What is the best course of treatment for a 10-month-old baby with cough, fever, diarrhea, elevated C-Reactive Protein (CRP) level, and a positive Widal test, suggestive of typhoid fever?

Treatment of 10-Month-Old with Suspected Typhoid Fever

This infant requires immediate empiric antibiotic therapy with azithromycin 20 mg/kg/day orally for 7 days, along with aggressive hydration management and close monitoring for clinical deterioration. 1

Immediate Antibiotic Management

Azithromycin is the preferred first-line treatment for this 10-month-old with suspected typhoid fever based on the positive Widal test and clinical presentation. 1 The recommended dose is 20 mg/kg/day (maximum 1g/day) orally for 7 days, which achieves a 94% cure rate in children and has significantly lower clinical failure rates compared to fluoroquinolones. 1

Alternative if Severe Illness Requiring Hospitalization

• Ceftriaxone 50-80 mg/kg/day IV/IM for 5-7 days should be used if the infant shows signs of severe illness, shock, or cannot tolerate oral medications. 1, 2
• For this age group, ceftriaxone should be administered over 60 minutes to reduce the risk of bilirubin encephalopathy. 2
• The total daily dose should not exceed 2 grams and can be given once daily or in divided doses every 12 hours. 2

Critical Diagnostic Considerations

The Widal test has significant limitations in infants and should not be solely relied upon for diagnosis. 3, 4, 5

• The Widal test shows only 61% sensitivity in bacteriologically confirmed typhoid fever, with false positives occurring in 10% of non-typhoidal febrile illnesses. 3
• In children with fever less than 7 days, Widal positivity is only 24%, making it particularly unreliable early in illness. 5
• Blood cultures should be obtained immediately before starting antibiotics (2-3 sets) as they have the highest yield within the first week of symptoms. 1

Important Caveat About CRP Level

The markedly elevated CRP of 241 mg/L is atypical for uncomplicated typhoid fever, where CRP is typically <20 mg/L in 72% of cases. 6 This extremely high CRP raises concern for:

• Concurrent bacterial pneumonia or other serious bacterial infection
• Complicated typhoid with secondary infection
• Alternative diagnosis requiring broader antimicrobial coverage

Concurrent Management of Respiratory and Gastrointestinal Symptoms

Respiratory Assessment

Evaluate for pneumonia given the cough and fever with markedly elevated CRP. 6

• Perform pulse oximetry immediately—hypoxia requires hospitalization. 6
• Obtain chest radiograph if the infant is hypoxic, has severe illness, or is deteriorating. 6
• Consider that the elevated CRP may indicate bacterial pneumonia requiring additional antibiotic coverage beyond typhoid treatment. 6

Diarrhea Management

Aggressive hydration is critical as dehydration increases risk of life-threatening complications in infants with typhoid. 1, 7

• Administer oral rehydration solution (ORS) in small volumes (5 mL every minute) using a spoon or syringe. 7
• Continue breastfeeding on demand if breastfed; continue full-strength formula if formula-fed. 7
• Replace each diarrheal stool with 10 mL/kg of ORS. 7
• Do NOT use antimotility agents (loperamide) in this age group—they are contraindicated and dangerous. 6, 7

Monitoring for Treatment Response

Fever should clear within 4-5 days of appropriate antibiotic therapy. 1

• If no clinical improvement by day 5, consider antibiotic resistance or alternative diagnosis. 1
• Children should demonstrate improvement in fever, respiratory rate, and activity level within 48-72 hours. 6
• Perform full blood count with differential, electrolytes, and blood culture to guide management. 6

Red Flags Requiring Immediate Hospitalization

• Inability to tolerate oral fluids or medications 7
• Signs of severe dehydration (decreased urine output <4 wet diapers/24 hours, lethargy, sunken fontanelle) 7
• Respiratory distress with oxygen saturation <92% 6
• Altered mental status or seizures 6
• Bilious (green) vomiting suggesting intestinal obstruction 7

Common Pitfalls to Avoid

1. Do not delay antibiotics while awaiting blood culture results in a toxic-appearing infant with suspected typhoid—empiric treatment is essential. 1

2. Do not rely solely on the Widal test—it has poor sensitivity (34-61%) and specificity, particularly in the first week of illness. 3, 5, 8

3. Do not use fluoroquinolones as first-line therapy—resistance exceeds 70% in most endemic regions, with rates up to 96% in South Asia. 1

4. Do not withhold fluids or nutrition—continue breastfeeding or formula feeding throughout illness. 1, 7

5. Do not assume typhoid is the only diagnosis with CRP of 241—this level suggests possible concurrent bacterial infection requiring broader evaluation. 6