients hospitalized for aspiration pneumonia. This retrospective cohort study included patients aged ≥ 65 years hospitalized for aspiration pneumonia and discharged alive from a tertiary care hospital in Japan between April 2009 and September 2014. Candidate prognostic factors were patient\'s age, sex, body mass index (BMI), performance status, chronic conditions, CURB-65 score, serum albumin level, hematocrit concentration, nutritional pathway at discharge, and discharge location. Kaplan-Meier curves were determined and multivariable survival analysis using Cox regression model was performed to analyze the effect of each factor on mortality. In total, 209 patients were included in this study. The median age was 85 years, 58% of the patients were males, 33% had a performance status of 4 and 34% were discharged home. Among the patients, 65% received oral intake, 23% received tube feeding, and 21% received parenteral nutrition at discharge. During the follow-up period, 77% of the patients died, and the median post-discharge survival time was 369 days. Besides male sex and low BMI, tube feeding (adjusted hazard ratio (aHR) = 1.70, 95% confidence interval (CI) 1.11-2.59) and parenteral nutrition (aHR = 4.42, 95% CI 2.57-7.60) were strongly associated with mortality. Long-term prognosis of patients hospitalized for aspiration pneumonia was extremely poor. The nutritional pathway at discharge was a major prognostic factor. These results may be useful for future care and research.

BACKGROUND: Antibiotics with extended anaerobic coverage are used commonly to treat aspiration pneumonia, which is not recommended by current guidelines.
OBJECTIVE: In patients admitted to hospital for community-acquired aspiration pneumonia, does a difference exist between antibiotic therapy with limited anaerobic coverage (LAC) vs antibiotic therapy with extended anaerobic coverage (EAC) in terms of in-hospital mortality and risk of Clostridioides difficile colitis?
METHODS: We conducted a multicenter retrospective cohort study across 18 hospitals in Ontario, Canada, from January 1, 2015, to January 1, 2022. Patients were included if the physician diagnosed aspiration pneumonia and prescribed guideline-concordant first-line community-acquired pneumonia parenteral antibiotic therapy to the patient within 48 h of admission. Patients then were categorized into the LAC group if they received ceftriaxone, cefotaxime, or levofloxacin. Patients were categorized into the EAC group if they received amoxicillin-clavulanate, moxifloxacin, or any of ceftriaxone, cefotaxime, or levofloxacin in combination with clindamycin or metronidazole. The primary outcome was all-cause in-hospital mortality. Secondary outcomes included incident C difficile colitis occurring after admission. Overlap weighting of propensity scores was used to balance baseline prognostic factors.
RESULTS: The LAC and EAC groups included 2,683 and 1,316 patients, respectively. In hospital, 814 patients (30.3%) and 422 patients (32.1%) in the LAC and EAC groups died, respectively. C difficile colitis occurred in five or fewer patients (≤ 0.2%) and 11 to 15 patients (0.8%-1.1%) in the LAC and EAC groups, respectively. After overlap weighting of propensity scores, the adjusted risk difference of EAC minus LAC was 1.6% (95% CI, -1.7% to 4.9%) for in-hospital mortality and 1.0% (95% CI, 0.3%-1.7%) for C difficile colitis.
CONCLUSIONS: We found that extended anaerobic coverage likely is unnecessary in aspiration pneumonia because it was associated with no additional mortality benefit, only an increased risk of C difficile colitis.

BACKGROUND: The incidence of aspiration pneumonia and the number of medicines prescribed increase with older age. Many medicines pose a risk for aspiration pneumonia, especially those that decrease swallowing function. Older adults with polypharmacy often receive a combination of these medicines. This study aimed to clarify whether polypharmacy is a risk factor for aspiration pneumonia.
METHODS: Older adults aged ≥ 65 years receiving oral medicines were included in this case-control study. Patients hospitalized for pneumonia served as the case group, and other age-matched hospitalized patients served as the control group. Patient data were collected retrospectively, and logistic regression analysis was performed using items that showed significant differences in the univariate analysis as explanatory variables.
RESULTS: Logistic regression analysis revealed that the number of medicines was not a risk factor for aspiration pneumonia; however, it was associated with the Functional Oral Intake Scale score, male sex, body mass index, and number of comorbidities.
CONCLUSIONS: Although polypharmacy is often defined only by the number of medicines, it is not a risk factor for aspiration pneumonia. A detailed comparison of prescription medicines between the pneumonia and non-pneumonia groups is necessary.

BACKGROUND: Aspiration pneumonia has a high recurrence rate, and oral care by dentists has been found effective in preventing its onset; however, this has not been evaluated using prospective studies. Therefore, we conducted a prospective study to evaluate the effectiveness of professional oral care by dentists in reducing aspiration pneumonia recurrence in older adult patients.
METHODS: In this prospective cohort study, we evaluated a dental oral care intervention, using a historical control group (control group). It was conducted at a single-centre regional core hospital in Japan that serves a large number of patients aged older than 80 years. Patients who were hospitalised for aspiration pneumonia were included in this study. During the study period (1 April 2021 to 31 March 2022), the clinical group received weekly professional cleaning by a dentist and the control group received standard oral care by a nurse as usual from 1 April 2020 to 31 March 2021. The dentist oral care group received weekly professional oral care from a dentist and was followed prospectively for 1 year. A Kaplan-Meier analysis was used to evaluate the timing of recurrent aspiration pneumonia or death. A Cox proportional hazards model was used to obtain a hazard ratio and determine the 95% confidence intervals.
RESULTS: There were 91 participants in the clinical group and 94 in the control group. The mean age of participants was 85 years, and 75 (40.5%) were female. The recurrence rate was 27.5% in the clinical group and 44.7% in the control group (P = .005). Professional cleaning by a dentist reduced the risk of recurrence of aspiration pneumonia by approximately 50% (adjusted hazard ratio, 0.465; 95% confidence interval, 0.278-0.78).
CONCLUSIONS: Professional cleaning by a dentist was associated with a lower rate of aspiration pneumonia recurrence than nurse-provided conventional oral care.

Introduction: Clinical pathways (CPWs) are patient management tools based on a standardized treatment plan aimed at improving quality of care. This study aimed to investigate whether CPW-guided treatment has a favorable impact on the outcomes of hospitalized older patients with aspiration pneumonia. Method: This retrospective study included patients with aspiration pneumonia, aged ≥ 65 years, and hospitalized at a community hospital in Japan. CPW implementation was arbitrarily determined by the attending physician upon admission. Outcomes were compared according to with or without the CPW (CPW-group and non-CPW groups). Propensity score (PS)-based analyses were used to control for confounding factors. Logistic regression analyses were conducted to evaluate the impact of CPW on the clinical course and outcomes. Results: Of 596 included patients, 167 (28%) received the CPW-guided treatment. The mortality rate was 16.4%. In multivariable model, CPW implementation did not increase the risk for total and 30-day mortality, and resulted in shorter antibiotic therapy duration (≤9 days) (PS matching (PSM): odds ratio (OR) 0.50, p = 0.001; inverse provability of treatment weighting (IPTW): OR 0.48, p < 0.001) and length of hospital stay (≤21 days) (PSM: OR 0.67, p = 0.05; IPTW: OR 0.66, p = 0.03). Conclusions: This study support CPW utility in this population.

BACKGROUND: Aspiration pneumonia (AP) is a subset of pneumonia caused by the aspiration of food and fluids to the lungs and is highly prevalent in the older population. Oropharyngeal dysphagia (OD) is one of the risk factors for AP and it is also associated with malnutrition, dehydration and poor functional outcomes. As pneumonia is the second most common infection in nursing homes (NHs) and OD represents a major concern to NH staff, good practices for the prevention of AP in older adults at risk of OD are needed.
OBJECTIVE: The aim of this modified e-Delphi study is to build consensus among a panel of experts regarding a set of recommendations for NH staff on good practices to prevent AP in older adults at risk of OD living in NHs. The objective of this paper is to establish the methodology inherent to the Delphi study.
METHODS: An online modified Delphi study will be developed in three rounds. Criteria for the Delphi panel participants include holding a master\'s or doctoral degree in OD or speech and language therapy; or having 10 or more years of experience in OD; or having at least one scientific publication related to OD. A previously described modified Delphi methodology will be used to achieve consensus (75% agreement). An additional round will be performed to collect the experts\' perspectives regarding the priority for application of each recommendation previously validated.
CONCLUSIONS: This protocol aimed to describe the methodology of a future Delphi study on the prevention of AP, seeking to fulfil the gap in the literature regarding this topic. The modified Delphi technique is a widely used method for collecting experts\' opinion in health sciences, but the absence of standardised guidelines allows some heterogeneity between studies with the same aim.
CONCLUSIONS: What is already known on the subject Aspiration pneumonia (AP) is related to three main risk factors: impaired safety of swallow, impaired nutritional status and poor oral health. It is known that being dependent for feeding is one of the main risk factors for AP and around 50% of nursing home (NH) residents need feeding assistance. Thus, it is important to promote specialised intervention and care by the NH staff for preventing AP. What this paper adds to existing knowledge It is hypothesised that increasing the knowledge of NH staff regarding the best practices for preventing AP in older adults at risk of oropharyngeal dysphagia (OD) will improve outcomes such as quality of life, incidence of AP and mortality. What are the potential or actual clinical implications of this work? The recommendations resulting from this study will address a current gap in healthcare practice of NH staff regarding older adults at increased risk for OD and, consequently, for AP.