Pneumonia syndromes may be caused by infection or the aspiration of food, acid, or particulate material. Antibiotic-resistant organisms or recurrent aspiration should be considered if the response to treatment is poor. Clinicians should consider discontinuing antibiotics if the resident's status rapidly returns to baseline after a noninfectious macro-aspiration event. The natural history of this process, however, is not well characterized. Diagnostic procedures including sputum gram stain, culture, and urinary antigen testing should be pursued to diagnose pathogens not covered by empiric therapy or to focus therapy with narrow spectrum agents. Sources of aspiration, including pharyngeal dysphagia, periodontal disease, and gastric regurgitation, should be identified and treated in hopes of preventing recurrence.