{"references": ["World Health Organization. Monitoring health for the SDGs, sustainable development goals. World Health Statistics 2018.", "Ostapchuk M, Roberts DM, Haddy R. Community Acquired Pneumonia in infants and children. American Family Physician 2004; 70(5): 899-908.", "Toh TH, Hii KC, Fieldhouse JK, Ting J, Berita A, Nguyen TT, et al. High Prevalence of Viral Infections Among Hospitalized Pneumonia Patients in Equatorial Sarawak, Malaysia. Open Forum Infectious Disease 2019 Feb 13; 6(3): ofz074.", "Agrawal A, Murphy TF. Haemophilus influenzae Infections in the H. influenzae Type b Conjugate Vaccine Era. Journal of Clinical Microbiology 2011; 49 (11): 3728-32.", "Zhang XX, Chen Z, Gu W, Ji W, Wang Y, Hao C, et al. Viral and bacterial co-infection in hospitalised children with refractory Mycoplasma pneumoniae pneumonia. Epidemiology and Infection 2018: 1-5.", "Nolan VG, Arnold SR, Bramley AM, Ampofo K, Williams DJ, Grijalva CG, et al. Etiology and Impact of Coinfections in Children Hospitalized with Community-Acquired Pneumonia. The Journal of Infectious Diseases 2018; 218: 179-88.", "Asner SA, Rose W, Petrich A, Richardson S, Tran DJ. Is virus coinfection a predictor of severity in children with viral respiratory infections? Clinical Microbiology and Infection 2015; 21: 264.e1\u2013264.e6", "Pretorius MA, Madhi SA, Cohen C, Naidoo D, Groome M, Moyes J, et al. Respiratory Viral Coinfections Identified by a 10-Plex Real-Time Reverse-Transcription Polymerase Chain Reaction Assay in Patients Hospitalized with Severe Acute Respiratory Illness\u2014South Africa, 2009\u20132010. The Journal of Infectious Diseases 2012; 206(S1): S159-65.", "McCullers JA. Insights into the Interaction between Influenza Virus and pneumococcus. Clinical Microbiology Reviews 2006; 19(3): 571-82.", "Bakaletz LO. Developing Animal Models for Polymicrobial Diseases. Nature Reviews Microbiology 2004; 2: 552-68.", "Bosch AATM, Biesbroek G, Trzcinski K, Sanders EAM, Bogaert D. Viral and Bacterial Interactions in the Upper Respiratory Tract. Public Library of Science Pathology 2013; 9(1): e1003057.", "Smith CM, Sandrini S, Datta S, Freestone S, Shafeeq S, Radhakrishnan P, et al. Respiratory Syncytial Virus Increases the Virulence of Streptococcus pneumoniae by Binding to Penicillin Binding Protein 1a, A New Paradigm in Respiratory Infection. American Journal of Respiratory and Critical Care Medicine 2014; 190(2): 196-207.", "Sommer C, Resch B, Sim\u00f5es EAF. Risk Factors for Severe Respiratory Syncytial Virus Lower Respiratory Tract Infection. The Open Microbiology Journal 2011; 5, (Suppl 2-M4): 144-54.", "Pan H, Cui B, Huang Y, Yang J, Ba-Thein W. Nasal carriage of common bacterial pathogens among healthy kindergarten children in Chaoshan region, southern China: a cross-sectional study. BMC Pediatrics. 2016; 16:161", "M Mohd Yatim, S N Masri, M N Mohd Desa, N Mohd Taib, S A Nordin, F Jamal. Determination of phenotypes and pneumococcal surface protein A family types of Streptococcus pneumoniae from Malaysian healthy children. Journal of Microbiology, Immunology and Infection 2013;46(3):180-6", "McNeil HC,Jefferies JMC,Clarke SC. Vaccine preventable meningitis in Malaysia: epidemiology and management. Expert Reviews Anti Infection Therapy 2015; 13(6): 705\u201314", "H.J. Adam, S.E. Richardson, F.B. Jamieson et al. Changing epidemiology of invasive Haemophilus influenzae in Ontario, Canada: Evidence for herd effects and strain replacement due to Hib vaccination. Vaccine 2010; 28: 4073-4078", "Flasche S, de Waroux OLP, O'Brien KL, Edmunds JW. The Serotype Distribution among Healthy Carriers before Vaccination Is Essential for Predicting the Impact of Pneumococcal Conjugate Vaccine on Invasive Disease. Public Library of Science (PLoS) Computational Biology 2015; 11(4): e1004173.", "Arushothy R, Ahmad N, Amran F, Hashim R, Samsudin N, Che Azih CR. Pneumococcal serotype distribution and antibiotic susceptibility in Malaysia: A four-year study (2014\u20132017) on invasive paediatric isolates. International Journal of Infectious Diseases 2019;129-33"]}

Abstract Objectives: To determine the prevalence of multiple respiratory pathogens in children with severe lower respiratory tract infection (LRTI), and compare disease severity, duration of hospitalization and ventilation between those with and without multiple respiratory pathogens. Methods: This was a cross-sectional, case record review of children aged between one month and 12 years, with severe LRTI in 2019. Case records were reviewed, and data extracted manually using a standard case report form. Statistical Analysis: Prevalence were expressed as numbers and percentages. Mean (or median) were compared using independent t-test (or Mann-Whitney test). Proportions were compared with chi-square test or Fisher exact test. Results: Sixty-four children were recruited, with median age of 9.5 months (IQR 17.25 months) and 37 (57.8%) children were male. Forty-six children (71.9%) had multiple respiratory pathogens, with 41 (89.1%) of them having both virus and bacteria. Respiratory syncytial virus (RSV) [RSV A (n=10, 15.6%) and RSV B (n=14, 21.9%)] being the commonest virus detected and children with RSV were significantly younger (7.0 months vs. 15.0 months, P=0.007). The most prevalent bacteria detected was Haemophilus influenzae (n=38, 59.4%), followed by Streptococcus pneumoniae (n=29, 45.3%). Children with multiple respiratory pathogens required higher FiO2 (mean difference 12.3%, 95% CI: 2.5, 25.9, P=0.014). Children with multiple respiratory pathogens were also more likely to require inotropes, have longer ventilation and hospitalization days, although not statistically significant. Conclusion: Multiple respiratory pathogens was common in children and associated with a higher FiO2 requirement, and a statistically non-significant risk of longer hospitalization, longer duration of ventilation days, and a higher need for inotropes.