OBJECTIVES: Many older patients with pneumonia cannot intake orally after admission and may need nutritional care such as nasogastric tube feeding or total parenteral nutrition. This study sought to compare in-hospital outcomes between patients receiving nasogastric tube feeding and total parenteral nutrition. DESIGN: This is a retrospective cohort study. SETTING: A hospital-based database constructed by the Diagnosis Procedure Combination survey data comprising more than 100 acute-care hospitals. PARTICIPANTS: The study included consecutive older inpatients aged >65 years admitted to participating hospitals with a diagnosis of pneumonia from 2014 through 2017. MEASUREMENTS: We compared patients who received total parenteral nutrition and those who received nasogastric tube feeding in terms of characteristics and outcomes. RESULTS: Among the included inpatients, a total of 336 (73.2%) patients received total parenteral nutrition and 123 (26.8%) patients received nasogastric tube feeding. Patients with nasogastric tube feeding had less in-hospital mortality (13.8% vs 27.1%, p = 0.003) and a smaller number of complications (mean; 0.71 vs 1.44, p <0.001), shorter length of hospital stay (mean; 27.6 vs 48.9, p <0.001), more discharges home (72.4% vs 35.1%, p <0.001), and more discharges without oral intake (65.9% vs 45.8%, p <0.001) than patients with total parenteral nutrition. The same results were obtained in propensity score analysis. CONCLUSIONS: Older patients with pneumonia treated with total parenteral nutrition were significantly more likely to have higher in-hospital mortality than those receiving nasogastric tube feeding.