European stroke organisation guideline on stroke-associated pneumonia

Stroke-associated pneumonia (SAP), which occurs in approximately 12%, is the most frequent infectious complication after acute stroke and a major contributor to morbidity and mortality. Despite its clinical importance, high-quality evidence to guide the diagnosis, prediction, prevention and treatment of SAP remains limited, underscoring the need for structured, consensus-based recommendations in stroke care. This guideline was developed following the standard methodology of the European Stroke Organisation (ESO): an interdisciplinary working group identified 15 clinically relevant questions, conducted systematic literature reviews and meta-analyses, appraised the quality of the available evidence and formulated evidence-based recommendations. Notably, only 3 of 15 questions were supported by predominantly low-quality evidence, and most guideline statements therefore rely on expert consensus rather than evidence-based recommendations. For clinical practice, standardised diagnostic criteria are recommended, while chest CT and plasma C-reactive protein may provide additional diagnostic value. Clinical prediction scores and biomarkers demonstrate moderate to good discriminative performance, However, their routine use will depend on the availability of effective preventive measures. Prevention strategies include positioning, early mobilisation and individualised nutritional approaches. Dysphagia screening and swallowing management are established components of post-stroke care for SAP prevention and are addressed in a separate ESO guideline. Adjunctive therapies are not part of standard care but may be considered in selected patients. Preventive antibiotic therapy is not recommended due to a lack of benefit on SAP incidence or clinical outcomes, whereas empirical antibiotic treatment should be initiated promptly after diagnosis and guided by local protocols targeting aspiration-associated pathogens. In addition, this guideline provides a framework for future randomised trials aimed at improving the evidence base for SAP management.