Pneumonia and Pneumonitis

Question 1

What are the major types of pneumonia?

Answer 1

• Community-acquired (CAP)
• Hospital-acquired (HAP)
• Ventilator-associated (VAP)
• Atypical pneumonia (walking pneumonia)
• Aspiration pneumonia

Question 2

What is the most common cause of pneumonia in neonates (<4 weeks)?

Answer 2

Group B Streptococcus > E. coli > Listeria

Question 3

What are the most common causes of pneumonia in pediatrics, aged 4 weeks to 18 years?

Answer 3

RSV (viral), Mycoplasma pneumoniae, Chlamydia trachomatis (infants 3 years), Chlamydia pneumoniae (school-aged), Strep pneumoniae.

Question 4

Children 1 month to 4 months most commonly get pneumonia from … ?

Answer 4

Viruses (most common overall) – Respiratory Syncytial Virus (RSV) is the leading cause. Bacterial causes fall after viral, with Streptococcus pneumoniae being the most common bacterial cause. Chlamydia trachomatis (afebrile pneumonia in neonates and a very common cause in 3 year olds), then Bordetella pertussis (if unvaccinated).

Question 5

Which pathogens commonly infect children aged 4 months to 5 years and cause pneumonia?

Answer 5

Viruses are the most common overall (RSV, Influenza, Parainfluenza, Adenovirus), followed by bacterial, where Streptococcus pneumoniae is the most common bacterial cause, followed by Haemophilus influenzae type B (if unvaccinated). The pathogen that is the most likely to cause atypical pneumonia is Mycoplasma pneumoniae, however, this form is a less common cause for pneumonia in this group (but still possible).

Question 6

What are the most common causes for pneumonia between 5 years to 18 years old?

Answer 6

Mycoplasma pneumoniae (most common), followed by Streptococcus pneumoniae (most common typical bacterial cause), and finally viral (RSV, Influenza, Parainfluenza, Adenovirus), however, viral is less common in this age group compared to younger children).

Question 7

What are the most common causes of pneumonia in adults (18-40 years)?

Answer 7

The most common overall is Mycoplasma pneumoniae and is associated with walking pneumonia (Chlamydia pneumoniae can be implicated as well, but less commonly). The most common bacterial cause is Streptococcus pneumoniae and this is associated with lobar pneumonia, high fever, productive cough. Common in seasonal outbreaks are viral causes for pneumonia like Influenza, RSV, and Adenovirus.

Question 8

What are the most common causes of pneumonia in older adults (40-65 years)?

Answer 8

The most common cause overall in this group is a bacterial, Strep pneumoniae, which happens to be the most common cause of pneumonia in all adults (overall) because younger adults tend to get walking (atypical) pneumonia more frequently than pneumonia secondary to Strep pneumoniae. Strep pneumoniae presents with lobar consolidation, high fever, and productive cough. In patients who smoke or have lung disease like COPD, the most common organism is Haemophilus influenzae. Anaerobes leading to pneumonia is commonly seen with aspiration pneumonia. Mycoplasma pneumoniae is still a possibility, but less common than Strep pneumoniae. Finally, viral causes (Influenza, RSV, Parainfluenza, Adenovirus) more commonly are seasonal or with outbreaks.

Question 9

What are the most common causes of pneumonia in elderly (>65 years)?

Answer 9

Strep pneumoniae > Influenza virus > Anaerobes > H. influenzae > Gram-negative rods

Question 10

When is it appropriate to consider Listeria as a cause of pneumonia in the elderly population?

Answer 10

• Immunocompromised elderly patients
• Severe underlying conditions (e.g., malignancy, end-stage renal disease, diabetes)
• Nursing home residents or patients with chronic illnesses

Question 11

What condition can be seen in the elderly population that causes pneumonia secondary to nutritional deficits?

Answer 11

Elderly patients with impaired nutritional status may develop a secondary hypogammaglobulinemia, and are at risk of recurrent infections due to encapsulated bacteria (eg, Streptococcus pneumoniae).

Question 12

What condition can cause of persistent/recurrent lung infections in the elderly, leading to infection in the upper or apical lobes?

Answer 12

Pulmonary tuberculosis is a potential cause of persistent/recurrent lung infections in the elderly. In the majority of cases
(>80%), tuberculosis will involve the upper/apical lung regions rather than the mid and lower lobes.

Question 13

What is the most common cause of pneumonia in alcoholics?

Answer 13

Klebsiella pneumoniae and anaerobes (aspiration pneumonia).

Question 14

What is the most common cause of pneumonia in IV drug users?

Answer 14

Staph aureus, Strep pneumoniae, and Pseudomonas

Question 15

What are the most common causes of pneumonia in cystic fibrosis?

Answer 15

Staph aureus when the patient is less than 20 years old
Pseudomonas aeruginosa when the patient is older than 20 years old

Question 16

What is a less common but more aggressive colonizer compared to Pseudomonas aeruginosa in cystic fibrosis?

Answer 16

Burkholderia cepacia. Importantly, this can exclude patients from a lung transplantation.

Question 17

What are the pathogens responsible for pneumonia in post-viral infections?

Answer 17

Strep pneumoniae, Staph aureus, Haemophilus influenzae.

Question 18

What are the common microbes responsible for pneumonia in aspiration?

Answer 18

Anaerobes (Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides). They commonly can form lung abscesses.

Question 19

What are the general symptoms of pneumonia?

Answer 19

Fever, chills, productive cough, dyspnea, pleuritic chest pain.

Question 20

What physical exam findings tend to be found with pneumonia?

Answer 20

Rales, dullness to percussion, increased tactile fremitus, bronchial breath sounds.

Question 21

What is the gold standard for pneumonia diagnosis?

Answer 21

Chest X-ray (CXR).

Question 22

A 53-year-old man presents to the emergency department due to chest pain with inspiration, shortness of breath, and a cough productive of yellow sputum. His symptoms developed two days prior and have progressively worsened. The patient was in good health prior to returning from an overseas trip to Europe five days ago. Medical history is notable for atrial fibrillation and coronary artery disease. Temperature is 39.2 °C (102.6 °F), blood pressure is 125/81 mmHg, pulse is 114/min, respiratory rate is 24/min, and oxygen saturation is 90% on room air. Physical examination is notable for decreased breath sounds in the left lower lung. Which of the following would be most helpful for confirming this patient’s diagnosis?
A) Serum alpha-fetoprotein levels
B) Sputum culture and Gram stain
C) CT angiography of the chest
D) Frontal and lateral view chest radiographs
E) Quantiferon gold assay

Answer 22

The diagnosis of pneumonia can be made based on a patient’s history, physical examination, and laboratory studies, and is confirmed with imaging. Chest radiograph is the first-line imaging modality. This patient presents with dyspnea, pleuritic chest pain, and a productive cough. Vital signs are notable for fever, tachypnea, and decreased oxygen saturation. Lung exam is significant for decreased breath sounds in the left lower lung field. In combination, these findings are most suggestive of community-acquired pneumonia. Chest radiography, ideally both frontal and lateral views, would be most helpful for confirming the patient’s condition. Pneumonia is an infection of the lung parenchyma that results in inflammation of one or both lungs. The diagnosis is made based on a combination of the history, physical examination, and laboratory studies. It is typically confirmed with chest imaging. Laboratory studies such as a complete blood count and arterial blood gas are often ordered. For imaging, chest radiography is the first-line modality. A CT scan of the chest can be obtained if there is strong clinical suspicion for pneumonia but the chest radiograph is negative. Once a diagnosis has been made, patients should be started on empiric antibiotics. This is typically a beta-lactam plus a macrolide, though a macrolide, doxycycline, or amoxicillin alone can be used in certain patients with mild CAP. Supplemental oxygen should be given to maintain oxygen saturation levels above 92%.

Question 23

What are the common chest X-ray findings in typical (bacterial) pneumonia?

Answer 23

Lobar consolidation (typical bacteria).

Question 24

What are the common chest X-ray findings in atypical pneumonia?

Answer 24

interstitial infiltrates (atypical pathogens)

Question 25

What are the common chest X-ray findings in pneumonia secondary to anaerobes, TB, fungal infections?

Answer 25

cavitation (anaerobes, TB, fungal infections).

Question 26

What is the role of sputum culture in pneumonia?

Answer 26

Used in severe pneumonia, not always required for mild outpatient cases.

Question 27

What is the role of urine antigen tests in pneumonia?

Answer 27

Legionella and Strep pneumoniae can be diagnosed via urine antigen testing (according to a video on Osmosis, so can Chlamydia).

Question 28

What is the purpose of CURB-65 criteria?

Answer 28

This is used to determine pneumonia severity and guide management. Each factor is 1-point, and more than 2 points requires inpatient stay: - Confusion - Uremia (BUN >19) - Respiratory rate >30 - BP <90/60 - Age >65.

Question 29

What are the antibiotics given for outpatient treatment for community-acquired pneumonia (CAP)?

Answer 29

- Macrolide (azithromycin) or doxycycline. - If recent antibiotic use, or high resistance use beta-lactam (Amoxicillin) + macrolide or respiratory fluoroquinolone (levofloxacin, moxifloxacin).

Question 30

What is the threshold for inpatient treatment for community acquired pneumonia?

Answer 30

2 points on CURB-65

Question 31

How is Inpatient treatment for CAP (non-ICU) treated?

Answer 31

Beta-lactam (ceftriaxone, ampicillin-sulbactam) + macrolide (azithromycin) OR fluoroquinolone (levofloxacin, moxifloxacin).

Question 32

What is the threshold for ICU management for CAP?

Answer 32

Usually 3 points on CURB-65.

Question 33

ICU treatment for CAP

Answer 33

Beta-lactam + macrolide OR Beta-lactam + fluoroquinolone. Cover MRSA with vancomycin or linezolid if the patient has signs of septic shock or mechanically ventilated. Cover pseudomonas for patients with structural lung disease such as bronchiectasis with Pip/tazo, cefepime, or meropenem.

Question 34

What are the common causes of HAP and VAP?

Answer 34

MRSA (Staph aureus), Pseudomonas, Gram-negative rods (E. coli, Klebsiella, Enterobacter), a common complication of ARDS.

Question 35

What should be the first diagnostic step in VAP?

Answer 35

An increased requirement for ventilatory support (going from 5 to 10 mmHg on PEEP, increasing FiO2, with lowering oxygen levels) is consistent with ventilator-associated pneumonia (VAP), VAP can develop after ≥ 48 hours of mechanical ventilation and is most commonly caused by microaspiration of virulent oropharyngeal organisms (eg, Escherichia coli, Streptococcus species). Other signs of VAP include leukocytosis, tachypnea, and decreased oxygenation. Due to the nonspecific nature of its presentation and the increasing prevalence of drug-resistant organisms, respiratory sampling is necessary to confirm the diagnosis and appropriately tailor antibiotic therapy. Options include **bronchoalveolar lavage** or **tracheobronchial aspiration**. Once sampling has been performed, empiric antibiotics can be initiated while awaiting culture data. The specific regimen depends on individual risk factors for multidrug-resistant organisms and typically includes gram-positive and gram-negative coverage. Patients with risk factors for resistant pathogens should receive coverage for methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa.

Question 36

What is the empiric antibiotic therapy for HAP/VAP?

Answer 36

Vancomycin or linezolid (MRSA) + Pip/tazo, cefepime, or meropenem (Pseudomonas).

Question 37

What is the best approach for VAP following positive cultures but declining condition?

Answer 37

Change Abx and assess for VAP complications such as abscess or empyema.

Question 38

What is the recommended imaging modality for recurrent pneumonia?

Answer 38

Computed tomography (CT) scan is frequently performed in patients with recurrent pneumonia to identify a mass lesion in the lung or airway. It can also help identify atypical infections as well as noninfectious pulmonary disorders. Additionally, bronchoscopy and biopsy can be useful in patients with recurrent pneumonia to rule out endobronchial obstruction. This is especially helpful in patients with known or suspected malignancy.

Question 39

What are the most common causes of atypical pneumonia?

Answer 39

Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella, Coxiella, Viruses.

Question 40

What are the distinguishing characteristics for Mycoplasma pneumoniae?

Answer 40

Most common in young adults (ages 5-40), especially, college students in dormitories, Military recruits, and School-aged children.

Question 41

How is Mycoplasma pneumoniae treated?

Answer 41

Macrolides (azithromycin, clarithromycin) or doxycycline

Question 42

What are the risk factors for Legionella pneumonia?

Answer 42

Contaminated water sources, smoking, immunosuppressed, lung disease diseases, chronic kidney disease, diabetes, or recent hospitalization.

Question 43

What are the distinguishing features of Legionella pneumonia?

Answer 43

High fever, GI symptoms (diarrhea), confusion, hyponatremia.

Question 44

What is the treatment for Legionella pneumonia?

Answer 44

Macrolides (azithromycin), Doxycycline or fluoroquinolones (levofloxacin).

Question 45

What are the most common aspiration pneumonia organisms?

Answer 45

Anaerobes (Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides).

Question 46

What can develop from aspiration pneumonia?

Answer 46

Lung abscess, which is a necrotizing pneumonia with cavitation and pus formation.

Question 47

What are the most common causes of lung abscesses?

Answer 47

Anaerobes (Peptostreptococcus, Fusobacterium, Prevotella, Bacteroides). Additionally MRSA and Klebsiella can cause lung a lung abscess. Consolidations and walled off abscesses generally takes 7-14 days, patients usually present with subacute symptoms. Common manifestations include fever, dyspnea, and cough productive of sour-tasting sputum. Chest imaging usually shows a fluid-filled space with an air-fluid level amid a pulmonary consolidation. Treatment with antibiotics (eg, ampicillin-sulbactam) is generally curative. Aspiration is common in individuals who have impaired cough or gag reflex due to periods of altered sensorium from seizure disorder, alcohol/substance use disorder, delirium, or dementia (eg, vascular dementia). Advanced age, poor dentition, and esophageal dysmotility also increase risk.

Question 48

How is a lung abscess diagnosed?

Answer 48

CXR or CT, showing pulmonary infiltrate with a cavitary region

Question 49

What techniques can help prevent aspiration pneumonia?

Answer 49

To prevent recurrent aspiration, patients with risk factors for aspiration should undergo a full speech and swallow evaluation. This evaluation is typically performed at the bedside; the patient is observed while ingesting liquids and solids of different consistencies. Modifications to position (eg, chin tuck) and diet (eg, thickened liquids) can often prevent additional episodes.

Question 50

What is the empiric treatment of lung abscess?

Answer 50

Clindamycin or ampicillin-sulbactam or carbapenem.

Question 51

What is the general vaccination recommendations for pneumonia prevention?

Answer 51

Pneumococcal vaccine for adults >65, high-risk patients, and yearly influenza vaccine.

Question 52

What is pneumonitis?

Answer 52

Inflammation of the lung parenchyma due to non-infectious causes such as aspiration, hypersensitivity reactions, medications, radiation, or environmental exposures.

Question 53

How does pneumonitis differ from pneumonia?

Answer 53

Pneumonitis is non-infectious lung inflammation, whereas pneumonia is infectious. Pneumonitis presents with dry cough and dyspnea, while pneumonia has productive cough, fever, and purulent sputum.

Question 54

What are the major types of pneumonitis?

Answer 54

Aspiration pneumonitis, hypersensitivity pneumonitis, radiation pneumonitis, drug-induced pneumonitis, and environmental/exposure pneumonitis.

Question 55

What are common symptoms of pneumonitis?

Answer 55

Nonproductive cough, dyspnea, fever, tachypnea, hypoxemia, and bibasilar rales.

Question 56

What causes hypersensitivity pneumonitis?

Answer 56

Organic dust exposure such as moldy hay (Farmer’s lung) or bird droppings (Bird Fancier’s lung).

Question 57

What medications can cause drug-induced pneumonitis?

Answer 57

Amiodarone, methotrexate, bleomycin, nitrofurantoin, checkpoint inhibitors like nivolumab.

Question 58

How does radiation pneumonitis occur?

Answer 58

Develops weeks to months after radiation therapy for breast cancer, lung cancer, or lymphoma.

Question 59

For hypersensitivity pneumonitis, drug-induced pneumonitis, and radiation pneumonitis, what is done first to diagnose?

Answer 59

First: Pulmonary Function Tests (PFTs) Second: High-Resolution CT (HRCT)

Question 60

What are the pulmonary function test (PFT) findings in pneumonitis?

Answer 60

Restrictive lung disease pattern (↓ FEV1, ↓ FVC, normal/increased FEV1/FVC) with decreased DLCO.

Question 61

What are key findings on chest imaging for pneumonitis?

Answer 61

Diffuse ground-glass opacities, bilateral patchy infiltrates, upper lobe fibrosis (chronic cases), honeycombing in late-stage disease.

Question 62

What is the first-line treatment for radiation pneumonitis?

Answer 62

Corticosteroids and oxygen therapy.

Question 63

How can hypersensitivity pneumonitis be confirmed?

Answer 63

Positive IgG antibodies against specific organic antigens and lymphocytic predominance on bronchoalveolar lavage.

Question 64

How is hypersensitivity pneumonitis managed?

Answer 64

Antigen avoidance and corticosteroids for severe cases.

Question 65

How is drug-induced pneumonitis managed?

Answer 65

Discontinue the offending drug and provide supportive care.

Question 66

How can exposure-related pneumonitis be prevented?

Answer 66

Avoid exposure to known causative agents (e.g., mold, bird droppings, asbestos).

Question 67

What are common causes of aspiration pneumonitis?

Answer 67

Post-anesthesia, Mechanical ventilation, GERD, Gastric acid aspiration, dysphagia, altered mental status, neurological disorders like Parkinson Disease and post-stroke, as well as altered consciousness (seizure or alcohol).

Question 68

How is aspiration pneumonitis managed, especially in patients with chronic diseases?

Answer 68

Supportive care with oxygen therapy, airway suctioning if needed; no routine antibiotics unless secondary infection occurs. For patients with neurological disorders like Parkinson's disease, oropharyngeal symptoms (dysarthria and drooling), and recurrent right-sided pneumonia, they typically have features of chronic aspiration. Nearly 90% of individuals with Parkinson's disease suffer from dysphagia during the course of the disease, and the resulting aspiration pneumonia is a leading cause of death. Aspiration pneumonia generally requires more aggressive intervention than typical community-acquired pneumonia. Aspiration often involves polymicrobial and anaerobic organisms, and patients with aspiration pneumonia often have poor underlying functional and nutritional status. Initial management includes blood and sputum cultures with initiation of broad-spectrum antibiotics with anaerobic coverage (eg, clindamycin). Once the patient has been stabilized, a bedside swallowing assessment may be helpful. Definitive diagnosis is made with a **videofluoroscopic swallowing study**. Based on results, a multidisciplinary dysphagia rehabilitation program can be initiated, usually with input from the dietary service, nursing, and speech therapy. Specific interventions typically include thickened liquids and modified swallowing techniques.

Question 69

An 83-year-old man presents to the emergency department for evaluation of shortness of breath. EMS reports that the patient was eating dinner when he suddenly started coughing and developed difficulty breathing. Past medical history includes Parkinson disease, hypertension, and hyperlipidemia. Temperature is 36.3°C (97.3°F), pulse is 120/min, blood pressure is 177/83 mmHg, respiratory rate is 18/min and oxygen saturation is 77% on room air. Physical exam shows an elderly patient unable to follow commands. Respiratory accessory muscle use, perioral cyanosis, and poor dental hygiene are noted. Which of the following is the best next step in management? A) Administer ceftriaxone and azithromycin B) Obtain ECG C) Rapid sequence intubation D) Administer albuterol nebulizer E) Bi-level positive airway pressure

Answer 69

Patients with suspected aspiration pneumonia/pneumonitis should first have their airway, breathing, and circulation evaluated. In patients with unstable vital signs and those at high risk for respiratory failure, endotracheal intubation and mechanical ventilation should be performed. This patient presents with acute onset shortness of breath. Given that the shortness of breath occurred abruptly while eating, this is likely an acute aspiration of Gl contents, likely causing aspiration pneumonitis. Given the patient's unstable vital signs and concern for airway compromise, the next best step in management is endotracheal intubation. Aspiration pneumonia and pneumonitis typically occur in individuals with impaired swallowing function or a decreased level of consciousness. In general, aspiration pneumonia occurs due to microaspirations of oropharyngeal contents, which are frequently colonized by pathogenic bacteria (most commonly Streptococcus pneumoniae, Staphylococcus aureus, and Haemophilus influenzae). Anaerobic bacteria may also be present. In general, aspiration (chemical) pneumonitis occurs due to aspiration of a large volume of sterile acidic gastric content, resulting in subsequent lung inflammation. Aspiration (chemical) pneumonitis can also predispose to aspiration pneumonia. Patients with symptoms suggestive of aspiration pneumonia/pneumonitis should first have their airway, breathing, and circulation evaluated. All unstable patients should have IV access established and continuous vital sign monitoring. Patients may require oropharyngeal or nasotracheal suctioning. Patients with normal mental status may benefit from noninvasive ventilation (e.g. bilevel positive airway pressure or high flow nasal cannula). Patients with findings of impending respiratory arrest, including persistent hypoxia, cyanosis, and altered mental status, should undergo endotracheal intubation and mechanical ventilation.

Question 70

A 79-year-old woman comes to the emergency department from an assisted living facility due to shortness of breath, cough, and fever. Past medical history is significant for dementia, prior right MCA stroke, hypertension, and diabetes mellitus. Temperature is 39.0°C (102.2°F), pulse is 108/min, blood pressure is 114/53 mmHg, respirations are 16/min, and oxygen saturation is 92% on room air. Physical examination shows a frail-appearing patient with poor dentition. Coarse lung sounds are auscultated over the right lung base. The patient is unable to pass a bedside swallow evaluation. Which of the following elements would favor a diagnosis of aspiration pneumonia over aspiration (chemical) pneumonitis? A) Recent administration of general anesthesia B) Gradual onset of symptoms C) Infiltrates in the dependent zones of the lungs D) Fever E) History of alcohol use disorder

Answer 70

Aspiration pneumonia and aspiration pneumonitis share many overlapping clinical features. A key differentiating clinical feature is that aspiration pneumonia tends to occur gradually in patients with impaired swallowing function, whereas aspiration pneumonitis tends to occur acutely after an inciting event. This patient presents with cough, shortness of breath, and fever without an acute inciting event. Examination is significant for rales over the right lung base, and the patient is unable to pass a bedside swallow evaluation. Together, these findings are concerning for aspiration pneumonia. In general, symptoms in aspiration pneumonia develop gradually, whereas symptoms typically occur acutely in aspiration (chemical) pneumonitis. Aspiration pneumonia occurs due to microaspiration of oropharyngeal contents and takes time for the pneumonia to develop, hence the gradual onset of symptoms. Aspiration pneumonitis, on the other hand, occurs due to large volume aspiration of sterile gastric contents. The acidic gastric contents cause an abrupt chemical irritation to the lungs, resulting in severe inflammation and the acute development of symptoms. Aspiration pneumonia and aspiration pneumonitis share many overlapping clinical features. Symptoms include chest discomfort, shortness of breath, cough, and fever. Physical examination may show labored breathing; rales or decreased breath sounds are usually auscultated in the gravity-dependent portions of the lung (usually the right lung base). Aspiration pneumonia is typically associated with impaired swallowing conditions (e.g. stroke, seizure disorder, motor neuron disease). Aspiration pneumonitis typically develops acutely, is more likely to be a witnessed event, and usually follows a state of impaired consciousness (e.g. severe alcohol intoxication or following administration of general anesthesia).

Question 71

A 75-year-old man is brought to the emergency department for evaluation of cough and shortness of breath. The patient's spouse is at the bedside and reports that the patient currently resides in a nursing facility due to advanced multiple sclerosis. The patient has had increased difficulty swallowing over the past week. Temperature is 39.0°C (102.2°F), pulse is 114/min, blood pressure is 148/91 mmHg, and oxygen saturation is 95% on room air. Physical examination is significant for a chronically ill-appearing male with contractures in the bilateral upper and lower extremities. The patient is coughing but has no significant increased work of breathing. Blood work is obtained and is pending, and chest radiograph is shown below. Which of the following is the best next step in management? A) Administer ampicillin-sulbactam B) Bi-level positive airway pressure C) Endotracheal intubation D) Administer azithromycin E) Bronchoscopy

Answer 71

Diagnosis of aspiration pneumonia can be made based on history, physical examination, and chest radiography findings that are consistent with aspiration. Ampicillin-sulbactam is an appropriate empiric antibiotic for treatment of aspiration pneumonia, especially if anaerobic bacteria are likely to be involved. This chronically ill patient presents for evaluation of cough, shortness of breath, and recent increased difficulty swallowing. Chest radiography shows a left lower lobe opacity, confirming aspiration pneumonia. Based on this patient's clinical history and exam and radiography findings, the best treatment to initiate is ampicillin-sulbactam. Aspiration pneumonia and pneumonitis share many overlapping clinical features. Symptoms include chest discomfort, shortness of breath, cough, and fever. Physical examination may show labored breathing, and rales or decreased breath sounds may be heard in the gravity-dependent portions of the lung, typically the right lung base. Aspiration pneumonia is typically gradual in onset and is usually associated with impaired swallowing conditions (e.g. stroke, seizure disorder, motor neuron disease). Aspiration pneumonitis generally develops acutely, is more likely to be a witnessed event, and usually occurs in patients with impaired consciousness (e.g. severe alcohol intoxication or following administration of general anesthesia). Chest radiography along with history and physical exam can be used to make the diagnosis. Chest radiography can show infiltrates in the dependent portions of the lungs, primarily the right basal segments of the lower lobes (if the patient has been upright) or the superior segments of the lower lobe/posterior segments of the upper lobes (if the patient has been supine). Appropriate treatment for uncomplicated aspiration pneumonia includes ampicillin-sulbactam or respiratory fluoroquinolones (levofloxacin or moxifloxacin).