The crux of NPO paradox revealed by increased pneumonia incidence in post-stroke dysphagia patients with dietary restrictions.

Dysphagia patients are at increased risk of stroke-associated pneumonia (SAP). This bicenter study evaluated whether dietary restrictions, specifically nil per os (NPO) and texture-modified food (TMF), reduce SAP incidence in post-stroke dysphagia (PSD). Data from 160 consecutive acute PSD patients treated in two university stroke units were retrospectively analyzed. The primary outcome was SAP incidence; secondary outcomes included length of hospitalization, mortality, and nasogastric tube placement. Stroke severity, male sex, and age emerged as significant SAP risk factors. On admission, 63% of SAP patients were already on NPO, 33.3% received TMF, and only 3.7% had unrestricted oral intake. Notably, NPO patients were 2.5 times more likely to develop SAP than those without dietary restrictions (p = 0.008). Most SAP cases were diagnosed before any oral intake, with the majority occurring by day three. These findings align with emerging evidence highlighting the role of oral hygiene factors and immune alterations in pulmonary bacterial defense. This study provides no support for NPO or TMF as effective pneumonia prophylaxis in PSD. Instead, early intervention and comprehensive care strategies are essential to mitigate SAP risk. Appropriate dysphagia diets enhancing residual swallowing capacity could positively impact both SAP rates and dysphagia rehabilitation.