What is the next step in managing a 13-month-old child with persistent fevers and cough, previously diagnosed with croup, who has not responded to two courses of antibiotics (antibacterial medications) over the past month?

Immediate Next Steps for This Child

This 13-month-old requires immediate chest radiograph and clinical reassessment to determine if the cough is wet/productive versus dry, as persistent fevers with cough for one month despite two courses of antibiotics suggests either protracted bacterial bronchitis, pertussis, or an alternative serious diagnosis that was missed—not viral croup. 1, 2

Critical Reassessment Required

The initial diagnosis of croup is highly questionable given the clinical course:

• Croup is self-limited and typically resolves within 2-7 days, not one month 3, 4
• Antibiotics have no role in viral croup, so prescribing two courses was inappropriate and suggests diagnostic uncertainty 3, 4
• Persistent fevers every few days for a month is incompatible with croup, which may have low-grade fever initially but does not cause recurrent fevers over weeks 3

Mandatory Initial Investigations

Obtain a chest radiograph immediately to evaluate for:

• Pneumonia
• Foreign body aspiration
• Bronchiectasis
• Other structural abnormalities 1, 2

Perform a systematic clinical evaluation focusing on:

• Cough quality: Is it wet/productive (suggests bacterial infection) or dry (suggests post-viral or other etiology)? 1, 2
• Specific cough pointers that indicate serious disease:
  • Coughing with feeding (aspiration)
  • Digital clubbing (chronic suppurative lung disease)
  • Hemoptysis
  • Failure to thrive 1, 2
• Paroxysmal cough with post-tussive vomiting or inspiratory "whoop": This strongly suggests pertussis, which can present with persistent cough and recurrent symptoms 2, 5

Management Algorithm Based on Findings

If Wet/Productive Cough Without Specific Pointers:

• Prescribe a 2-week course of antibiotics targeting common respiratory bacteria (amoxicillin 45 mg/kg/day divided every 12 hours) for likely protracted bacterial bronchitis 2, 6
• If cough persists after 2 weeks, extend antibiotics for an additional 2 weeks 2, 5
• If cough persists after 4 weeks total, proceed to further investigations including consideration of bronchoscopy, CT chest, and referral to pediatric pulmonology 2, 5

If Paroxysmal Cough with Post-Tussive Vomiting:

• Test for Bordetella pertussis immediately (PCR or culture) 5
• Initiate macrolide antibiotics (azithromycin) if pertussis is suspected clinically, as treatment is most effective in early stages 5
• Pertussis is highly contagious with 80% secondary attack rate—evaluate household contacts and consider prophylaxis 5

If Dry/Non-Productive Cough Without Specific Pointers:

• Adopt a "watch, wait, and review" approach initially 2
• Review in 2-4 weeks to assess for resolution or development of specific pointers 1, 2
• Consider a 2-4 week trial of inhaled corticosteroids (400 mcg/day beclomethasone equivalent) only if risk factors for asthma are present 1

Critical Management Principles

Do not continue empirical antibiotic therapy without a clear diagnosis—the failure of two courses suggests either:

1. Wrong diagnosis (not bacterial)
2. Wrong organism coverage
3. Inadequate duration
4. Alternative pathology 1, 2

Eliminate environmental tobacco smoke exposure, which is a major contributor to chronic cough in children 2, 6

Do not use over-the-counter cough medications, as they lack efficacy and carry risk of adverse effects 2, 6

Red Flags Requiring Urgent Evaluation

• High persistent or recurrent fevers (present in this case) 6
• Respiratory distress (increased respiratory rate, retractions) 6
• Failure to thrive or weight loss 1
• Hemoptysis 1
• Digital clubbing 1, 2

This child requires immediate reassessment with chest radiograph and systematic evaluation using a pediatric-specific chronic cough algorithm, not continued empirical treatment. 1, 2