Overview/Definition
Definition:
• Enteric fever in children is systemic infection caused by Salmonella enterica serovar Typhi (typhoid fever) and Paratyphi A, B, C (paratyphoid fever)
Characterized by prolonged fever, systemic toxicity, and potential complications
Major public health concern in developing countries with emerging antibiotic resistance posing therapeutic challenges.
Epidemiology:
• India reports 200,000-300,000 enteric fever cases annually with children comprising 60-70% of cases
Endemic regions include North India (Punjab, Haryana, Delhi), Eastern states
Peak incidence during monsoon and post-monsoon period
Case fatality rate 1-4% in children with higher rates in multidrug-resistant (MDR) strains.
Age Distribution:
• Infants (<1 year): Rare but severe illness with higher mortality
Children (1-5 years): Classical presentation less common, complications more frequent
School age (6-12 years): Highest incidence, typical fever pattern
Adolescents (13-18 years): Adult-like presentations with systemic complications.
Clinical Significance:
• Critical topic for DNB Pediatrics and NEET SS examinations focusing on changing antibiotic resistance patterns, treatment modifications, and complications management
Understanding of MDR, XDR (extensively drug-resistant) strains essential
Knowledge of current treatment guidelines mandatory for clinical practice.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Extremely rare, maternal transmission during delivery possible
Severe sepsis-like presentation with poor feeding, lethargy
Higher risk of complications: Meningitis, intestinal perforation
Empirical broad-spectrum antibiotic therapy required
Close monitoring in NICU setting.
Infant:
• Infants (1-24 months): Atypical presentations common, prolonged fever may be only sign
Higher risk of complications: Seizures, meningitis, intestinal bleeding
Diagnosis challenging due to non-specific symptoms
Blood culture sensitivity higher in this age group
Nutritional support crucial during illness.
Child:
• Children (2-12 years): Classic stepped-ladder fever pattern in 80% cases
Rose spots seen in 30% fair-skinned children
Higher cooperation for clinical examination and sample collection
Better response to oral therapy when sensitive strains
School absenteeism significant during illness.
Adolescent:
• Adolescents (12-18 years): Adult-like presentations with severe headache, malaise
Higher rates of typhoid hepatitis and neuropsychiatric complications
Risk-taking behavior may lead to repeated exposure
Better medication compliance but may hide symptoms
Menstrual irregularities in females during illness.
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Clinical Presentation
Symptoms:
• Prolonged fever (7-14 days) with step-ladder pattern: Gradual rise over 3-4 days reaching 39-40°C
Headache severe, frontal in location
Abdominal symptoms: Pain, distention, constipation early, diarrhea later
Systemic symptoms: Malaise, weakness, anorexia
Respiratory symptoms: Dry cough in 60-80% cases.
Physical Signs:
• Rose spots: 2-4 mm pink macules on chest/abdomen in 30% cases (day 7-10)
Hepatosplenomegaly in 60-80% cases, spleen more commonly enlarged
Abdominal distention with tenderness in right iliac fossa
Relative bradycardia: Pulse-temperature dissociation
Coated tongue with red tip and edges.
Severity Assessment:
• Uncomplicated enteric fever: Fever with systemic symptoms, no complications
Complicated enteric fever: Intestinal complications (bleeding, perforation), neurological complications (meningitis, encephalopathy), hepatic complications, myocarditis
Severe disease: Multi-organ involvement, shock, altered consciousness.
Differential Diagnosis:
• Malaria: Thick and thin smears, rapid antigen test
Dengue fever: NS1 antigen, platelet count
Viral hepatitis: Hepatitis markers
Tuberculosis: Chest X-ray, tuberculin test
Brucellosis: Rose Bengal test, serology
Infectious mononucleosis: Monospot test, EBV serology.
Diagnostic Approach
History Taking:
• Detailed history of fever pattern, duration, associated symptoms
Travel history to endemic areas, contact with confirmed cases
Food and water consumption habits, street food exposure
Previous antibiotic use affecting culture sensitivity
Vaccination history including typhoid vaccine.
Investigations:
• Blood culture: Gold standard, positive in 80-90% first week
Bone marrow culture: Higher sensitivity (90-95%) especially after antibiotic use
Stool and urine culture: Positive in 30% cases, higher in chronic carriers
Widal test: Supportive evidence, rising titers significant
Typhidot: Rapid diagnosis, IgM/IgG detection.
Normal Values:
• White blood cell count: Normal or low (4000-8000/μL), relative lymphocytosis
Platelet count: Normal or thrombocytopenia (<100,000/μL)
Liver enzymes: ALT/AST elevation in 80% cases
Widal test: O antigen >1:160, H antigen >1:160 significant in endemic areas.
Interpretation:
• Blood culture: Definitive diagnosis with antimicrobial sensitivity testing
Widal test: Single high titer >1:160 or four-fold rise in paired sera
Typhidot: IgM positive indicates recent infection, IgG suggests past infection
Bone marrow culture: Positive even after antibiotic treatment for 2-3 days.
Management/Treatment
Acute Management:
• Antibiotic therapy based on local resistance patterns and culture sensitivity
First-line for sensitive strains: Chloramphenicol, amoxicillin, co-trimoxazole
MDR strains: Fluoroquinolones (ciprofloxacin, ofloxacin) in children >12 years
XDR strains: Azithromycin, ceftriaxone
Supportive care: Hydration, nutrition, fever management.
Chronic Management:
• Treatment duration: 7-10 days for sensitive strains, 10-14 days for resistant strains
Monitoring for complications: Daily clinical examination, weekly blood counts
Carrier state screening: Stool culture at 1, 3, 6 months post-treatment
Family screening for contacts and carriers.
Lifestyle Modifications:
• Strict isolation precautions during acute illness
Hand hygiene education for family members
Safe food and water practices: Boiled water, cooked food consumption
Avoid street food and unhygienic eating places
School exclusion until 3 consecutive negative stool cultures.
Follow Up:
• Clinical response expected within 3-5 days of appropriate antibiotic therapy
Weekly follow-up during treatment period
Post-treatment follow-up: Stool culture at 1 week, 1 month, 3 months
Annual screening for chronic carrier state in household contacts.
Age-Specific Dosing
Medications:
• Sensitive strains - Chloramphenicol: 50-75 mg/kg/day divided every 6 hours for 10-14 days
Amoxicillin: 75-100 mg/kg/day divided every 8 hours
MDR strains - Azithromycin: 10-20 mg/kg/day once daily for 7 days
Ceftriaxone: 75-100 mg/kg/day once daily for 10-14 days.
Formulations:
• Chloramphenicol: Capsules 250 mg, suspension 125 mg/5 ml
Amoxicillin: Suspension 125 mg/5 ml, 250 mg/5 ml, dispersible tablets
Azithromycin: Suspension 200 mg/5 ml, tablets 250 mg, 500 mg
Ceftriaxone: Injectable 250 mg, 500 mg, 1 g vials for IV/IM use.
Safety Considerations:
• Chloramphenicol: Bone marrow suppression risk, regular blood count monitoring
Fluoroquinolones: Cartilage toxicity concern in children <18 years, avoid unless XDR strain
Ceftriaxone: Gallbladder sludging, hypersensitivity reactions
Azithromycin: QT prolongation risk, cardiac monitoring.
Monitoring:
• Complete blood count: Weekly during chloramphenicol therapy for bone marrow suppression
Liver function tests: Baseline and weekly if elevated
Clinical response: Fever chart, symptomatic improvement
Culture clearance: Blood culture negativity by day 3-5 of appropriate therapy.
Prevention & Follow-up
Prevention Strategies:
• Primary prevention: Safe food and water practices, improved sanitation
Typhoid conjugate vaccine (TCV): WHO prequalified, single dose providing 3-5 years protection
Hand hygiene education, proper sewage disposal
Food safety education: "Cook it, boil it, peel it, or forget it".
Vaccination Considerations:
• TCV recommended for children >6 months in high-risk areas
Vi polysaccharide vaccine for children >2 years, single dose
Oral Ty21a vaccine not recommended in children <6 years
Revaccination: TCV every 3-5 years, Vi polysaccharide every 2-3 years.
Follow Up Schedule:
• Acute phase: Daily monitoring for complications, weekly blood tests
Recovery phase: Weekly for 4 weeks, then monthly for 3 months
Carrier screening: Stool culture at 1, 3, 6 months post-treatment
Annual health check-up for high-risk contacts.
Monitoring Parameters:
• Growth parameters in children with prolonged illness
Developmental assessment if neurological complications occurred
School performance evaluation post-recovery
Family screening for chronic carriers
Vaccination status review and catch-up.
Complications
Acute Complications:
• Intestinal complications: Bleeding (10-15%), perforation (1-3%) requiring surgical intervention
Neurological complications: Meningitis, encephalopathy, seizures in 10-15% cases
Typhoid hepatitis with hepatomegaly and elevated liver enzymes
Myocarditis: ECG changes, cardiac enzymes elevation.
Chronic Complications:
• Chronic carrier state: 1-3% of patients, higher in females and immunocompromised
Relapse: 5-10% rate within 2-3 weeks of treatment completion
Gallbladder complications in chronic carriers: Cholecystitis, gallstones
Osteomyelitis: Rare but reported in immunocompromised patients.
Warning Signs:
• Severe abdominal pain suggesting intestinal complications
Altered consciousness, seizures indicating neurological involvement
Massive hematemesis or melena suggesting intestinal bleeding
Respiratory distress with myocarditis
Jaundice with hepatic complications.
Emergency Referral:
• Immediate surgical consultation for intestinal bleeding or perforation
ICU referral for severe complications: Shock, altered consciousness, respiratory failure
Hematology consultation for severe bleeding complications
Gastroenterology referral for hepatic complications.
Parent Education Points
Counseling Points:
• Enteric fever is serious bacterial infection requiring complete antibiotic treatment
Importance of medication compliance to prevent resistance development
Understanding of antibiotic resistance and appropriate use
Prevention through vaccination and hygiene measures
Recognition of complications requiring immediate medical attention.
Home Care:
• Complete bed rest during febrile phase with gradual activity increase
High-calorie, high-protein diet as tolerated
Adequate fluid intake to prevent dehydration
Isolation precautions: Separate utensils, hand hygiene after patient contact
Temperature monitoring and symptom diary maintenance.
Medication Administration:
• Complete prescribed antibiotic course even if symptoms improve
Administer medications at regular intervals for optimal efficacy
Monitor for side effects: Rash, diarrhea, abdominal pain
Store medications as per instructions
Report adverse reactions or treatment failure promptly.
When To Seek Help:
• Immediate medical attention for severe abdominal pain, blood in vomit/stool
Altered consciousness, seizures, or severe headache
High fever persisting beyond 3 days of treatment
Signs of dehydration: Decreased urination, dry mouth, lethargy
Any new symptoms or worsening of existing symptoms.