A 53 year-old woman with newly-diagnosed right frontal GBM, pre-diabetes, and GERD has just been admitted to the NCCU after undergoing an awake craniotomy for a gross total resection. Post-operative non-contrast head CT demonstrates the expected post-operative changes without any concerning findings.
On post-op day 1, she is eating her breakfast and then suddenly desats. Her husband at bedside said she just aspirated. Nursing suctions her and places her on 6L nasal cannula. Urgent chest X-ray is obtained. Two hours later, she's weaned down to 3L.
This patient just aspirated. Her chest X-ray does show patchy opacities throughout the left lung, worse in the lower lobe. However, it takes time for pneumonia to develop; perhaps hours, more likely days. It would actually be very reasonable not to start antibiotics for pneumonia right now. If her oxygen requirement doesn't improve and persists beyond 48 hours, or worsens, then it'd be reasonable to start antibiotics.
If you do start antibiotics, which ones would be necessary? It's been an old-school teaching to include anaerobes. This actually is not true, and thus anaerobic coverage is no longer recommended as per ATS/IDSA guidelines. Ceftriaxone or ampicillin/sulbactam (though this does cover anaerobes, we don't explicitly need it to) would provide adequate coverage for community-acquired organisms.
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