Anaerobic Antibiotic Coverage in Aspiration Pneumonia

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ORIGINAL RESEARCH | ARTICLES IN PRESS
Anaerobic antibiotic coverage in

aspiration pneumonia and the
associated benefits and harms: A
retrospective cohort study
Anthony D. Bai, MD MSc  ∗
 •
Siddhartha Srivastava, MD MSc ∗
•
Geneviève C. Digby, MD MSc • Vincent Girard, MD •
Fahad Razak, MD MSc ∗∗
•
Amol A. Verma, MD MPhil ∗∗
• Show footnotes
Open Access • Published: February 20, 2024 •
DOI: https://doi.org/10.1016/j.chest.2024.02.025
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Abstract
Background
Antibiotics with extended anaerobic coverage are
commonly used to treat aspiration pneumonia,
which is not recommended by current guidelines.
Research question
In patients admitted to hospital for community-
acquired aspiration pneumonia, is there a
difference between antibiotic therapy with limited
anaerobic coverage (LAC) versus 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 the patient with
aspiration pneumonia and prescribed guideline-
concordant first-line community-acquired
pneumonia parenteral antibiotic therapy within 48
hours of admission. Patients were then
categorized into LAC group if they received
ceftriaxone, cefotaxime or levofloxacin. Patients
were in 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 mortality in hospital.
Secondary outcomes included incident C. difficile
colitis occurring after admission. Overlap weighting
of propensity scores was used to balance baseline
prognostic factors.
Results
There were 2,683 and 1,316 patients in the LAC
and EAC group respectively. In hospital, 814
(30.3%) and 422 (32.1%) patients in the LAC and
EAC group died respectively. C. difficile colitis
occurred in 5 or less (≤0.2%) and 11 to 15 (0.8%
to 1.1%) patients in the LAC and EAC group
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% to 1.7%)
for C. difficile colitis.
Interpretation
Extended anaerobic coverage is likely
unnecessary in aspiration pneumonia because it is
associated with no additional mortality benefit, only
an increased risk of C. difficile colitis.
Key Words
Aspiration pneumonia • antibiotic treatment •
mortality
Abbreviations list:
ATS (American Thoracic Society), CAP

(Community Acquired Pneumonia), COPD (chronic
obstructive pulmonary disease), CI (Confidence
Interval), CIF (Cumulative Incidence Function),
EAC (Extended Anaerobic Coverage), ICD-10-CA
(International and Statistical Classification of
Diseases and Related Health Problems, Tenth
Revision, Canada), ICU (Intensive Care Unit),
IDSA (Infectious Diseases Society of America),
IQR (Interquartile Range), LAC (Limited Anaerobic
Coverage), mLAPS (modified Laboratory-based
Acute Physiology Score), RCT (Randomized
Controlled Trial), SD (Standard Deviation), sHR
(sub-distribution Hazard Ratio), STROBE
(Strengthening the Reporting of Observational
Studies in Epidemiology)
Article info
Publication history
Accepted: February 19, 2024
Received in revised form: February 8, 2024
Received: December 12, 2023
Publication stage
In Press Journal Pre-Proof
Footnotes
Conflict of Interest Statement
Financial / non-financial disclosures: There was no

specific funding for this study. The development of
the GEMINI Data platform has been supported
with funding from the Canadian Cancer Society,
the Canadian Frailty Network, the Canadian
Institutes of Health Research, the Canadian
Medical Protective Association, Green Shield
Canada Foundation, the Natural Sciences and
Engineering Research Council of Canada, Ontario
Health, the St. Michael’s Hospital Foundation, the
St. Michael’s Hospital Association Innovation
Fund, the University of Toronto Department of
Medicine, and in-kind support from partner
hospitals and the Vector Institute. Amol Verma
receives salary support as the Temerty Professor
of Artificial Intelligence Research and Education at
the University of Toronto. There are no conflicts of
interest for the other authors.
Role of the sponsors: The funder had no role in

the design and conduct of the study.
Identification
DOI: https://doi.org/10.1016/j.chest.2024.02.025
Copyright
© 2024 Published by Elsevier Inc under license
from the American College of Chest Physicians.
User license
Creative Commons Attribution (CC BY 4.0) |
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Anaerobic antibiotic coverage in

This paper is only available as a PDF. To

ATS (American Thoracic Society), CAP

Financial / non-financial disclosures: There was no

Role of the sponsors: The funder had no role in

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