RUJUKAN CAP ANAK

1. Definisi CAP Anak

Pneumonia is a common pediatric infectious disease that is familiar to pediatricians
and a major cause of hospitalization worldwide. Recent well-designed epidemiologic studies
in developed countries indicated that respiratory viruses are detected in 30%–70%, atypical
bacteria in 7%–17%, and pyogenic bacteria in 2%–8% of children hospitalized with
community-acquired pneumonia (CAP). The etiological distri bution of CAP varies widely by
child age and the epidemiological season of the respiratory pathogen. Moreover, diagnostic
tests, particularly for the detection of Streptococcus pneumoniae and Mycoplasma
pneumoniae, the 2 major bacterial pathogens involved in pediatric CAP, have several
limitations. Therefore, management and empirical antimicrobial therapy for children with
CAP should be applied in a stepwise manner based on recent epidemiological, etiological, and
microbiologica evidence. (Yun, 2024)

Community-acquired pneumonia (CAP) is an acute infection of the lung parenchyma

acquired outside the hospital or other health care settings. It is one of the most common
causes of hospitalization in children in developed countries [1] and the leading cause of death
in children in developing countries [2, 3]. Clinical diagnosis of CAP is difficult because
symptoms vary with age and may be nonspecific in young children. In addition, determining
the aetiology of CAP remains a major challenge.. (Meyer Sauteur, 2024)

2. Epidemiologi CAP Anak

Pneumonia is the leading cause of death in children aged <5 years worldwide.
Estimated numbers of global deaths by pneumonia were 0.76 million, while the cause specific
mortality rate was 5.5 cases per 1,000 livebirths in 2015.1) Although mortality rates in
developed countries do not reach the levels observed in low- and middle-income countries,
the morbidity and financial burden associated with pneumonia remain signifi cant. In a recent
large epidemiological study in the United States (US), the annual incidence of community-
acquired pneumonia (CAP) requiring hospitalization was 15.7 cases per 10,000 children, with
the highest rate among children younger than 2 years.2) Over the past 20 years, the incidence
of lower respiratory tract infections (LRTIs) has declined worldwide. A total number of
episodes of clinical pneumonia in young children (<5 years of age) in 132 developing
countries decreased by 22% from 178×106 in 2000 to 138×106 in 2015.3) There has been a
substantial decrease in the number of deaths and the mortality rate, which reflects not only
economic development, improved nutrition, and reduced household crowding but also the use
of pneumonia-specific interventions such as improved case management—including empirical
antibiotic treatment—and effective vaccines aga inst
leading causes of pneumonia in children While the number of pneumonia cases and death
rates have significantly decreased, hospital visits and hospitalization rates are increasing in
both developing and developed countries, and the situation in South Korea is no
exception.3,5) According to the National Health Insurance Corporation database, the number
of hospital visits increased from 9,509 to 12,833 per 100,000 population between 2004 and
2014, especially for those <10 years of age.5) In an Asian multinational study, a total of
3,151 CAP patients <5 years of age were hospitalized in 2011 at 3 Korean hospitals,which
accounted for 22.4% of all hospi talizations during that period. It was higher than Vietnam
(5.4%), Malaysia (2.8%), and Indonesia (18.2%).6) In another study using National
Emergency Department Information System data, a total of 329,380 children were diagnosed
with pneumonia at Emergency Departments (EDs) nationwide between 2007 and 2014.
(Yun, 2024)

Recent large-scale studies have performed extensive microbiological testing to investigate

the aetiology in children with radiologically confirmed CAP.A viral and/or bacterial
pathogen was detected in the upper respiratory tract (URT) in 81–99% of these children.
Viruses accounted for the majority of pathogens [1–3], particularly in young children (>
90%) (Meyer Sauteur, 2024)
Prior to the COVID-19 pandemic, the most common pathogen detected in hospitalized
children with CAP in the USA was respiratory syncytial virus (RSV). The most commonly
detected bacterial pathogen was Mycoplasma pneumoniae. However, the detection of
pathogens varied
with age (Table 1). The proportion of RSV was significantly higher in children < 5 years of
age compared with older children (37% vs. 8%). In contrast, the proportion of M. pneumo-
niae was higher in children ≥ 5 years of age compared with younger children (19% vs. 3%)
(Meyer Sauteur, 2024)

Gambar Epidemiologi CAP (Meyer Sauteur, 2024)

Penjelasan Gambar
Tonggak Sejarah dan Perubahan Etiologi Pneumonia pada Masa Kanak-Kanak:
 Hib (Haemophilus influenzae tipe b): Bakteri yang dulu umum menyebabkan pneumonia dan infeksi serius lainnya pada anak-anak,
kini telah banyak berkurang karena vaksinasi.
 PCR (Reaksi Berantai Polimerase): Teknik laboratorium yang memungkinkan deteksi DNA patogen secara cepat dan akurat,
membantu diagnosis pneumonia dengan lebih baik.
 PCV (Vaksin Konjugat Pneumokokus): Vaksin yang melindungi terhadap Streptococcus pneumoniae, bakteri umum penyebab
pneumonia.
Sejarah Pneumonia:
 Sejak tahun 1800: Sebelum tahun 1800, istilah "perifer-pneumonia" digunakan untuk menggambarkan pola klinis tanpa membedakan
pneumonia dari radang selaput dada.
 Penemuan Stetoskop: Membantu dalam diagnosis klinis pneumonia melalui auskultasi (mendengarkan bunyi paru-paru).
 Otopi: Memungkinkan diferensiasi antara pneumonia lobar (mempengaruhi satu lobus paru-paru) dan bronkopneumonia
(mempengaruhi bronkus dan sekitarnya).
Penemuan Patogen Penyebab Pneumonia:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Mycoplasma pneumoniae
 Kemajuan Teknologi:
 Teknologi Sinar-X: Memungkinkan visualisasi infiltrat di paru-paru yang menunjukkan adanya pneumonia.
 Era Antibiotik: Dimulai dengan penemuan penisilin yang secara dramatis mengurangi kematian akibat pneumonia.
 PCR: Memungkinkan deteksi cepat dan akurat dari berbagai bakteri dan virus penyebab pneumonia.
Peran Vaksinasi:
 Vaksin Hib: Pengembangan dan pengenalan vaksin Hib telah secara signifikan mengurangi insiden pneumonia yang disebabkan oleh
Haemophilus influenzae tipe b.
 Vaksin PCV: Vaksin konjugat pneumokokus telah mengurangi distribusi Streptococcus pneumoniae, penyebab umum pneumonia
pada anak-anak. (Meyer Sauteur, 2024)

Faktor Resiko CAP Anak

3. Penyebab CAP Anak

As a result of this compre- hensive etiologic work-up for CAP in children, pathogens
were detected in 81%, viruses in 73%, pyogenic bacteria in 7%, and atypical bacteria
such as M. pneumoniae in 8%.A Japanese study in 2005–2006 investigated the detection
frequency of pathogens in nasopharyngeal swabs of child- ren with CAP using real-time
PCR and bacterial culture. S. pneumoniae and M. pneumoniae were the most commonly
detected at 24% and 15%, respectively. Among viruses, rhinovirus was detected most
commonly at 14.5%. This result showed that S. pneumoniae colonized the naso-
pharynx of children before the introduction of PCV in 2010. However, in a Taiwanese
study conducted in 2010–2013 at 8 participating medical centers, the prevalence of S.
pneumoniae was very high despite the introduction of PCV in 2005. In this study,
respiratory specimens were excluded from the detection of S. pneumoniae; however,
they incorporated urinary antigen test results, which could not di fferentiate between
colonization and true infection, particularly in children. The most common pathogen
was S. pneumoniae (31.6%), but it was detected using only the urinary antigen test
(83.1%). In addition, they mainly used serological tests, which have relatively low
specificity, to detect M. pneumo- niae, the second most commonly identified pathogen
(22.6
%).13)
In China, a multicenter prospective study was conducted on the etiology of
radiologically confirmed CAP in hospitalized children aged 6 months to 14 years in
2015. They tested only 8 respiratory viruses from oropharyngeal swabs using the direct
fluorescent antibody technique, used an immunoglobulin M (IgM) serologic test for M.
pneumoniae detection, and did not report the test results for pyogenic bacteria. M.
pneumoniae was the most frequently detected pathogen (32.4%). 14) In the major Asian
studies above, the rates of pyogenic bacteria and M. pneumoniae were repor- tedly very
high, including culture and/or PCR results from upper respiratory tract specimens and
serological tests, respectively.

Variable GABRIEL9) PERCH10) EPIC2) CHIRP11)

Region/center Multinational (n=8)
a)
Multinational (n=7)b)
US (3 hospitals) US (6 hospitals)
Period 2010–2014 2011–2014 2010–2012 2015–2018
Setting Prospective Prospective observationalProspective Prospective observational
observational case-case-control observational case-case- control
control control
Subject Hospitalized Hospitalized Hospitalized Hospitalized and outpatient
clinic
Age 2–60 Months 1–59 Months <18 Years 2 Months–18 years
CAP categoryRadiologically WHO-defined severe orRadiologically confirmed Radiologically confirmed
included confirmed, primaryvery severe pneumonia65)
end-point pneumoniawith a positive x-ray
(WHO64))c)
Cases (n) 888 1,769 2,222 441
Controls (n) 870 5,102 521 50
 Pathogen detected NA 98.2% 81% 64.6%
Virus 78.3% 61.4% 73% 55.6%
HRV (24.9%), RSVRSV (31.1%), HRV (NA),RSV (28%), HRV (27%),HRV/EV (18.6%), RSV
(20.0%), HMPV (NA) HMPV (16.8%), HMPV
bocavirus (9.2%) (13%) (10.0%)
Pyogenic bacteria 15.2% 27.3% 7% 4.3%
Spn (9.9), Hib (2.7), SANA Spn (4%) Spn (2.3%)
(2.0)
Atypical bacteria 1.9% NA 8% 8.8%
Mpn (1.5%), Cpn (0.4%)NA Mpn (8%) Mpn (8.2%)

CAP, community-acquired pneumonia; GABRIEL, Global Approach to Biological Research, Infectious disease, and Epidemics
in Low-income countries; PERCH, Pneumonia Etiology Research for Child Health; EPIC, Etiology of Pneumonia in the
Community; CHIRP, Conventional Versus Hypofractionated Radiation in High Risk Prostate Patients; US, United States;
WHO, World Health Organization; HRV, human rhinovirus; RSV, respiratory syncytial virus; HMPV, human metapneumovirus;
NA, not available; Spn, Streptococcus pneumoniae; Hib, Haemophilus influenza type b; SA, Staphylococcus aureus; Mpn,
Mycoplasma pneumoniae; Cpn, Chlamydia pneumoniae.
a)Cambodia, China, Haiti, India, Madagascar, Mali, Mongolia, and Paraguay.
b)Bangladesh, The Gambia, Kenya, Mali, South Africa, Thailand, Zambia. c)The presence
of end-point consolidation (as defined above) or pleural effusion in the lateral pleural space (not just in the minor or oblique
fissure) that was spatially associated
with a pulmonary parenchymal infiltrate (including other infiltrates). (Yun, 2024)

Pathogens detected in children with CAP according to age group (Meyer Sauteur, 2024)

4. Patomekanisme CAP Anak

Pathogens initially colonize the pharynx, followed by micro-aspiration, which is
the mechanism of entry into the lower respiratory tract. Once there, the pathogen
induces the host's pulmonary defense. If there is a defect in the host's defense or it is
overcome by high inoculum or virulence of the pathogen, then pneumonia will result.
Pathogens may also spread through the hematogenous route and macro-aspiration.
(Regunath H, Oba Y.2024) cited : Regunath H, Oba Y. Community-Acquired
Pneumonia. [Updated 2024 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430749/

5. Gambaran Klinik CAP Anak

 Common symptoms of pneumonia include fever, chills, cough productive of purulent
sputum, dyspnea, pleuritic chest pain, and weight loss. Patients with alcohol use disorder and
those who are immune-compromised may have an absence of fever and less evident or
systemic symptoms such as weakness, lethargy, altered mental status, dyspepsia, or other
upper gastrointestinal symptoms. The presence of some symptoms may provide etiological
clues. For example, diarrhea, headache, and confusion (related to hyponatremia) can
indicate Legionella infection; otitis media, Stevens-Johnson syndrome, or anemia with
jaundice (hemolytic anemia) may indicate Mycoplasma infection. Pneumonia can provoke
acute decompensation of an underlying chronic illness, such as congestive heart failure, and
can confound the initial presentation of pneumonia and result in delays in diagnosis and
treatment. (Regunath H, Oba Y.2024)

6. Diagnosis CAP Anak

a. Diagnosis Klinis
The diagnosis of pneumonia is based on respiratory symp- toms, physical examination,
and/or chest radiographic findings. However, in the absence of clear alveolar consolida- tion
and PE on chest radiography (CXR), it may be difficult to distinguish other LRTI such as
croup, bronchitis, and bronchiolitis from pneumonia.. Pneumonia is defined as
cough/difficulty breathing and age-adjusted tachypnea. In addition, the etiological diagnosis
of pneumonia is complicated and di- fficult in typical clinical situations. (Yun, 2024)

b. Diagnosis Microbiology
When pneumococci are present in the nasopharynx, genomic fragments of the bacteria
can be detected in the blood through PCR. Therefore, blood PCR for pneumococcus has
low specificity in children with CAP.26) Moreover, diagnostic serology is insensitive in
children, and paired samples are difficult to obtain. BAL or lung biopsy, performed to
avoid contamination with upper respiratory secretions, is the gold standard diagnostic
technique for pneumonia; how- ever, these procedures are rarely performed in children
with CAP because of their invasiveness. Thus, even with a sufficient etiologic work-up,
the diagnosis of some bacterial pneumonias may be missed, even in cases of pneumonia
for which the causative bacteria have not been identified or respiratory viruses have been
detected.
Therefore, it is common to use empirical antibiotics based on clinical findings suggesting
the possibility of pyogenic bacterial pneumonia, such as lobar/lobular consolidation,
empyema/PE, and high inflammatory markers (C-reactive protein and procalcitonin). In
 particular, if these findings occur outside the M. pneumoniae epidemic period (which
may have similar clinical manifestations) or in children who have not completed PCV
immunization, the probability of a pneumococcal etiology of this pneumonia might be
high. Recent studies additionally suggested that the naso- pharyngeal carriage load of
pneumococcus is higher in pneumococcal CAP than in other etiologic CAP and thus can
be used to diagnose pneumococcal CAP (Yun, 2024)

b.1. M. Pneumoniae
Atypical pneumonia pathogens include M. pneumoniae, Chlamydophila pneumoniae,
Chlamydophila trachomatis, and Legionella pneumophilia; however, M. pneumoniae
accounts for most of the causes of atypical CAP in children. However, in neonates and
infants less than 3 months of age, C. trachomatis can manifest similar to viral pneumonia
such as RSV. A repetitive staccato cough, tachypnea, and rales are characteristic, but
wheezing is uncommon.30) All atypical bacteria are usually detected by PCR in
respiratory samples because culturing is difficult and time-consuming. Recent- ly,
multiplex PCR kits containing major respiratory viruses and atypical bacteria have been
commercialized and are now frequently used in clinical settings. (Yun, 2024)

b.2. Pneumococcal Pneumonia

In particular, bacterial pneumonia, such as that caused by S. pneumoniae, the most
important pathogen in CAP because it should be treated with antibiotics, is difficult to
accurately identify in children.26) A small proportion of cases are detected by blood
and/or PE culture, even under ideal conditions. Sputum cannot be adequately produced by
young children but can be easily contaminated by organisms present in the nasopharynx.
In addition, the detection of pneumococcus in the nasopharynx or positivity on a uri-
nary antigen test may indicate asymptomatic carriage, which is prevalent even in healthy
young children.
However, caution is required for interpretation as M. pneumoniae may be detected in
nasopharyngeal swabs from asymptomatic healthy children depending on the time of
prevalence, region, target age, and race.32) Mycoplasma PCR in sputum samples show
widely distributed sensitivity of 9%–100%, has poor concordance with paired serology,
and does not reliably differentiate infection from coloniza- tion .33) On the other hand,
serology is among the most widely used methods for the diagnosis of M. pneumoniae. A
four-fold or higher increase in antibody levels in acutecon- valescent serum is considered
diagnostic, but it is difficult to apply in clinical settings . Therefore, a single IgM titer is
usually measured, but it can remain high for months or pos- sibly years, may not appear
in very young children or during reinfection, and the positive predictive value can be as
low as 15%.32-34) However, a single antibody titer of 1:640 or higher in an antibody test
including both immunoglobulin G (IgG) and IgM was highly concordant with the
positive results of a Mycoplasma PCR test from nasopharyngeal aspirates in Korean
children.35) Thus, we may use a high single titer of serologic (IgG + IgM) test for M.
pneumoniae to enhance its specificity, although the sensitivity is probably reduced,
 particularly in school-aged children and adolescents with CAP during the M.
pneumoniae epidemic.
(Yun, 2024)

b.3. Respiratory viruses

The detection of respiratory viruses in patients with pneu- monia is mainly performed on
nasopharyngeal aspirate or swabsamplesusingcommerciallyavailablemultiplexreal-time
reverse transcription PCR (RT-PCR) Unlike most bacteria, respiratory viruses have a
low probability of asymptomatic colonization; therefore, those detected in children and
ado- lescents with pneumonia are generally accepted as causative agents. However,
HRV, HBoV, and HCoV are the exceptions. Because these viruses often cause
asymptomatic infection or can shed for a long time after infection, they are detected at a
similar rate in the asymptomatic control group as in patients with pneumonia. Serology
can support RT-PCR, but it is also clinically limited because of possible false-positive
and -negative results; thus, acute and convalescent serum should be obtained.
(Yun, 2024)

b.4. Novel etiologic diagnostics

Syndromic multiplex PCR panels have been developed for this purpose. It enables the
detection of viruses, atypical bacteria, pyogenic bacteria, and antimicrobial resistance
marker genes in respiratory specimens. Semiquantitative results were also obtained for
bacterial targets. The panel showed a sensitivity of 100% and specificity of 87.2%.31)
Metagenomics and pan-viral group PCR can detect additional viruses, some of which are
known to be pathogenic, in nasopharyngeal/oropharyngeal specimens from one-third of
children hospitalized with CAP of unknown etiology. Both broad-range methods could
be useful tools in future epidemiological and diagnostic studies. 40) Cell-free plasma next-
generation sequencing was made available in 2017 to supplement the standard of care
diagnostic techniques. In a previous study in the US, among 15 children hospitalized
with CAP, a pathogen was identified in 13 of 15 children (86
%) with cell-free plasma sequencing compared with 47% for those using standard
culture and PCR-based methods alone.41) RNA sequencing profiles by transcriptional
analy- sis of blood from infants with RSV LRTI allow specific diagnosis, better
understanding of disease pathogenesis, and assessment of disease severity. This
technique may open a new era for the identification of potential therapeutic or preventive
targets, if applied in an appropriate clinical setting. (Yun, 2024)
 Specimens and diagnostic methods for the microbiological diagnosis of CAP in children. Abbreviations: ASC, antibody-secreting
cell; ELISA, enzyme-linked immunosorbent assay (serology); ELIS-pot, enzyme-linked immunospot assay (cell-based assay); PCR,
polymerase chain reaction. Figure adapted from Meyer Sauteur. Samples taken directly from the lungs are shown in bold and are the
“gold standard” for the microbiological diagnosis of CAP. *The detection of pathogen-specific ASCs by ELISpot is not yet a
validated method for the microbiological diagnosis of CAP (Meyer Sauteur, 2024)

7. Penilaian CAP Anak

Initial workup for pneumonia will include imaging and blood work
(see Images. Lung Abscess, Computed Tomography Scan and Bilateral
Pneumonia, Computed Tomography Scan and Lung Pneumonia with Fibrosis). A chest
x-ray will be needed to identify an infiltrate or effusion, which, if present, will improve
diagnostic accuracy (see Image. Healthy Lung and Q Fever Pneumatic Lung, Chest X-
ray). Bloodwork should include a complete blood count with differentials; serum
electrolytes with renal and liver function tests help confirm evidence of inflammation and
assess severity. Influenza testing is recommended during the winter season. Testing for
respiratory viruses on nasopharyngeal swabs by molecular methods can be considered if
available.
Tools such as CURB 65 (confusion, urea greater than or equal to 20 mg/dL,
respiratory rate greater than or equal to 30/min, blood pressure systolic less than 90 mm
Hg or diastolic less than 60 mm Hg), and Pneumonia Severity Index for severity
assessment may assist in determining the treatment setting, such as outpatient versus
inpatient. Still, accuracy is limited when used alone or without practical clinical
judgment.
In hospitalized patients, blood and sputum cultures should be collected, preferably
before the institution of antimicrobial therapy, but without delay in treatment. If cultures
are negative, urine collection and testing for legionella and pneumococcal antigens must
be considered as they aid in diagnosis. In the presence of confounding comorbidities,
such as congestive heart failure, serum procalcitonin levels can be used as a biomarker to
initiate and guide antimicrobial therapy. Serology for tularemia, endemic mycoses, or C
psittaci can be evaluated in the presence of epidemiologic clues. . (Regunath H, Oba
Y.2024)
8. Penatalaksaaan CAP Anak

8.1. Empirical antimicrobial therapy

Among children with CAP in developed countries, 60%– 90% might have a viral
etiology; thus, they would require conservative management with symptomatic care
during the disease course. However, children with presumed bacterial and influenza virus
pneumonia require empirical antimicrobial therapy during their initial presentations. The
Pediatric Infectious Disease Society and Infectious Disease Society of America (IDSA)
in the US recommended amoxicillin or ampicillin for children with presumed pyogenic
bacterial pneumonia, azithromycin for children with presumed atypical pneumonia, and
oseltamivir or zanamivir for children with presumed influenza pneumonia.43) The
Korea Centers for Disease Control and Pre- vention (KCDC) similarly recommended the
2017 guidelines for antibiotic use in children with LRTI.

However, clinical suspicion of the etiology of CAP in children is di fficult and

inaccurate; therefore, most clinicians usually prescribe antibiotics. Thus, unless
pyogenic bacterial pneumonia is carefully considered, the effect of empirical amoxicillin
administration is generally insignifi- cant.
In terms of antibiotic treatment duration, 10-day treatment courses of
amoxicillin have been best studied and recommended by both 2011 IDSA and 2017
KCDC guide- lines.43,44) However, a 5-day course of high-dose oral amo- xicillin was not
inferior to a 10-day course in 6- to 59-month- old outpatients with alveolar CAP, which is
more likely to have a pyogenic bacterial cause. 48) In Malawian children, 3-day treatment
with amoxicillin for chest-indrawing pneu- monia was noninferior to 5-day treatment. 49)
In the United Kingdom, among children with CAP discharged from an ED or hospital
ward (within 48 hours), lower-dose outpatient oral amoxicillin was noninferior to higher-
dose amoxicillin and 3-day duration was noninferior to 7 days in terms of the need for
antibiotic re-treatment.50) In the SAFER (Short- Course Antimicrobial Therapy for
Pediatric Respiratory Infections) trial in Canada, short-course (5-day) antibiotic therapy
appeared comparable to standard care (10-day) for the treatment of previously healthy
children with CAP not requiring hospitalization. (Yun, 2024)
8.2. Antimicrobial therapy for M. pneumoniae
Macrolides are recommended as first-line therapy; how- ever, macrolide
resistance rates to M. pneumoniae among children have been increasing substantially.
Macrolide resistance does not contribute to the clinical severity of M. pneumoniae
pneumonia; however, it may be an aggravating factor. Antibiotics may not be required
for treatment in mild cases due to the self-resolving nature of M. pneumonia infection
regardless of macrolide resistance.52) The clinical benefit of tetracyclines and
fluoroquinolones has been shown in terms of shortening symptom duration and ac-
hieving rapid defervescence in some reports. However, due to safety concerns
regarding these 2 alternative anti- biotics, clinicians should weigh the risks and
benefits when selecting treatment options. Alternative antibiotics may be considered
when patients remain febrile or when chest x-rays show deterioration at least 48–72 hours
after macro- lide treatment (Yun, 2024)

8.3. Antiviral therapy

Among the viral pathogens that cause CAP in children, influenza virus and severe
acute respiratory syndrome coronavirus 2 are currently recommended treatment with
antiviral agents. Early treatment with oseltamivir reduces the illness and hospitalization
durations for patients with serious illness or those with ongoing clinical deteriora-
tion.55,56) Zanamivir (in ≥7 years-old) and peramivir (in ≥6 months-old) could also be
administered by inhalation and parenterally, respectively, for the treatment of influenza
pneumonia.57) Remdesivir is suggested for children (≥3.5 kg) with severe COVID-19
including pneumonia who need supplemental oxygen without mechanical ventilation.
Nirmatrelvir/ritonavir is considered for adolescents (≥12 years and ≥40 kg) at high risk of
progression to severe disease who do not require supplemental oxygen and are within 5
days of symptom onset.58) High risk factors include obesity, diabetes, heart disease,
chronic lung diseases, sei- zure disorders, and an immunocompromised status.59)
Otherwise, for the treatment of other common respiratory viruses causing CAP in
children, specific antiviral therapies including ribavirin for RSV and cidofovir for
adenovirus are not usually recommended. (Yun, 2024)
 Figure. ..CXR, chest x-ray; PE, pleural effusion; Flu, influenza; Mpn, Mycoplasma
pneumoniae; LFX, levofloxacin; DOX, doxycycline; COVID-19, coronavirus disease 2019.
a)
Lobar/lobular consolidation, not fully vaccinated with pneumococcal conjugate vaccine, or
high concentration of inflammatory markers (C-reactive protein >10 mg/dL and/or
procalcitonin >5 mg/dL) during the no Mpn epidemic season. (Yun, 2024)
8.4. Steroids
Clinical trials have yielded conflicting data regarding the benefits of adding systemic
corticosteroids to CAP treat- ment. Recent randomized clinical trials conducted in
adults indicated that short-term corticosteroid treatment reduces the time to clinical
stability in patients admitted to the hospital for CAP 60) or reduces the risk of treatment
failure among patients with severe CAP and a high initial inflamma- tory response,61) but
these effects were not clinically signifi- cant. Pediatric studies must evaluate the strengths
and weaknesses of steroid therapy in children with CAP. However, for some pathogens,
the effectiveness of corticosteroids has been relatively well evaluated and corticosteroids
are recom- mended for treatment in some situations. First, early cortico- steroid therapy
 reduces disease morbidity in children with CAP caused by M. pneumoniae, particularly
macrolide- resistant M. pneumoniae, without increasing the incidence of adverse
reactions.62,63) In addition, corticosteroids are recommended for children and adolescents
with severe to critical COVID-19. This might reduce excessive immune and
inflammatory responses during the severe course of COVID-19 pneumonia. (Yun, 2024)

Intravenous glucocorticoids can be considered adjunctive therapy in critically ill

patients with severe community-acquired pneumonia without risk factors for adverse
outcomes from using steroids (eg, influenza infection). They are associated with
reductions in short-term mortality and duration of intensive care days. (Regunath H,
Oba Y.2024)
9. Komplikasi dan Akibat CAP Anak
1. Complicated community-acquired pneumonia in a previously well child is a severe
illness characterised by combinations of local complications (eg, parapneumonic
effusion, empyema, necrotising pneumonia, and lung abscess) and systemic
complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory
distress syndrome, disseminated intravascular coagulation, and, rarely, death).
Complicated community-acquired pneumonia should be suspected in any child with
pneumonia not responding to appropriate antibiotic treatment within 48–72 h. Common
causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients
have initial imaging with chest radiography and ultrasound, which can also be used to
assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually
indicated. Complicated pneumonia is treated with a prolonged course of intravenous
antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local
microbiological knowledge and by subsequent positive cultures and molecular testing,
including on pleural fluid if a drainage procedure is done. Information from pleural space
imaging and drainage should guide the decision on whether to administer intrapleural
fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely
needed; in any event, in low-income and middle-income countries, resources for
extensive surgeries are scarce. The clinical course of complicated community-acquired
pneumonia can be prolonged, especially when patients have necrotising pneumonia, but
complete recovery is the usual outcome. Complicated pneumonia in children de
 Benedictis, Fernando M et al.The Lancet, Volume 396, Issue 10253, 786 – 798 in :
Complicated pneumonia in children - The Lancet

10. Prognosis CAP Anak

Influenza vaccination is recommended for all adult patients at risk for influenza-related
complications. Inactivated flu shots (trivalent or quadrivalent, egg-based or recombinant) are
usually recommended for adults. Live attenuated intranasal vaccine can be given to healthy,
nonpregnant adults under 49. This is contraindicated in pregnancy, the immune-suppressed
and health care workers caring for them, and in those with comorbidities.
COVID-19 vaccination is recommended for all non-immune-compromised adults with either
a single dose of a 2023-24 mRNA vaccine regardless of previous vaccination and that it be
given at least 2 months after the most recent prior dose of COVID-19 vaccine. Novavax
(protein-based) vaccine is given in 2 doses separated by 3 to 8 weeks for unvaccinated
individuals. In contrast, a single dose after 2 months of the last dose is sufficient for those
previously vaccinated with any other formulation of the COVID-19 vaccine. For individuals
with moderate to severe immune compromise, 3 or 4 vaccine doses are recommended, with
at least one using an mRNA formulation. A vaccine against respiratory syncytial virus is
recommended for adults over 60 who may be at risk for severe disease (Regunath H, Oba Y.
Community-Acquired Pneumonia. [Updated 2024 Jan 26]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2024 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430749/
11. Pengendalian CAP Anak

Patients with community-acquired pneumonia may present to the clinician or the

emergency department. The medical staff should be aware of the signs and symptoms
associated with pneumonia. Working together, the healthcare team will improve outcomes.
Members can include primary care, emergency department personnel, specialists, nurses, and
pharmacists. Most patients respond to outpatient antibiotic therapy for 5 to 7 days. Patients
who are short of breath, febrile, and in respiratory distress need to be admitted. An infectious
disease or pulmonology consult is recommended if the diagnosis is unclear. Some patients
may present with a parapneumonic effusion, which may require drainage. Typically, nurses
monitor the patients and report current status and updates to the rest of the team. Pharmacists
evaluate medication choices, check for allergies and drug interactions, and educate patients
about possible side effects and the importance of compliance.
The providers should encourage all patients to get the annual influenza vaccine. In addition,
all adults 65 and older and those considered at risk for pneumonia must receive the
pneumococcal vaccination. The outcomes in most patients with community-acquired
pneumonia are favorable`(Regunath H, Oba Y. Community-Acquired Pneumonia. [Updated
2024 Jan 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430749/