Background: Aspiration pneumonia remains a preventable yet common complication of acute stroke, strongly associated with dysphagia and inadequate adherence to evidence-based protocols. International guidelines, including those of NICE and AHA/ASA, emphasize early swallowing assessments, safe feeding strategies, multidisciplinary team involvement, and prudent antibiotic stewardship. However, evidence from low- and middle-income countries (LMICs), including Pakistan, suggests variable implementation of these recommendations. Objective: This audit aimed to evaluate adherence to national and international guideline standards for the prevention and management of aspiration pneumonia among stroke patients in a tertiary-care hospital in Pakistan. Methods: A clinical audit was conducted at MTI–Lady Reading Hospital, Peshawar, from January 2023 to January 2024. Records of 186 stroke patients were systematically reviewed for dysphagia screening, swallowing assessments, feeding practices, referral to speech therapy, antibiotic use, and patient outcomes. Findings were benchmarked against NICE, AHA/ASA, and Pakistan Society of Neurology standards. Results: Swallowing assessment was documented in 71% of patients, but only 30% underwent testing within 24 hours. Speech therapy referral was documented in 22.6%, while prophylactic antibiotics were administered in 18.3% despite guideline discouragement. Aspiration pneumonia developed in 22.6% of patients, leading to significantly higher in-hospital mortality (19.0% vs. 6.2%) and longer hospital stay. Conclusion: The audit reveals major gaps in adherence to guideline-based preventive and management practices. Targeted interventions, including mandatory early swallowing assessments, enhanced speech therapy services, and improved antibiotic stewardship, are urgently needed to reduce aspiration pneumonia burden in stroke care.