Epidemiology of community-acquired pneumonia among hospitalised children in Indonesia: a multicentre, prospective study

Dewi Lokida, Helmia Farida, Rina Triasih, Yan Mardian, Herman Kosasih, Adhella Menur Naysilla, Arif Budiman, Chakrawati Hayuningsih, Moh Syarofil Anam, Dwi Wastoro, Mujahidah Mujahidah, Setya Dipayana, Amalia Setyati, Abu Tholib Aman, Nurhayati Lukman, Muhammad Karyana, Ahnika Kline, Aaron Neal, Chuen-Yen Lau, Clifford Lane, Dewi Lokida, Helmia Farida, Rina Triasih, Yan Mardian, Herman Kosasih, Adhella Menur Naysilla, Arif Budiman, Chakrawati Hayuningsih, Moh Syarofil Anam, Dwi Wastoro, Mujahidah Mujahidah, Setya Dipayana, Amalia Setyati, Abu Tholib Aman, Nurhayati Lukman, Muhammad Karyana, Ahnika Kline, Aaron Neal, Chuen-Yen Lau, Clifford Lane

Abstract

Objective: To identify aetiologies of childhood community-acquired pneumonia (CAP) based on a comprehensive diagnostic approach.

Design: 'Partnerships for Enhanced Engagement in Research-Pneumonia in Paediatrics (PEER-PePPeS)' study was an observational prospective cohort study conducted from July 2017 to September 2019.

Setting: Government referral teaching hospitals and satellite sites in three cities in Indonesia: Semarang, Yogyakarta and Tangerang.

Participants: Hospitalised children aged 2-59 months who met the criteria for pneumonia were eligible. Children were excluded if they had been hospitalised for >24 hours; had malignancy or history of malignancy; a history of long-term (>2 months) steroid therapy, or conditions that might interfere with compliance with study procedures.

Main outcomes measures: Causative bacterial, viral or mixed pathogen(s) for pneumonia were determined using microbiological, molecular and serological tests from routinely collected specimens (blood, sputum and nasopharyngeal swabs). We applied a previously published algorithm (PEER-PePPeS rules) to determine the causative pathogen(s).

Results: 188 subjects were enrolled. Based on our algorithm, 48 (25.5%) had a bacterial infection, 31 (16.5%) had a viral infection, 76 (40.4%) had mixed bacterial and viral infections, and 33 (17.6%) were unable to be classified. The five most common causative pathogens identified were Haemophilus influenzae non-type B (N=73, 38.8%), respiratory syncytial virus (RSV) (N=51, 27.1%), Klebsiella pneumoniae (N=43, 22.9%), Streptococcus pneumoniae (N=29, 15.4%) and Influenza virus (N=25, 13.3%). RSV and influenza virus diagnoses were highly associated with Indonesia's rainy season (November-March). The PCR assays on induced sputum (IS) specimens captured most of the pathogens identified in this study.

Conclusions: Our study found that H. influenzae non-type B and RSV were the most frequently identified pathogens causing hospitalised CAP among Indonesian children aged 2-59 months old. Our study also highlights the importance of PCR for diagnosis and by extension, appropriate use of antimicrobials.

Trail registration number: NCT03366454.

Keywords: epidemiology; infectious diseases; paediatrics.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1
Figure 1
Subject screening, enrolment and monitoring flow chart. CAP, community-acquired pneumonia; CRP, C reactive protein; CXR, chest X-ray; PCT, procalcitonin; RR, respiratory rate.
Figure 2
Figure 2
Pathogen distribution. (A) Overall proportion of identified viral/bacterial/mixed pathogen, (B) Viral/bacterial/mixed pathogens by age group, (C) pattern of detection of the ten most identified pathogens, (D) distribution of 10 most identified pathogens by age group. *P

Figure 3

Distribution of the (A) monthly…

Figure 3

Distribution of the (A) monthly count and (B) seasonal pattern of infection caused…

Figure 3
Distribution of the (A) monthly count and (B) seasonal pattern of infection caused by Haemophilus influenzae non-type B, RSV, Klebsiella pneumoniae, Streptococcus pneumoniae and influenza virus during a 27-month study period. RSV, respiratory syncytial virus.
Figure 3
Figure 3
Distribution of the (A) monthly count and (B) seasonal pattern of infection caused by Haemophilus influenzae non-type B, RSV, Klebsiella pneumoniae, Streptococcus pneumoniae and influenza virus during a 27-month study period. RSV, respiratory syncytial virus.

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