**6. Management of nosocomial pneumonia**

Based on the clinical backgrounds, MHD patients suffered from nosocomial pneumonia with multi-drug resistant pathogens. Significantly, we reported that *S. maltophilia-*related infections should be taken seriously due to the associated high mortality rate. In addition, we stressed the clinical importance of AP for MHD patients suffering from PEW. Various treatment options to prevent AP were advocated, including oral hygiene, altered food viscosity, and positioning [9]. Medications for this purpose include angiotensin-converting enzyme inhibitors and amantadine. In our study, early initiation of tube feeding appears to provide more favorable outcomes in light of intestinal conditions or fluid restrictions in HD patients. Parenteral nutrition directly affects the total body fluid volume and is prone to volume overload as compared to tube feeding. In addition, malnutrition and sarcopenia lead to silent aspiration where the symptoms are not always clinically evident. Since hospitalized patients with hemodialysis often progress to a state of malnutrition, the patients should be considered to have silent aspiration and treated with tube feeding.
