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Post-stroke pneumonia is associated with increased mortality and poor functional outcomes. This study assessed the effectiveness of antibiotic prophylaxis for reducing pneumonia in patients with dysphagia after acute stroke. We did a prospective, multicentre, cluster-randomised, open-label controlled trial with masked endpoint assessment of patients older than 18 years with dysphagia after new stroke recruited from 48 stroke units in the UK, accredited and included in the UK National Stroke Audit. We excluded patients with contraindications to antibiotics, pre-existing dysphagia, or known infections, or who were not expected to survive beyond 14 days. We randomly assigned the units (1:1) by computer to give either prophylactic antibiotics for 7 days plus standard stroke unit care or standard stroke unit care only to patients clustered in the units within 48 h of stroke onset. We did the randomisation with minimisation to stratify for number of admissions and access to specialist care. Patient and staff who did the assessments and analyses were masked to stroke unit allocation. The primary outcome was post-stroke pneumonia in the first 14 days, assessed with both a criteria-based, hierarchical algorithm and by physician diagnosis in the intention-to-treat population. Safety was also analysed by intention to treat. This trial is closed to new participants and is registered with isrctn.com, number ISRCTN37118456. Between April 21, 2008, and May 17, 2014, we randomly assigned 48 stroke units (and 1224 patients clustered within the units) to the two treatment groups: 24 to antibiotics and 24 to standard care alone (control). 11 units and seven patients withdrew after randomisation before 14 days, leaving 1217 patients in 37 units for the intention-to-treat analysis (615 patients in the antibiotics group, 602 in control). Prophylactic antibiotics did not affect the incidence of algorithm-defined post-stroke pneumonia (71 [13%] of 564 patients in antibiotics group vs 52 [10%] of 524 in control group; marginal adjusted odds ratio [OR] 1·21 [95% CI 0·71–2·08], p=0·489, intraclass correlation coefficient [ICC] 0·06 [95% CI 0·02–0·17]. Algorithm-defined post-stroke pneumonia could not be established in 129 (10%) patients because of missing data. Additionally, we noted no differences in physician-diagnosed post-stroke pneumonia between groups (101 [16%] of 615 patients vs 91 [15%] of 602, adjusted OR 1·01 [95% CI 0·61–1·68], p=0·957, ICC 0·08 [95% CI 0·03–0·21]). The most common adverse events were infections unrelated to post-stroke pneumonia (mainly urinary tract infections), which were less frequent in the antibiotics group (22 [4%] of 615 vs 45 [7%] of 602; OR 0·55 [0·32–0·92], p=0·02). Diarrhoea positive for Clostridium difficile occurred in two patients (<1%) in the antibiotics group and four (<1%) in the control group, and meticillin-resistant Staphylococcus aureus colonisation occurred in 11 patients (2%) in the antibiotics group and 14 (2%) in the control group. Antibiotic prophylaxis cannot be recommended for prevention of post-stroke pneumonia in patients with dysphagia after stroke managed in stroke units. UK National Institute for Health Research.

Patients with cerebral hemorrhage often require a tracheal intubation to protect the airway and maintain oxygenation. Due to the use of analgesic and sedative drugs during endotracheal intubation and the opening of the glottis may easily cause aspiration pneumonia. Ceftriaxone is a semi-synthetic third-generation cephalosporin with strong antimicrobial activity against most gram-positive and gram-negative bacteria. It can effectively prevent and treat aspiration pneumonia. This is a prospective, randomized, controlled, double-blind clinical study. Patients with intracerebral hemorrhage (ICH) undergoing endotracheal intubation in Dong E Hospital of Shandong Province from April 2023 to April 2025 will be enrolled and randomly assigned to the intervention group or control group. The intervention group will be treated using 100mL 0.9% sodium chloride with 2g ceftriaxone intravenously over the course of one hour beginning within two hours after endotracheal intubation. The control group will be given 100mL 0.9% sodium chloride injection intravenously of the course of one hour beginning within two hours after endotracheal intubation. The primary outcome is the incidence of aspiration pneumonia within 48 hours after endotracheal intubation. Secondary outcomes include: intensity of antimicrobial use, length of hospital stay, duration without mechanical ventilation, and 28-day mortality. The primary objective of this study is to explore whether a single dose of ceftriaxone administered during endotracheal intubation in patients with ICH reduced the incidence of pneumonia within 48 hours and provide evidence for the prevention of aspiration pneumonia in patients with ICH with endotracheal intubation. The trial is registered at the Chinese Clinical Trial Registry: ChiCTR2200066837. Registered on December 19, 2022.

The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient’s sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia ( n  = 26) and moderate-to-severe dysphagia ( n  = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0–4) vs. 2.5 (0–4) ( p  = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.

Background Pneumonia is common among post-stroke dysphagia (PSD) patients, especially in the week following a stroke; pneumonia may prolong hospital stays or lead to mortality. We examined whether a tailored “CEME” (oral cleaning, oral motor exercises, Chinese acupoint and salivary gland massage, and safe-swallowing education) oral health intervention program could improve swallowing function and oral health and reduce the incidence of stroke-associated pneumonia (SAP) in PSD patients. Methods We conducted an assessor-blinded randomized controlled trial in a tertiary hospital in China. Eighty-four PSD patients were recruited and randomly assigned to either the control group ( n  = 42) or the experimental group ( n  = 42). The control group received conventional oral care, whereas those in the experimental group participated in the “CEME” oral health intervention program, which included oral cleaning, oral motor exercises, Chinese acupoint and salivary gland massage, and safe-swallowing education. Outcome measures were conducted on day 7 of the implementation of the intervention, including stroke-associated pneumonia incidence, swallowing function (measured via the Water Swallowing Test (WST) and the Functional Oral Intake Scale [FOIS]), overall oral health (measured via the Oral Health Assessment Tool [OHAT]), salivary secretion status (measured via the modified Schirmer test [MST]), oral hygiene status (measured via the Plaque Index [PI]), and stroke severity (assessed via the National Institute of Health Stroke Scale [NIHSS]). Results The incidence of SAP in the experimental group was 10.26% (4/39), lower than the corresponding figure in the control group of 32.43% (12/37) ( P  < 0.05); furthermore, the WST grades, OHAT scores, and Plaque Index exhibited by the experimental group were better than the control group ( P  < 0.05). No significant differences were observed in FOIS grades, MST or NIHSS scores ( P  > 0.05). Conclusion The tailored CEME intervention effectively reduced SAP incidence in PSD patients while concomitantly improving oral health and water swallowing function. Trial registration ChiCTR2300074510, registered on August 08, 2023.

•This study compared intermittent oro-esophageal and nasogastric tubes in cerebral small vessel disease patients.•Intermittent oro-esophageal tubes showed advantages in improving function and nutritional status.•Intermittent oro-esophageal tubes can significantly improve aspiration pneumonia. This study reported the clinical effect of intermittent oro-esophageal tube feeding (IOE) versus nasogastric tube feeding (NGT) on cerebral small vessel disease (CSVD) patients with dysphagia. This randomized controlled study included 60 CSVD patients with dysphagia who received routine treatment. Participants were randomly divided into the intervention group (with IOE, n = 30) and the control group (with NGT, n = 30). The study lasted 15 days for each patient and assessments were conducted at baseline and after treatment. The primary outcome was dysphagia including Penetration-Aspiration Scale and Functional Oral Intake Scale. The secondary outcomes were 1) nutritional status, including (i) body mass index, (ii) serum albumin, (iii) hemoglobin, 2) aspiration pneumonia, 3) activities of daily living (ADL), 4) quality of life (QOL). At admission, there were no significant differences (P > 0.05) in baseline assessment. After treatment, both groups showed significant improvement in dysphagia, nutritional status, ADL, and QOL. There were significant differences (P < 0.05) between the two groups in dysphagia, nutritional status [body mass index: (19.53 ± 1.40) kg/m2 vs. (18.35 ± 1.54) kg/m2; albumin: (42.06 ± 2.64) g/L vs. (39.49 ± 2.77) g/L; hemoglobin: (128.85 ± 6.34) mg/L vs. (123.14 ± 7.92) mg/L], aspiration pneumonia (6.67% vs. 33.33%), ADL [(69.07 ± 6.33) vs. (63.56 ± 6.75)], and QOL [(78.07 ± 8.64) vs. (72.48 ± 7.76)]. There were no severe adverse events during the treatment. Compared to NGT, IOE demonstrated advantages in improving dysphagia, nutritional status, ADL, QOL, and aspiration pneumonia in CSVD patients with dysphagia who received routine treatment.

Risk factors for nosocomial pneumonia, such as gastro-oesophageal reflux and subsequent aspiration, can be reduced by semirecumbent body position in intensive-care patients. The objective of this study was to assess whether the incidence of nosocomial pneumonia can also be reduced by this measure. This trial was stopped after the planned interim analysis. 86 intubated and mechanically ventilated patients of one medical and one respiratory intensive-care unit at a tertiary-care university hospital were randomly assigned to semirecumbent (n=39) or supine (n=47) body position. The frequency of clinically suspected and microbiologically confirmed nosocomial pneumonia (clinical plus quantitative bacteriological criteria) was assessed in both groups. Body position was analysed together with known risk factors for nosocomial pneumonia. The frequency of clinically suspected nosocomial pneumonia was lower in the semirecumbent group than in the supine group (three of 39 [8%] vs 16 of 47 [34%]; 95% CI for difference 10·0–42.0, p=0·003). This was also true for microbiologically confirmed pneumonia (semirecumbent 2/39 [5%] vs supine 11/47 [23%]; 4.2–31.8, p=0·018). Supine body position (odds ratio 6.8 [1.7–26.7], p=0·006) and enteral nutrition (5.7 [1.5–22.8], p=0·013) were independent risk factors for nosocomial pneumonia and the frequency was highest for patients receiving enteral nutrition in the supine body position (14/28, 50%). Mechanical ventilation for 7 days or more (10·9 [3.0–40·4], p=0·001) and a Glasgow coma scale score of less than 9 were additional risk factors. The semirecumbent body position reduces frequency and risk of nosocomial pneumonia, especially in patients who receive enteral nutrition. The risk of nosocomial pneumonia is increased by long-duration mechanical ventilation and decreased consciousness.

Background There are limited data from low‐ to middle‐income countries (LMIC) on the incidence, risk factors, treatment outcomes, and antibiotic susceptibility spectrum of aspiration pneumonia (AsP). Methods We conducted a post hoc analysis of a randomized control trial in which adult patients with locally advanced head and neck cancers had received 66–70 Gy of radiation combined with cisplatin 30 mg/m2 weekly for 6–7 weeks or cisplatin at the same dose with nimotuzumab 200 mg once weekly till the completion of radiation. The following data were extracted and analyzed—the incidence of AsP, time to the onset of AsP, risk factors, treatment outcomes of AsP, and its impact on progression‐free survival (PFS), locoregional control (LRC) rates, and overall survival (OS). Results Out of 536 patients enrolled in the study, 151 (28.3%, 95% confidence interval [CI] 24.5–2.1) patients developed AsP. The median time to develop AsP was 39 days (95% CI 34–44). Only baseline dysphagia (odds ratio = 3.76, 95% CI 1.05–13.51, p = 0.042) was associated with a significant risk of development of AsP. Among the patients in which pathogenic organism was isolated (69 patients), gram‐negative species was isolated in 63 patients (89%). Cisplatin at 200 mg/m2 or more was delivered in 312 (81%) patients in the non‐AsP cohort versus 107 (70.9%) patients in AsP cohort (p = 0.014). There was no statistical difference in LRC (hazard ratio [HR] = 1.057; 95% CI 0.771–1.448), PFS (HR = 1.176; 95% CI 0.89–1.553), and OS (HR = 1.233; 95% CI 0.939–1.618) between the two cohorts. Conclusion Aspiration pneumonia is a common complication in head and neck malignancies and patients with baseline dysphagia are at high risk. Gram‐negative bacteria are the predominant causative agents. The use of broad‐spectrum antibiotics results in resolution of symptoms. Aspiration pneumonia is a common complication in head and neck malignancies and patients with baseline dysphagia are at high risk. Gram‐negative bacteria are the predominant causative agents. The use of broad‐spectrum antibiotics results in resolution of symptoms.

There is considerable clinical interest in the risks and benefits of offering oral water intake, in the form of water protocols, to patients with thin-liquid dysphagia. We describe the design and implementation of a water protocol for patients in a rehabilitation setting with videofluoroscopically confirmed thin-liquid aspiration. The GF Strong Water Protocol (GFSWP) is an interdisciplinary initiative, with roles and accountabilities specified for different members of the interprofessional health-care team. Rules of the water protocol specify mode of water access (independent, supervised), the implementation of any safe swallowing strategies recommended on the basis of the patient’s videofluoroscopy, and procedures for evaluating and addressing oral care needs. Trial implementation of the water protocol in 15 participants showed that they remained free of adverse events, including pneumonia, over the course of an initial 14-day trial and continuing until discharge from the facility (range = 13–108 days). Seven participants were randomly assigned to a 14-day control phase in which they received standard care (without water access). Fluid intake measures taken after the oral water intake phase were increased (mean = 1,845 cc; 95% confidence interval: 1,520–2,169 cc) compared to those in the control phase (mean = 1,474 cc; 95% CI: 1,113–1,836 cc), with oral water intake measures comprising, on average, 563 cc (range = 238–888 cc) of the total post water trial fluid intake values. Fluid intake increased at least 10% of the calculated fluid requirements in 11/15 participants who received oral water access. These participants reported favorable quality-of-life outcomes, measured using the Swal-QOL. These findings support the implementation of the GFSWP, including its exclusion criteria, rules, and plans of care, for rehabilitation patients who aspirate thin liquids.

Our clinical experience suggested that elemental diets were associated with a reduction in aspiration pneumonia among bedridden patients with percutaneous endoscopic gastrostomy (PEG). We compared the effects of elemental and standard liquid diets on the risk of clinical aspiration pneumonia and gastric emptying in bedridden patients receiving PEG feedings. Study 1: consecutive bedridden PEG patients received elemental diets or standard liquid diets in the same fashion. The frequency of defecation, diet aspirated from the trachea, and aspiration pneumonia during hospitalization were prospectively recorded. Study 2: a randomized, crossover trial using elemental or standard liquid diets containing (13)C sodium acetate as a tracer given to bedridden PEG patients who had experienced aspiration pneumonia. (13)C breath tests were performed to estimate gastric emptying. Study 1: 127 patients were enrolled, 60 with elemental and 67 with standard liquid diets. The diet was aspirated from the trachea in none (0%) with the elemental diet vs. 8 (11.9%) with standard liquid diets (P=0.0057); aspiration pneumonia developed none with the elemental diet vs. 5 (7.5%) with standard liquid diets (P=0.031) (number needed to treat 14, 95% confidence interval 7-85). Study 2: 19 patients were enrolled. The elemental diet was associated with a significant increase in the 10, 30 or 50% emptying (excretion) time (P<0.001) and increased the area under the curve (% dose/h) compared with the standard liquid diet (P<0.05). Elemental diets were associated with more rapid gastric empting and fewer episodes of aspiration than standard liquid diets in bedridden PEG patients. They may be preferred for bedridden PEG patients especially who have experienced aspiration pneumonia. Properly performed randomized-controlled trials are needed to prove this potential benefit.

Objective: To examine whether patients assessed for initiation of oral intake only by Facial-Oral Tract Therapy had a greater risk of developing aspiration pneumonia during neurorehabilitation than patients assessed by Fibreoptic Endoscopic Evaluation of Swallowing. Design: Randomized controlled trial. Setting: Specialized, national neurorehabilitation centre. Subjects: Adult patients with acquired brain injury. Six hundred and seventy-nine patients were assessed for eligibility and 138 were randomly allocated between June 2009 and April 2011. Interventions: Assessment by Facial-Oral Tract Therapy (control group) or Fibreoptic Endoscopic Evaluation of Swallowing (intervention group). Main measure: Primary outcome was the number of aspiration pneumonias that developed after initiation of oral intake. Results: One hundred and nineteen patients were included in the analysis of the primary outcome (62 controls/57 interventions). Sixteen patients were clinically diagnosed with pneumonia (4 controls/12 interventions). Nine patients had to be excluded: 6 patients got pneumonia before initiating oral intake; 3 patients with the clinical diagnosis of pneumonia did not show radiological signs. Seven patients were left for analysis, 4 of whom developed aspiration pneumonia within 10 days after initiating oral intake (1 control/3 interventions). Conclusion: In the presence of a structured clinical assessment with the Facial-Oral Tract Therapy approach, it is unnecessary to undertake an instrumental investigation of swallowing before initiation of oral intake.