On 29 September 2009, a large tsunami struck the Samoan Islands in the South Pacific Ocean, causing 142 deaths and large numbers of casualties. 199 patients presented to the emergency department within the first 72 hours. Twenty-nine patients were admitted with respiratory symptoms and histories of aspirating contaminated seawater and were diagnosed with tsunami-associated aspiration pneumonia. These patients were initially treated with empiric antibiotics based on drug availability and published experience after the Asian Boxing Day Tsunami of 2006. Antibiotic treatment was subsequently modified with sputum culture information. The good outcomes of the Samoa Tsunami patients may be attributed to early initiation of appropriate antibiotics and timely coordinated management.